Dissociation of Plasma Atrial Natriuretic Peptide Responses to Upright Posture and Furosemide Administration in Patients with Normal-, Low Renin Essential Hypertension and Primary Aldosteronism

Plasma levels of atrial natriuretic peptide (ANP) were measured in patients with normal renin essential hypertension (n = 12), low renin essential hypertension (n = 11) and primary aldosteronism due to aldosterone producing adenoma (APA, n = 8) and idiopathic hyperaldosteronism (IHA, n = 3) after overnight rest in the supine position and after 4 h upright posture and furosemide administration. Plasma renin activity (PRA) and aldosterone (Aldo) levels were also determined. Compared to normal renin essential hypertension (33.6± 2.2 pg/ml), basal plasma ANP was significantly higher in low renin essential hypertension (66.8± 6 pg/ml), IHA (54.1± 6.3 pg/ml) and APA before (62.4± 4.9 pg/ml) but not after adrenal surgery (22± 3 pg/ml). After upright posture and furosemide administration plasma ANP was decreased (p < 0.01) in patients with low renin and, less markedly, with normal renin essential hypertension, however not in IHA and APA. In about half of the patients with low renin essential hypertension, unchanged PRA after upright posture and furosemide administration was associated with increased plasma Aldo and decreased ANP levels. We conclude that (i) the relatively high basal plasma ANP levels in low renin essential hypertension, IHA and APA may reflect the presence of volume expansion in these patients; (ii) the hormonal responses to upright posture and furosemide administration in patients with normal and low renin essential hypertension may indicate a counterregulatory role of ANP during activation of the renin-angiotensin-aldosterone system; (iii) the high plasma ANP, which is unresponsive to upright posture and furosemide administration, in patients with APA and IHA may be a potentially interesting new finding whose pathophysiological significance remains to be established.     

Primary Aldosteronism: A Practical Approach to Diagnosis and Treatment

Primary aldosteronism (PA) may account for as many as 10%–14% of hypertension cases. The plasma aldosterone concentration/plasma renin activity ratio is a simple screening test for PA that should be performed in all patients with refractory/severe hypertension, spontaneous or provoked (by diuretics) hypokalemia, or a requirement for excessive potassium supplementation to maintain normokalemia. PA can be confirmed by a fludrocortisone suppression test or 24-hour urine collection for aldosterone. Confirmatory testing should be followed by high-resolution computerized tomography of the adrenal glands to distinguish bilateral hyperplasia or an adenoma. A solitary tumor greater than 1 cm in size in a younger patient is an indication for surgery; all other (nondiagnostic) findings should be followed by bilateral adrenal venous sampling (if available) to identify a unilateral cause of PA. Treatment for a later alizing positive study is surgical; spironolactone or another mineralocorticoid receptor antagonist is the treatment of choice for a nonlateralizing study. If adrenal venous sampling is not readily available, patients may be successfully treated pharmacologically.     

Single Oral Administration of Captopril may not bring an Improvement in Screening of Primary Aldosteronism

Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were measured in 19 cases with primary aldosteronism (PA) and 72 with essential hypertension (EHT) to differentiate the two disorders in the following conditions: 1) after overnight recumbency (basal state) and 2) after oral administration of captopril. Screening criteria were determined in order to pick up all of PA patients as positive. After the captopril administration, the specificity of a criterion based on the combination of PAC and PAC/PRA ratio was 93 % and positive predictive value 79 %. This criterion was superior to other conventional screening methods. However, higher specificity (97 %) and positive predictive value (90 %) were obtained from a combination criterion based on the basal PAC and PAC/PRA ratio. The single oral administration of captopril may not bring an improvement in the screening of PA.     

