立位醛固酮肾素比值联合立位醛固酮对老年原发性醛固酮增多症的诊断价值

The Value of Upright Aldosterone-renin Ratio Combined with Upright Aldosterone in Diagnosing Primary Aldosteronism of the Elderly

中文关键词: 老年  原发性醛固酮增多症  醛固酮肾素比值  血浆醛固酮浓度

英文关键词: elderly  primary aldosteronism  aldosterone-renin ratio  plasma aldosterone concentration

中文摘要:

      目的 探讨适合住院老年原发性醛固酮增多症(primary a1dosteronism,PA)患者的诊断方法.方法 2005年1月-2016年1月,复旦大学附属华东医院收治住院的30例60～75岁临床表现、实验室检查及辅助检查明确诊断为PA的患者为老年PA组,同时收集53例60～78岁的经实验室检查、辅助检查及功能试验检查结果排除PA,确诊为原发性高血压(essential hypertension,EH)的患者为老年EH组.住院期间进行病史采集及常规生化、血浆肾素活性、血醛固酮、血尿同步电解质、肾上腺CT和生理盐水抑制试验等检查.利用血醛固酮肾素比值(aldosterone-renin ratio,ARR)绘制受试者工作特征曲线(ROC),取得最佳筛查切点,结合立位醛固酮绝对值来进一步诊断.结果 卧位ARR ROC曲线下面积为0.867(0.788 ～0.947),立位ARR ROC曲线下面积为0.864(0.788 ～0.941),2曲线下面积比较差异无统计学意义.ARR切点定在300 ng/L:ng/mL/h时,立位、卧位ARR的敏感性相似,但特异性立位高于卧位,立位ARR300 ng/L:ng/mL/h诊断PA患者的敏感性为93.3％,特异性为62.3％.在28例(93.3％)立位ARR＞ 300 ng/L:ng/mL/h的老年PA患者中,27例(96.4％)患者的立位醛固酮＞150ng/L,21例(75％)患者的立位醛固酮＞250ng/L;在21例(39.6％)立位ARR＞300 ng/L:ng/mL/h的老年EH患者中,11例(52.3％)患者的立位醛固酮＞150 ng/L,1例(4.8％)患者的立位醛固酮＞ 250 ng/L,老年PA患者立位醛固酮＞250 ng/L比例显著高于老年EH患者,2组比较差异有统计学意义(P＜0.01).对49例ARR＞ 300 ng/L:ng/mL/h的患者以立位醛固酮水平绘制相关ROC曲线,立位醛固酮曲线下面积为0.888(0.793 ～0.982),当立位醛固酮切点定为150 ng/L时,敏感性为96.4％,特异性为42.9％,切点定为250 ng/L时,敏感性为64.3％,特异性为95.2％.结论 立位ARR300ng/L:ng/mL/h适合作为老年PA的筛查切点,同时可结合立位醛固酮＞ 150 ng/L来决定是否进行确诊试验.对行确诊试验有禁忌的老年患者,建议可同时结合立位醛固酮绝对值大于250 ng/L来初步诊断.

英文摘要:

      Objective To explore the proper method of diagnosing primary aldosteronism (PA) in the hospitalized elderly.Methods 30 hospitalized elderly in Huadong Hospital,during the period from Jan.,2005 to Jan.,2016,with definite diagnosis of PA confirmed by clinical manifestations,lab tests and auxiliary examinations,aged from 60 to 75,were selected (PA group) while 53 elderly with no PA confirmed by lab tests,auxiliary examinations and function tests but with essential hypertension (EH) of confirmed diagnosis were selected as well (EH group);case history of the elderly were collected and tests of routine biochemistry,plasma renin activity,plasma aldosterone,blood/urine electrolyte,adrenal CT and saline infusion were made to the elderly in both groups;aldosterone-renin ratio (ARR) was applied in making ROC curve to find out the best cut-off point for PA diagnosis and upright aldosterone levels were combined in further diagnosis.Results The area under the curve (AUCROC) of the supine ARR was 0.867 (0.826-0.908) while that of the upright ARR was 0.864 (0.825-0.903),the difference between the two was of no statistical significance;the sensitivity of supine and upright ARR was similar while the specificity was higher in upright ARR than in supine ARR;the cut-off point with ARR level of 300 ng/L:ng/mL/h was of a sensitivity of 93.3 ％ and a specificity of 62.3 ％ in diagnosing PA;among the 28 PA elderly with upright ARR ＞300 ng/L:ng/mL/h,27 elderly (96.4％) were with upright aldosterone ＞ 150 ng/L and 21 elderly (75％) with upright aldosterone ＞ 250 ng/L;among the 21 EH elderly with upright ARR ＞ 300 ng/L:ng/mL/h,11 elderly (52.3) were with upright aldosterone ＞ 150 ng/L and 1 elderly (4.8％) with upright aldosterone ＞250 ng/L,the proportion of upright aldosterone ＞ 150 ng/L in PA elderly was obviously higher than that in EH elderly and the difference was of statistical significance (P＜ 0.01);when the upright aldosterone levels of 49 elderly with ARR ＞ 300 ng/L:ng/mL/h were applied in making ROC curves,the area under the curve (AUCROC) was 0.888 (0.793-0.982);the cut-off point with aldosterone level of 150 ng/L was of a sensitivity of 96.4％ and a specificity of 42.9％ in diagnosing PA while that of aldosterone level of 250 ng/L was of sensitivity of 64.3％ and a specificity of 95.2％.ConclusionThe upright ARR of 300 ng/L:ng/mL/h can be the cut-off point of elderly PA screening and the upright aldosterone＞ 150 ng/L can be combined with for confirmatory tests or not;for those elderly unfit for confirmatory tests,the upright aldosterone ＞250 ng/L can be combined with in primary diagnosis.