Hyperaldosteronism

Definition

Renin is an enzyme released by the kidney to help control the body's sodium-potassium balance, fluid volume, and blood pressure.

Purpose

Plasma renin activity (PRA), also called plasma renin assay, may be used to screen for high blood pressure (hypertension) of kidney origin, and may help plan treatment of essential hypertension, a genetic disease often aggravated by excess sodium intake. PRA is also used to further evaluate a diagnosis of excess aldosterone, a hormone secreted by the adrenal cortex, in a condition called Conn's syndrome.

Precautions

Patients taking diuretics, antihypertensives, vasodilators, oral contraceptives, and licorice should discontinue use of these substances for two to four weeks before the test. It should be noted that renin is increased in pregnancy and in diets with reduced salt intake. Also, since renin is affected by body position, as well as by diurnal (daily) variation, blood samples should be drawn in the morning, and the position of the patient (sitting or lying down) should be noted.

Description

When the kidneys release the enzyme renin in response to certain conditions (high blood potassium, low blood sodium, decreased blood volume), it is the first step in what is called the renin-angiotensin-aldosterone cycle. This cycle includes the conversion of angiotensinogen to angiotensin I, which in turn is converted to angiotensin II, in the lung. Angiotensin II is a powerful blood vessel constrictor, and its action stimulates the release of aldosterone from an area of the adrenal glands called the adrenal cortex. Together, angiotensin and aldosterone increase the blood volume, the blood pressure, and the blood sodium to re-establish the body's sodium-potassium and fluid volume balance. Primary aldosteronism, the symptoms of which include hypertension and low blood potassium (hypokalemia), is considered "low-renin aldosteronism."

Renin itself is not actually measured in the PRA test, because renin can be measured only with great difficulty even in research laboratories. In the most commonly used renin assay, the test actually determines, by a procedure called radioimmunoassay, the rate of angiotensin I generation per unit time, while the PRC (plasma renin concentration) measures the maximum renin effect.

Both the PRA and the PRC are extremely difficult to perform. Not only is renin itself unstable, but the patient's body position and the time of day affect the results. Also, the sample must be collected properly: drawn into a chilled syringe and collection tube, placed on ice, and sent to the performing laboratory immediately. Even if all these procedures are followed, results can vary significantly.

A determination of the PRA and a measurement of the plasma aldosterone level are used in the differential diagnosis of primary and secondary hyperaldosteronism. Patients with primary hyperaldosteronism (caused by an adrenal tumor that overproduces aldosterone) will have an increased aldosterone level with decreased renin activity. Conversely, patients with secondary hyperaldosteronism (caused by certain types of kidney disease) will have increased levels of renin.

Renin stimulation test

The renin stimulation test is performed to help diagnose and distinguish the two forms of hyperaldosteronism. With the patient having been on a low- salt diet and lying down for the test, a blood sample for PRA is obtained. The PRA is repeated with the patient still on the low-salt diet but now standing upright. In cases of primary hyperaldosteronism, the blood volume is greatly expanded, and a change in position or reduced salt intake does not result in decreased kidney blood flow or decreased blood sodium. As a result, renin levels do not increase. However, in secondary hyperaldosteronism, blood sodium levels decrease with a lowered salt intake, and when the patient is standing upright, the kidney blood flow decreases as well. Consequently, renin levels do increase.

Captopril test

The captopril test is a screening test for hypertension of kidney origin (renovascular hypertension). For this test, a baseline PRA test is done first, then the patient receives an oral dose of captopril, which is an angiotensin-converting enzyme (ACE) inhibitor. Blood pressure measurements are taken at this time and again at 60 minutes when another PRA test is done. Patients with kidney-based hypertension demonstrate greater falls in blood pressure and increases in PRA after captopril administration than do those with essential hypertension. Consequently, the captopril test is an excellent screening procedure to determine the need for a more invasive radiographic evaluation such as renal arteriography.

Preparation

This test requires a blood sample. For the PRA, the patient should maintain a normal diet with a restricted amount of sodium (approximately 3 g per day) for three days before the test. It is recommended that the patient be fasting (nothing to eat or drink) from midnight the day of the test.

Risks

Risks for this test are minimal, but may include slight bleeding from the puncture site, fainting or feeling lightheaded after venipuncture, or hematoma (blood accumulating under the puncture site).

Normal results

Reference values for the PRA test are laboratory-specific and depend upon the kind of diet (sodium restricted or normal), the age of the patient, and the patient's posture at the time of the test. Values are also affected if renin has been stimulated or if the patient has received an ACE inhibitor, like captopril.

Abnormal results

Increased PRA levels are seen in essential hypertension (uncommon), malignant hypertension, and kidney-based (renovascular) hypertension. Renin-producing renal tumors, while rare, can also cause elevated levels, as can cirrhosis, low blood volume due to hemorrhage, and diminished adrenal function (Addison's disease). Decreased renin levels may indicate increased blood volume due to a high-sodium diet, salt-retaining steroids, primary aldosteronism, licorice ingestion syndrome, or essential hypertension with low renin levels.

Key Terms

Aldosteronism

A disorder caused by excessive production of the hormone aldosterone, which is produced by a part of the adrenal glands called the adrenal cortex. Causes include a tumor of the adrenal gland (Conn's syndrome), or a disorder reducing the blood flow through the kidney. This leads to overproduction of renin and angiotensin, and in turn causes excessive aldosterone production. Symptoms include hypertension, impaired kidney function, thirst and muscle weakness.

Conn's syndrome

A disorder caused by excessive aldosterone secretion by a benign tumor of one of the adrenal glands. This results in malfunction of the body's salt and water balance and subsequently causes hypertension. Symptoms include thirst, muscle weakness, and excessive urination.

Further Reading

For Your Information

Books

• Cahill, Mathew. Handbook of Diagnostic Tests. Springhouse Corporation, 1995.
• Jacobs, David S. Laboratory Test Handbook, Fourth Edition. Hudson, OH: Lexi-Comp Inc., 1996.
• Pagana, Kathleen Deska. Mosby's Manual of Diagnostic and Laboratory Tests. St. Louis, MO: Mosby, Inc., 1998.

Gale Encyclopedia of Medicine. Gale Research, 1999.