640例高血压患者中原发性醛固酮增多症患病率及临床特点

目的　探讨高血压患者中原发性醛固酮增多症（PA）的患病率,并分析PA患者的临床特点。方法　选择就诊于东莞市中医院内科门诊高血压患者640例,于清晨9∶30～10∶30患者起床2小时后,取坐位5～15　min后采血测定血浆醛固酮（ALD）水平和肾素活性（PRA）,计算血浆醛固酮/血浆肾素活性比值（ARR）。ARR≥30且ALD水平≥15　ng／dL的患者接受开博通试验,服开博通后2小时血浆醛固酮水平抑制程度≤30%,则试验结果为阳性,诊断为原发性醛固酮增多症^［1］。进一步分型时,PA患者均进行肾上腺薄层增强CT检查,诊断为特发性醛固酮增多症（IHA）的患者加用盐皮质激素受体拮抗剂（螺内酯）治疗,诊断为醛固酮瘤（APA）患者予以在腹腔镜下行单侧肾上腺切除术。结果　640例患者中112例（17.5%）ARR≥30,其中87例（13.59%）ARR≥30且ALD水平≥15　ng／dL的患者接受开博通试验。服用开博通2　h后血ALD水平抑制≤30%者32例,确诊为PA（5%）,其中20例诊断为APA（3.125%）,另外12例（1.875%）诊断为IHA。诊断为IHA的患者加用螺内酯治疗,醛固酮瘤患者予以在腹腔镜下行单侧肾上腺切除术。结论　高血压人群中原发性醛固酮增多症的患病率较高,要重视高血压患者中原发性醛固酮增多症的筛查,原发性醛固酮增多症患者临床具有高血压、低血钾、高尿钾、高醛固酮、低肾素、高ARR的典型临床特点。     

Primary Aldosteronism: Effects of Inhibition of ACTH and Potassium Administration on Plasma Aldosterone Concentration

The relative roles of ACTH, angiotensin and potassium in influencing aldosterone secretion in primary aldosteronism were assessed by direct or indirect means. In untreated patients with primary aldosteronism caused either by adrenal adenoma or hyperplasia plasma aldosterone and cortisol concentrations fluctuated in unison and dexamethasone reduced both hormones markedly. Only when renin-angiotensin system was greatly activated and plasma potassium normalized by medical treatment was dexamethasone less successful in lowering plasma aldosterone concentration. Potassium infusion of 10,20 and 30 mEq/hr in patients with adenoma failed to elicit any increase in plasma aldosterone concentration despite significant increases in plasma potassium levels. These results suggest that patients with primary aldosteronism due to adrenal adenoma are relatively more sensitive to small changes in plasma ACTH level than those in plasma angiotensin or potassium levels. In recumbent patients with adrenal hyperplasia ACTH also modulates plasma aldosterone concentration.     

Primary Aldosteronism: Effects of Inhibition of ACTH and Potassium Administration on Plasma Aldosterone Concentration

The relative roles of ACTH, angiotensin and potassium in influencing aldosterone secretion in primary aldosteronism were assessed by direct or indirect means. In untreated patients with primary aldosteronism caused either by adrenal adenoma or hyperplasia plasma aldosterone and cortisol concentrations fluctuated in unison and dexamethasone reduced both hormones markedly. Only when renin-angiotens in system was greatly activated and plasma potassium normalized by medical treatment was dexamethasone less successful in lowering plasma aldosterone concentration. Potassium infusion of 10, 20 and 30 mEq/hr in patients with adenoma failed to elicit any increase in plasma aldosterone concentration despite significant increases in plasma potassium levels. These results suggest that patients with primary aldosteronism due to adrenal adenoma are relatively more sensitive to small changes in plasma ACTH level than those in plasma angiotensin or potassium levels. In recumbent patients with adrenal hyperplasia ACTH also modulates plasma aldosterone concentration.     

