血浆醛固酮/肾素活性比值在原发性醛固酮增多症筛查诊断中的价值

Clinical significance of aldosterone to renin ratio in screening primary aldosteronism

关键词:  原发性醛固酮增多症  原发性高血压；血浆醛固酮/血浆肾素活性比值  筛查试验  静脉盐水负荷试验

Key words:  [Key words]　primary aldosteronism  essential hypertension  plasma aldosterone to renin ratio  screening test  saline infusion test

摘要:

[摘要]　目的　在严格控制体位、药物、检测条件等情况下，评估血浆醛固酮与肾素活性比值（ARR）[ARR=血浆醛固酮（plasma aldosterone concentration，PAC）/血浆肾素（plasma rennin activity，PRA）]在原发性醛固酮增多症（原醛症，primary aldosteronism，PA）中的临床应用价值；并应用接受者操作特征（receiver operating characteristic，ROC）曲线下面积评估汉族人高血压患者中的ARR值在PA筛查诊断中的最佳标准。　方法　收集2012年3月—2014年8月大连医科大学附属第一医院高血压科就诊的301例怀疑PA的汉族高血压患者，均行卧位/立位ARR的检测及静脉盐水负荷试验。其中确诊PA的患者105例，原发性高血压（essential hypertension，EH）的196例，并分别对两组间患者的一般临床资料和卧位PRA、立位PRA、卧位PAC、立位PAC、卧位ARR、立位ARR等免疫指标进行统计分析，利用ROC曲线下面积探讨汉族人高血压患者筛选PA的ARR值。　结果　在PA组及EH组的临床资料分析中，EH组卧位/立位PAC、ARR水平均较PA组低，差异均有显著性意义(P<0.05)；EH组卧位/立位血浆PRA较PA组高，两组比较差异有显著性意义（P<0.05）；立位PRA作为PA筛查指标优于立位PAC，而立位ARR作为PA的筛查指标优于立位PRA和立位PAC；将不同立位ARR切点进行比较，可见立位ARR切点为240(pg/mL)/(ng·mL-1·h-1)时对PA患者诊断的灵敏度和特异度较高。　结论　立位ARR相对于卧位ARR、立位PRA、立位PAC更适合作为PA患者的筛查方法，但其检测时需控制体位、药物、标本采集和测定等影响因素，立位ARR切点为240(pg/mL)/(ng·mL-1·h-1)时对于在汉族高血压患者中筛查PA的诊断价值更高。

Abstract:

[Abstract]　Objective　In recent years, the assessment of the plasma aldostemne-to-renin ratio (ARR) has become a every effective and widely used method for screening primary aldosteronism from hypertensives．It is well known that there is a large variance in ARR value between different races and region. Meanwhile ARR can be affected by many factors, such as drugs, posture and detection time etc．The receiver operating characteristic (ROC) curve was used to evaluate the value of aldosterone to renin ratio (ARR) in screening primary aldosteronism. 　Methods　 Clinical data of ARR in supine and upright positions were collected from 301 patients who was suspected with primary aldosteronism during March 2012 to August 2014. Supine and upright ARR detection and Saline infusion test were performed for all the participants. 105 patients were diagnosed with primary aldosteronism and 196 patients were essential hypertension among all participants. Gender, age, the course of hypertension, BMI, systolic blood pressure, diastolic blood pressure, serum sodium, potassium, urinary sodium, urinary potassium, supine PRA, upright PRA, supine PAC, upright clinical data PAC, supine ARR, and upright ARR were collected for statistical analysis. At last use the ROC curve was used curve to define the best cut-off value of ARR for screening primary aldosteronism from hypertensives．　Results　In the analysis of the clinical data of PA group and EH group, We found supine / upright PAC, ARR levels in EH group were lower than those in PA group, and the supine / upright plasma PRA was higher than that in PA group, the difference both have statistical significance (P<0.05). The area under the ROC curve of supine ARR was 0.763 (0.717-0.813), the area under the ROC curve of upright ARR was 0.909 (0.868-0.941), there was significantly difference between the two values (P<0.01). The area under the ROC curve of upright PRA was 0.814 (0.762-0.859), the area under the ROC curve of upright PAC was 0.684 (0.625-0.074), there was significantly difference between these two areas under the ROC curve (P< 0.05). The statistical analysis of the area under the ROC curve of the upright ARR, supine ARR, upright PRA, upright PAC, upright ARR show that the Z of the upright ARR(Z =4.663) was higher, the difference has statistical significance (P<0.01). The upright ARR cut-off value with 240(pg/mL)/(ng·mL-1·h-1) yielded a sensitivity of 100％ and a specificity of 74.09% for diagnosis of PA．　Conclusion　In our research, under strict consol of the drug, position and detection time, Upright ARR value is more suitable in the screening test than supine ARR. It is suitable to use upright ARR 240(pg/mL)/(ng·mL-1·h-1) as a cut-off threshold for screening primary aldostemnism in hypertensives．