难治性高血压患者中原发性醛固酮增多症的筛查

目的探讨难治性高血压患者中原发性醛固酮增多症(PA)的患病状况,并分析其临床特点。方法连续选择就诊于同济大学附属同济医院内分泌科门诊的难治性高血压患者125例,于清晨8:00—9:00卧位采血测定血浆醛固酮(ALD)水平和肾素活性(PRA),计算ALD/PRA(ARR)。ARR≥20且ALD水平≥207.75pmol/L的患者接受盐溶液负荷试验,负荷试验后血ALD水平仍≥207.75pmol/L者诊断为PA。进一步分型时,所有患者均进行肾上腺薄层增强CT检查,其中1例患者因难以判断是单侧还是双侧肾上腺病变而接受双侧肾上腺静脉采血检查。诊断为醛固酮瘤(APA)的患者在腹腔镜下行单侧肾上腺切除,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,随访患者的血压控制和血钾改善情况。结果 125例患者中31例(24.8%)ARR≥20,其中24例(19.2%)ARR≥20且ALD水平≥207.75pmol/L的患者接受盐溶液负荷试验。输注0.9%氯化钠溶液后血ALD水平仍≥207.75pmol/L者8例,确诊为PA(6.4%),其中4例诊断为APA,在腹腔镜下行单侧肾上腺切除;另外4例诊断为IHA的患者加用螺内酯治疗。随访半年的结果显示,所有患者的高血压均获良好控制,低血钾治愈。结论难治性高血压人群中PA的患病率低于以前国外的报道,其中50%为APA,高于其他报道。需要设计规模更大、入选标准更严格的前瞻性研究进一步探讨中国难治性高血压患者中PA的流行病学特点。

Screening for primary aldosteronism in patients with resistant hypertension

Objective To investigate the prevalence of primary aldosteronism (PA) in patients with resistant hypertension and analyze the clinical features of the confirmed PA. Methods A total of 125 consecutive outpatients with resistant hypertension were enrolled for screening of PA. Plasma aldosterone (ALD) and plasma renin activity (PRA) were determined at 8:00-9:00 in the morning. Then the ratio of ALD to PRA (ARR) was calculated. Patients with a positive result (ARR≥20 and ALD≥207.75 pmol/L) underwent saline solution loading test and were diagnosed as PA if ALD was still above 207.75 pmol/L after the test. Further classification of PA subtype was carried out by adrenal enhancement CT scan in all the patients. One patient underwent adrenal vein sampling because of equivocal findings on adrenal CT scan. Patients with aldosterone-producing adenoma (APA) underwent unilateral laparoscopic adrenalectomy. Patients with idiopathic hyperaldosteronism (IHA) were additionally treated with mineralocorticoid receptor antagonist-spironolactone. All of them were followed up for observing blood pressure and serum potassium. Results Of the 125 patients, 31 (24.8%) had an elevated ARR (≥20) and 24 (19.2%) had both elevated ARR and ALD (≥207.75 pmol/L). Only 8 patients (6.4%) were definitely diagnosed as having PA by saline infusion test. Four patients with APA underwent unilateral laparoscopic adrenalectomy, and another 4 patients with IHA were additionally treated with spironolactone. All the patients displayed a marked improvement in hypertension control and cure of hypokalemia during a follow-up of 6 months. Conclusion The PA prevalence in the patients with resistant hypertension in this study is lower than previously reported in foreign literatures. Half of the patients with PA have APA, and it seems to be higher than those in other reports. A large-scale prospective study with more strict inclusion criteria should be designed to exactly assess the epidemiologic characteristics of PA in Chinese patients with resistant hypertension.