Hormones Other Than Aldosterone May Contribute to Hypertension in 3 Different Subtypes of Primary Aldosteronism

Blood pressure (BP) level is similar in patients with 3 subtypes of primary aldosteronism (PA), even though aldosterone levels may vary. Glucocorticoids and adrenomedullary hormones may be influenced and may contribute to hypertension in PA. The authors' objective was to investigate the influence of PA on adrenal gland secretion and the roles of these hormones in hypertension. Patients diagnosed with PA (229 cases) were enrolled and classified into 3 subgroups: aldosterone‐producing adenoma (APA), unilateral nodular adrenal hyperplasia (UNAH), and idiopathic hyperaldosteronism (IHA). Patients with essential hypertension served as the control group (100 cases). Concentration of the above hormones was measured and compared between groups. Level of plasma adrenocorticotrophic hormone (ACTH) in patients with APA was significantly lower than that in patients with IHA (P<.001) and UNAH (P<0.5). The 24‐hour urinary free cortisol and adrenomedullary hormone levels were highest in patients with IHA, lower in patients with APA, and lowest in patients with UNAH. Systolic BP level was positively correlated with 8 am plasma cortisol level (r=0.142, P=.039) and plasma ACTH level (r=0.383, P=.016). Cortisol and adrenomedullary hormones were different between PA subtypes and they might involve regulation of BP in those patients.     

Suppression of Primary Aldosteronism and Resistant Hypertension by the Peroxisome Proliferator-activated Receptor Gamma Agonist Pioglitazone

The peroxisome proliferator-activated receptor gamma (PPAR γ) agonists have been reported to have antiproliferative and tumor-suppressive effects. We report a case of 55-year-old man with primary aldosteronism (PA) whose hyperaldosteronism was suppressed with the PPAR γ agonist pioglitazone. He had drug-resistant hypertension, hypokalemia, and diabetes mellitus. The diagnosis of PA was confirmed by the oral sodium loading test (20.5 μg/d of urinary aldosterone) and Captopril challenge test (19.5 ng/dL of plasma aldosterone). Computed tomography imaging revealed no apparent adrenal mass. The result of the posture stimulation test was consistent with the diagnosis of idiopathic adrenal hyperplasia. On administration of pioglitazone (30 mg/d) and nifedipine (40 mg/d), hypertension and hypokalemia improved and plasma aldosterone decreased for more than 6 months. The sodium loading test done after 6 months of the administration revealed the near normal results (11.2 ng/dL of plasma aldosterone and 13.1 μg/d of urinary aldosterone). The findings indicated that pioglitazone suppressed PA.     

The Cutoff Value of Aldosterone-to-Renin Ratio for the Diagnosis of Primary Aldosteronism in Patients Taking Antihypertensive Medicine

Background. Primary aldosteronism (PA) may account for as much as 6–20% of cases of refractory hypertension referred to hypertension clinics. Because antihypertensive agents affect the physiologic renin-angiotensin-aldosterone system, screening diagnostic tests for PA are generally performed after antihypertensive agents are discontinued. However, such tests can be dangerous for patients with severe hypertension or other cardiovascular complications. However, a reliable cutoff value for the aldosterone-to-renin ratio (ARR) has not been established, especially for Asians, including the Japanese. Method. Fifty-five consecutive patients with clinically suspected PA were evaluated from July 10, 2001, to March 1, 2005, at the National Cardiovascular Center in Japan. Every referred patient was screened prospectively for PA with the ARR at the outpatient clinic. The patients tested continued to be treated with a variety of antihypertensive agents. We reviewed the sensitivity, specificity, and accuracy of the ARR without modifying the antihypertensive agents. The diagnosis of PA was established with the results of both abdominal computed tomography and adrenal scintigraphy. Results. Of the 55 patients, 27 were found to have PA, including adrenal adenoma (n = 18) and bilateral adrenal hyperplasia (n = 9). The mean ARR of patients with PA was significantly higher than that of patients without PA. By assuming a cutoff value of the ARR ≥ 69 calculated from the receiver operating characteristics curve, the highest sensitivity (81%), specificity (82%), positive-predictive value (81%), and negative-predictive value (81%) were obtained. Conclusion. The data suggest that an ARR ≥ 69 strongly indicates PA in Japanese patients with hypertension being treated with antihypertensive agents.     

