https://orcid.org/0009-0000-8560-9920
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Sybille Fuld, Georgiana Constantinescu, Jacques Lenders, Letter to the Editor From Fuld et al: “Performance of Aldosterone-to-renin Ratio Before Washout of Antihypertensive Drugs in Screening of Primary Aldosteronism”, The Journal of Clinical Endocrinology & Metabolism, Volume 110, Issue 5, May 2025, Pages e1698–e1699, https://doi.org/10.1210/clinem/dgaf139
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Dear Editor,
In the recent report by Liu et al (1) directed at screening patients for primary aldosteronism (PA), it was concluded that washout of antihypertensive drugs can be omitted if the aldosterone:renin ratio (ARR) is ≤ 0.7 (ng/dL)/(µIU/mL). Several aspects of this study require closer scrutiny as some critical issues limit applicability of the findings in clinical practice.
One potential source of bias is the imbalance between the groups with 1 (n = 12 475; 89%) vs 2 ARR measurements (n = 1540; 11%), of which only the latter group was included in this study. This represents selection bias. After further exclusion of 234 patients, the authors retrospectively classified the remaining 1306 patients into 215 and 1091 patients in whom PA was respectively confirmed and excluded. In the majority of patients, PA was excluded based on an ARR of <2.4 (ng/dL)/(µIU/mL) after washout without further confirmatory tests (n = 858). Use of this relatively high ARR cutoff for the exclusion of PA without consideration of possible false-negative ARR results might lead to an overestimation of sensitivity at those cutoffs due to confirmation bias. In many European clinics, lower cutoffs for the ARR are used to ensure sufficient sensitivity. An ARR cutoff of 30 pmol/mIU, equivalent to 1.08 (ng/dL)/(µIU/mL), has been found necessary to achieve a sensitivity of 95% (2).
