Confirmatory testing of primary aldosteronism with saline infusion test and LC-MS/MS

Carmina Teresa Fuss, Katharina Brohm, Max Kurlbaum, Anke Hannemann, Sabine Kendl, Martin Fassnacht, Timo Deutschbein, Stefanie Hahner, Matthias Kroiss, Carmina Teresa Fuss, Katharina Brohm, Max Kurlbaum, Anke Hannemann, Sabine Kendl, Martin Fassnacht, Timo Deutschbein, Stefanie Hahner, Matthias Kroiss

Abstract

Objective: Saline infusion testing (SIT) for confirmation of primary aldosteronism (PA) is based on impaired aldosterone suppression in PA compared to essential hypertension (EH). In the past, aldosterone was quantified using immunoassays (IA). Liquid chromatography tandem mass spectrometry (LC-MS/MS) is increasingly used in clinical routine. We aimed at a method-specific aldosterone threshold for the diagnosis of PA during SIT and explored the diagnostic utility of steroid panel analysis.

Design: Retrospective cohort study of 187 paired SIT samples (2009-2018). Diagnosis of PA (n = 103) and EH (n = 84) was established based on clinical routine workup without using LC-MS/MS values.

Setting: Tertiary care center.

Methods: LC-MS/MS using a commercial steroid panel. Receiver operator characteristics analysis was used to determine method-specific cut-offs using a positive predictive value (PPV) of 90% as criterion.

Results: Aldosterone measured by IA was on average 31 ng/L higher than with LC-MS/MS. The cut-offs for PA confirmation were 54 ng/L for IA (sensitivity: 95%, 95% CI: 89.0-98.4; specificity: 87%, 95% CI: 77.8-93.3; area under the curve (AUC): 0.955, 95% CI: 0.924-0.986; PPV: 90%, 95% CI: 83.7-93.9) and 69 ng/L for LC-MS/MS (79%, 95% CI: 69.5-86.1; 89%, 95% CI: 80.6-95.0; 0.902, 95% CI: 0.857-0.947; 90%, 95% CI: 82.8-94.4). Other steroids did not improve SIT.

Conclusions: Aldosterone quantification with LC-MS/MS and IA yields comparable SIT-cut-offs. Lower AUC for LC-MS/MS is likely due to the spectrum of disease in PA and previous decision making based on IA results. Until data of a prospective trial with clinical endpoints are available, the suggested cut-off can be used in clinical routine.

Figures

Figure 1
Figure 1
Study flow: 236 patients underwent saline infusion testing (SIT) for suspected primary aldosteronism (PA). 187 patients were included in the final analysis. Unknown = subtype of PA not known due to unsuccessful adrenal vein sampling or patient’s refusal to undergo adrenal vein sampling or surgery.
Figure 2
Figure 2
Aldosterone concentrations measured by immunoassay and LC-MS/MS during saline infusion testing in patients with essential hypertension (EH, A, B, C and D), primary aldosteronism (PA, A and C), aldosterone-producing adenoma (APA, B and D) and bilateral adrenal hyperplasia (BAH, B and D) before (0 h, A and B) and after (4 h, C and D) saline infusion. *P < 0.01 (Wilcoxon test).
Figure 3
Figure 3
(A and B) Scatter plot of aldosterone concentrations measured by RIA (n = 162), CLIA (n = 212) and LC-MS/MS. Dashed lines: 95% confidence interval. (A) RIA: Spearman correlation coefficient 0.878 (P < 0.001), Pearson r coefficient 0.833 (P < 0.001). (B) CLIA: Spearman correlation coefficient 0.877 (P < 0.001), Pearson r coefficient 0.952 (P < 0.001). (C and D) Bland-Altman analysis of all aldosterone measurements by RIA (C, n = 162), CLIA (D, n = 212) and LC-MS/MS. Continuous line: mean difference, dashed lines: 95% limits of agreement. For better visualization, x- and y-axes were cut at 1200 ng/L, excluding one single data point from the plot as marked by the dot and arrow in panel D.
Figure 4
Figure 4
Receiver operating characteristics (ROC) curve for aldosterone concentrations after saline infusion measured by immunoassay and LC-MS/MS for detection of primary aldosteronism. AUC,area under the curve. P < 0.001 for both ROC curves.
Figure 5
Figure 5
Fold changes (before vs after saline infusion) of steroids measured by LC-MS/MS during saline infusion testing in patients with essential hypertension (EH, n = 84) and primary aldosteronism (PA, n = 103). Dashed line: no change in steroid concentration before vs after saline infusion.
Figure 6
Figure 6
(A) Principal component analysis score plot for separation between primary aldosteronism (PA) and essential hypertension (EH) based on steroid profiles. (B) Partial least square – discriminant analysis score plot for separation between primary aldosteronism (PA) and essential hypertension (EH) based on steroid profiles. (C) Principal component analysis score plot for separation between unilateral (APA) and bilateral (BAH) primary aldosteronism based on steroid profiles. (D) Partial least square – discriminant analysis score plot for separation between unilateral (APA) and bilateral (BAH) primary aldosteronism based on steroid profiles.

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