Adrenal Venous Sampling for Primary Aldosteronism and Clinical Outcomes After Unilateral Adrenalectomy: A Single-Center Experience

Adrenal venous sampling (AVS) remains controversial in the management of primary aldosteronism. Retrospective chart review was conducted at the Hospital of the University of Pennsylvania from July 2001 to September 2007. A total of 113 patients underwent AVS, 16 patients were excluded as records were unavailable. Among 97 remaining patients, 61 had unilateral disease and 57 underwent unilateral adrenalectomy. Blood pressure (BP) improved significantly with less antihypertensive medication requirement. Among those with different BP responses to adrenalectomy (cure, improvement, or no change), a higher number of preoperative antihypertensive medications was associated with persistent hypertension ( P  = .03). There were no significant differences in age ( P  = .14), duration of hypertension ( P  = .60), family history of hypertension ( P  = .68), or serum creatinine ( P  = .34). When AVS shows lateralization, age, duration of hypertension, family history, or renal dysfunction did not predict BP response to adrenalectomy. Results suggest that these factors should not preclude AVS and subsequent adrenalectomy. Further studies are indicated to confirm these findings.     

Prevalence and characteristics of familial hyperaldosteronism: the PATOGEN study (Primary Aldosteronism in TOrino-GENetic forms)

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension, and patients display an increased prevalence of cardiovascular events compared with essential hypertensives. To date, 3 familial forms of PA have been described and termed familial hyperaldosteronism types I, II, and III (FH-I to -III). The aim of this study was to investigate the prevalence and clinical characteristics of the 3 forms of FH in a large population of PA patients. Three-hundred consecutive PA patients diagnosed in our unit were tested by long-PCR of the CYP11B1/CYP11B2 hybrid gene that causes FH-I, and all of the available relatives of PA patients were screened to confirm or exclude PA and, thus, FH-II. Urinary 18-hydroxycortisol and 18-oxocortisol were measured in all of the familial PA patients. Two patients were diagnosed with FH-I (prevalence: 0.66%), as well as 21 of their relatives, and clinical phenotypes of the 2 affected families varied markedly. After exclusion of families who refused testing and those who were not informative, 199 families were investigated, of which 12 were diagnosed with FH-II (6%) and an additional 15 individuals had confirmed PA; clinical and biochemical phenotypes of FH-II families were not significantly different from sporadic PA patients. None of the families displayed a phenotype compatible with FH-III diagnosis. Our study demonstrates that familial forms of hyperaldosteronism are more frequent than previously expected and reinforces the recommendation of the Endocrine Society Guidelines to screen all first-degree hypertensive relatives of PA patients.     

40例原发性醛固酮增多症手术前后血压与血液生化改变对比分析

目的：研究原发性醛固酮增多症患者血压及血液生化改变与手术效果的关系。方法：分析４０例原发性醛固酮增多症患者，其中男１７例，女２３例，年龄１８～５６岁，平均４０．３岁。对手术后病理诊断进行分类，术前术后测定血压，血钾、钠，尿钾，血浆肾素活性、醛固酮并计算醛固酮／肾素活性比值。结果：单纯腺瘤２６例，增生９例，混合５例，术后平均收缩压自２４．０±３．３ｋＰａ（１８０±２５ｍｍＨｇ）降至１７．７±１．９ｋＰａ（１３３±１４ｍｍＨｇ），平均舒张压自１５．６±２．４ｋＰａ（１１７±１８ｍｍＨｇ）降至１１．６±１．２ｋＰａ（８７±９ｍｍＨｇ），血钾自２．８±０．５ｍｍｏｌ／Ｌ升至４．１±０．４ｍｍｏｌ／Ｌ，２４小时尿钾排泄自４９．０ｍｍｏｌ降至２９．８ｍｍｏｌ，血浆肾素活性自０．５０±０．４３ｎｇＡＩｍｌ－１／ｈ升至５．４７±２．６８ｎｇＡＩｍｌ－１／ｈ，血浆醛固酮由３８５．７±２０４．１ｐｇ／ｍｌ降至１２９．０±６１．９ｐｇ／ｍｌ，血浆醛固酮／血浆肾素活性比值由７７３．９降至４６．２。结论：原发性醛固酮增多症患者血液生化改变，对原发性醛固酮增多症诊断及术后疗效判定有重要价值。     

钠盐摄入对卡托普利抑制试验和盐水负荷试验一致性的影响

目的:本研究旨在探讨不同水平钠盐摄入对两种原发性醛固酮增多症诊断试验卡托普利抑制试验(CCT)和盐水负荷试验(SIT)结果一致性的影响。方法:本研究回顾了中国医学科学院阜外医院自2016年10月至2018年8月同时行CCT和SIT的298例患者的临床资料。根据试验前24 h尿钠排泄量由低到高三等分将患者分为低钠组(<93 mmol/24 h)、中钠组(93~144 mmol/24 h)、高钠组(>144 mmol/24 h);四等分将患者分为低钠组(<75 mmol/24 h)、中钠组A(75~116 mmol/24 h)、中钠组B(117~164 mmol/24 h)、高钠组(>164 mmol/24 h),通过比较不同组别中CCT和SIT结果一致性的差异来探讨钠盐摄入对两种不同确诊试验的影响。结果:共有145例(48.7%)患者两种确诊试验结果不同,其中103例(34.6%)呈CCT单阳性,42例(14.1%)呈SIT单阳性。三等分时高钠组中CCT单阳性比例较高(高钠组49.0%vs中钠组26.7%vs低钠组28.3%,P<0.001),四等分时结果相似(高钠组48.0%vs中钠组B 36.5%vs中钠组A 25.7%vs低钠组28.0%,P=0.018)。多因素Logistic回归分析显示,24 h尿钠排泄量是影响CCT单阳性患者比例的因素(P=0.006)。结论:高钠组患者CCT结果和SIT结果一致性低于中钠组。进行原发性醛固酮增多症诊断试验前应标准化钠盐摄入而非单纯不限制钠盐摄入。     

Proportion of Patients With Hypertension Resolution Following Adrenalectomy for Primary Aldosteronism: A Systematic Review and Meta‐Analysis

Unilateral primary aldosteronism (PA) is often treated with adrenalectomy, but hypertension resolution rates are variable. A valid estimate of the postoperative normotension rate is necessary to inform the utility of PA testing and treatment. The authors searched MEDLINE In‐Process & Other Non‐Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials. Prospective adult cohort studies with surgically treated PA that reported resolution of hypertension without the aid of medications were included. Among 2620 abstracts identified by the search, 25 studies in the systematic review with data on 1685 patients were investigated. The pooled proportion of normotension following adrenalectomy was 52% (95% confidence interval, 0.44–0.60). Meta‐regression demonstrated a significant negative association between length of follow‐up and proportion of normotension, with normotension dropping by 6.7% per year of follow‐up (coefficient −0.006; 95% confidence interval, −0.01 to 0.002). Overall, approximately half of the patients experienced hypertension resolution, although this outcome may not be durable in all patients.

Primary aldosteronism (PA) is defined as a form of drug‐resistant and potentially curable hypertension with evidence of excess aldosterone secretion, suppressed plasma renin activity, and often hypokalemia.¹ Initially thought to be rare, PA is the leading cause of secondary hypertension. With increased screening and detection, the incidence of PA among hypertensive patients is currently reported at approximately 10%.² This syndrome has multiple etiologies, including inherited gene mutations,³ development of autoantibodies,⁴ and ectopic aberrant functional adrenal receptors.⁵ The clinical management is guided by the definition of unilateral vs bilateral adrenal involvement. With rare exception, adrenalectomy is reserved for unilateral adrenal disease.The proportion “cured” following adrenalectomy for patients with PA has been reported to range from 0% to 100%.⁶ However, “cure” is variably defined in the literature. These definitions include normal blood pressure (BP), normal BP without aid of antihypertensive medications, a reduced need for antihypertensive medications, and biochemical normalization, among others. Biochemical normalization of the aldosterone‐renin ratio is likely a necessary part of a definition of “cure.” At this time, however, there is no global consensus on the interpretation of postoperative aldosterone‐renin ratios with the existence of variable assays and cutoffs for even initial diagnosis. Therefore, from the patient''s perspective and in the absence of patient‐level clinical end point data, attainment of medication‐free normotension may be the most uniform and recognizable health benefit of surgical PA treatment. Individually reported results of long‐term resolution of hypertension without antihypertensive medications are between 30% and 70% following adrenalectomy.⁷ The primary aim of this systematic review and meta‐analysis was to determine the proportion of hypertension resolution without the aid of antihypertensive agents following adrenalectomy in patients with PA. To our knowledge, no previous meta‐analysis has been performed. A secondary objective was to identify patient‐level factors reported to be associated with hypertension resolution in patients managed with adrenalectomy.     

Battenin相互作用蛋白的筛选与初步鉴定

目的 寻找Battenin相互作用蛋白的筛选方法，并对筛选出的Battenin相互作用蛋白进行初步鉴定。方法将编码Battenin相互作用蛋白肽段的cDNA序列与pier＆质粒的DNA结合结构域基因重组作为诱饵，应用MATCHMAKER LexA酵母双杂交系统从人胎脑cDNA文库中筛选与Battenin相互作用蛋白再发生相互作用的蛋白质的cDNA，并进行生物信息学分析。结果从胎脑cDNA文库中筛选得到7个阳性克隆，其中一个基因与人TEGT基因有99％的同源性，TEGT编码蛋白为Bax抑制子1。结论Battenin相互作用蛋白与Bax抑制子1或类似物相互作用，Bax抑制子1具有反式调控因子特性，二者都可能参与基因表达调控。     

Screening for Problem Drinking and Counseling by the Primary Care Physician-Nurse Team

Present methods to screen for alcohol abuse are generally obtrusive and result in referral to services that deal mainly with alcoholics. These factors deter physicians from identifying alcohol abuse patients at an early stage. In the present study, 81% of all primary care physicians of a single city evaluated (i) the efficiency and the acceptability of a nonobtrusive screening method for the identification of problem drinkers and (ii) the effectiveness of brief cognitive behavioral counseling given by a nurse in a lifestyle context. Patients (n = 15,686) attending the private practices of 42 primary–care physicians were asked four alcohol–neutral trauma questions in the reception area. Physicians asked about alcohol use and alcohol-related problems only to patients with previous trauma. Problem drinkers by defined criteria were offered an appointment with a nurse who, by random assignment, gave either 3-hr of cognitive behavioral counseling over 1 year or simply advised patients to reduce their alcohol intake. The screening method identified 62–85% of expected number of problem drinkers in this population. Following the application of exclusion criteria, 105 problem drinkers were entered in the intervention part of the study. After 1 year, patients who received counseling showed significant reductions in reported alcohol consumption (-70%; p < 0.001), psychosocial problems (-85%; p < 0.001) and serum gamma glutamyl transferase (-32%h to -58%; p < 0.02). Physician visits were reduced (-34%; p < 0.02) following counseling. Patients receiving only advice showed neither reductions in psycho-social problems nor in serum gamma glutamyl transferase or physician visits, but reported a 46% reduction (p < 0.01) in alcohol consumption. Data indicate that asking patients about recent trauma is efficient and is well accepted as the first screening instrument in the identification of the problem drinker. Cost of screening per patient is under one dollar. Counseling of 3 hr given by a nurse is markedly superior (p < 0.05) to simple advice in reducing alcohol consumption, objective indicators of alcohol-related morbidity, and the frequency of physician visits.     

Recurrence of Hypertension in Primary Aldosteronism after Discontinuation of Spironolactone. Time Course of Changes in Cardiac Output and Body Fluid Volumes

Hemodynamic mechanisms underlying the hypertensive action of longstanding sodium overload were studied in ten subjects with aldosterone-producing adenoma. Arterial pressure was 129±4/91±4 mm Hg (mean±SEM) during spironolactone treatment, 177±5/114±3 mm Hg six weeks after the drug had been stopped, and 136±4/94±3 mm Hg two months after operation. In the six weeks following cessation of spironolactone, cardiac output, stroke volume, blood volume and sodium space were determined at weekly intervals. In each subject the biochemical syndrome of aldosterone-excess had been fully developed in two weeks. The hemodynamic changes in that period were also uniform. Mean arterial pressure in week 2 was increased by 20±3% with parallel increments of cardiac output and stroke volume of 22±5 and 30±6%. Blood volume and sodium space were increased by 11±2 and 29±4%. The patterns in weeks 2–6 were not uniform. In five subjects (age 33–49 yr) the hypertension was maintained through increased cardiac output; in week 6 it was 34±7% above its initial value, and stroke volume and blood volume were 37±4 and 16±4% above control. In the remaining five subjects (age 50–60 yr) cardiac output, stroke volume and blood volume returned to their initial values, and total peripheral resistance in week 6 was 36±13% above control. Sodium space remained expanded in both groups. The measurements after surgery confirmed the existence of the high-flow and high-resistance patterns; there was a decrease in cardiac output in the former group of subjects and a decrease in resistance in the latter. Apparently, increased resistance is not a direct consequence of increased flow. The observed age-related differences in hemodynamic patterns of sodium overload bear some resemblance to essential hypertension where a high-flow state of long duration may precede the ultimate phase of low vascular capacitance and high resistance.     

Captopril Test and Renal Duplex Scanning for the Primary Screening of Renovascular Disease

To evaluate the utility of renal duplex scanning and the captopril test in the detection and functional assessment of renovascular disease, by comparing their results with those of angiography and captopril isotopic renography (CIR).Sixty hypertensive patients with aortoiliac disease and 16 with clinically suspected renovascular hypertension (RVH) were included. All the patients underwent renal duplex scanning prior to angiography. In addition, isotopic renograms and a determination of peripheral plasma renin activity (PRA) at baseline and 60 min after oral intake of 50 mg of captopril were both performed. A postcaptopril PRA > 5.7 ng/mL/h was considered as diagnostic of a positive captopril test. On the basis of the results of the angiography and isotopic renograms, all the patients were classified into three groups: group I (n = 33), essential hypertension (EHT); group II (n = 20), hypertension and angiographic RAS > 60% but negative CIR; and group III (n = 24), RAS > 60% and positive CIR. This last condition was considered as highly suspicious for RVH.Renal duplex scanning showed greater accuracy than captopril PRA or CIR for detecting RAS > 60% (groups II and III) with 87.3% versus 52.4% and 45.3% sensitivity (S), and 91.5% versus 84.4% and 92.8% specificity (Sp), respectively. The captopril test correctly identified 44 of 51 EHT patients (groups I and II) and 20 of 23 highly suspected of RVH (group III) with 87% S, 86.5% Sp, 74.1% PPV, and 93.6% NPV. Accuracy was further increased when a combined approach (renal duplex scanning and captopril test) was followed (82.6% S, 93.7% Sp, 86.4 PPV, and 91.8 NPV).In our study, renal duplex scanning was a useful screening method for detecting anatomical RAS. A combination of both renal duplex scanning and captopril test may be an appropriate approach to the primary screening for RVH, thereby permitting the selection of those patients indicated for angiography.