Hypertension

ORIGINAL ARTICLE

Intraindividual Variability of Aldosterone

Concentrations in Primary Aldosteronism
Implications for Case Detection
Nicholas Yozamp, Gregory L. Hundemer, Marwan Moussa, Jonathan Underhill, Tali Fudim, Barry Sacks, Anand Vaidya

ABSTRACT: Primary aldosteronism is an underdiagnosed cause of hypertension. Although inadequate screening is one reason
for underdiagnosis, another important contributor is that clinicians may inappropriately exclude the diagnosis when screening
aldosterone concentrations fall below traditionally established thresholds. We evaluated the intraindividual variability in
screening aldosterone concentrations and aldosterone-to-renin ratios, and how this variability could impact case detection,
among 51 patients with confirmed primary aldosteronism who had 2 or more screening measurements of renin and aldosterone
on different days. There were a total of 137 screening measurements with a mean of 3 (range 2–6) per patient. The mean
intraindividual variability, expressed as coefficients of variation, was 31% for aldosterone and 45% for the aldosterone-
to-renin ratio. Aldosterone concentrations ranged from 4.9 to 51 ng/dL; 49% of patients had at least one aldosterone
measurement below 15 ng/dL, 29% had at least 2 aldosterone measurements below 15 ng/dL, and 29% had at least one
measurement below 10 ng/dL. Individual aldosterone-to-renin ratios ranged from 8.2 to 427 ng/dL per ng/mL·hour; 57%
had at least one ratio below 30 ng/dL per ng/mL·hour, 27% had at least 2 ratios below 30 ng/dL per ng/mL·hour, and 24%
had at least one ratio below 20 ng/dL per ng/mL·hour. Aldosterone concentrations and aldosterone-to-renin ratios are highly
variable in patients with primary aldosteronism, with many screening values falling below conventionally accepted diagnostic
thresholds. The diagnostic yield for primary aldosteronism may be substantially increased by recalibrating the definition of
a positive screen to include more liberal thresholds for aldosterone and the aldosterone-to-renin ratio. (Hypertension.
2020;77:00-00. DOI: 10.1161/HYPERTENSIONAHA.120.16429.) Data Supplement •
Key Words: aldosterone ◼ angiotensins ◼ diagnosis ◼ plasma ◼ renin

P
rimary aldosteronism is common but largely underdi-
agnosed. The prevalence ranges from 5% to 20% in
patients with hypertension and can exceed 30% in
patients with resistant hypertension.1–11 Correct identifica-
tion and treatment of primary aldosteronism is critical, as
patients with this syndrome have excess cardiovascular
morbidity and mortality compared with patients with essen-
tial hypertension, independent of blood pressure.12–16
See Editorial Commentary, pp XXX–XXX
One major reason for primary aldosteronism under-
diagnosis is that <3% of patients who meet criteria for
primary aldosteronism screening actually undergo testing
for the disorder in the United States,17,18 and <7% to 8%
of eligible patients are screened in Europe.19,20 However,
beyond insufficient screening for primary aldosteronism, a
second major contributor to underdiagnosis is the misin-
terpretation of screening tests, which leads to inappropri-
ate exclusion of the diagnosis. Conventionally, the first step
in making a diagnosis is to demonstrate a positive screen
based on the aldosterone-to-renin ratio (ARR). Commonly
accepted guidelines define a positive screen for primary
aldosteronism as an ARR of ≥30 ng/dL per ng/mL·hour,
with a suppressed renin and plasma aldosterone concen-
tration (PAC) of at least 15 ng/dL.21,22 However, these
thresholds are the focus of considerable debate.

Correspondence to: Anand Vaidya, Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard
Medical School, 221 Longwood Ave, Boston, MA. Email anandvaidya@bwh.harvard.edu
The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/HYPERTENSIONAHA.120.16429.
For Sources of Funding and Disclosures, see page XXX.
© 2020 American Heart Association, Inc.
Hypertension is available at www.ahajournals.org/journal/hyp

Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429 February 2021   1

 Yozamp et al
Novelty and Significance
Original Article
What Is New?
• We analyzed the intraindividual variability of screening
aldosterone concentrations and aldosterone-to-renin
ratios in patients with confirmed primary aldosteronism
to evaluate the potential impact of this variability on
conventional diagnostic approaches.
What Is Relevant?
• Aldosterone concentrations in primary aldosteronism
patients ranged from 4.9 to 51 ng/dL, with 49% of
patients having at least one aldosterone measurement
below 15 ng/dL and 29% having at least one mea-
surement below 10 ng/dL.
• Individual aldosterone-to-renin ratio values ranged
from 8.2 to 427 ng/dL per ng/mL·hour, with 57%
Nonstandard Abbreviations and Acronyms
ACE angiotensin-converting enzyme
ARR aldosterone-to-renin ratio
CV coefficient of variation
PAC plasma aldosterone concentration
PASO Primary Aldosteronism Surgical Outcome
PACs exhibit substantial variability, both in normal subjects
and in patients with primary aldosteronism, which can cre-
ate misleading results for primary aldosteronism screening
when the PAC falls below conventional thresholds required
for a positive screen.23–26 For example, nearly a quarter of
patients with resistant hypertension and primary aldoste-
ronism may have at least one PAC below 10 ng/dL.27,28 To
account for this increasingly recognized aldosterone vari-
ability and to diminish the likelihood of a false-negative test,
more permissive screening recommendations for primary
aldosteronism have been proposed which consider an ARR
≥20 ng/dL per ng/mL·hour with a PAC of at least 10 ng/
dL to constitute a positive screen and warrant a dynamic
confirmatory test.21,29 Some have proposed even more per-
missive criteria wherein any aldosterone >5 or 6 ng/dL in
the context of a suppressed renin may represent a positive
screen worthy of further evaluation.16,21,30–32 This shift from
relying only on the ARR to considering lower thresholds of
aldosterone in the context of a suppressed renin parallels
the use of newer liquid chromatography with tandem mass
spectroscopy (LC-MS/MS) aldosterone assays that report
substantially lower aldosterone values than immunoas-
says33 and reflects the increasing awareness that primary
aldosteronism exists on a spectrum of severity where PAC
and ARR can vary considerably to include levels below the
traditional thresholds for diagnosis.8,16,23–26
2   February 2021 Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Aldosterone Variability in Primary Aldosteronism
having at least one aldosterone-to-renin ratio below
30 ng/dL per ng/mL·hour and 24% having at least
one aldosterone-to-renin ratio below 20 ng/dL per
ng/mL·hour.
Summary
Patients with primary aldosteronism exhibit marked
intraindividual variability of aldosterone concentra-
tions and aldosterone-to-renin ratios, such that many
patients had values below conventionally accepted
screening thresholds. A recalibration of diagnostic
thresholds, and reliance on more than one screening
assessment, could improve the diagnostic yield of pri-
mary aldosteronism case detection.
Herein, we investigated the intraindividual variability of
aldosterone and ARR values among patients with con-
firmed primary aldosteronism to characterize its potential
impact on using traditionally accepted diagnostic thresh-
olds for diagnosis.
METHODS
The data that support the findings of this study are available
and can be requested from the corresponding author.
Study Objectives
The purpose of this study was to characterize the intraindividual
variability in aldosterone concentrations and ARRs over mul-
tiple measurements in patients with confirmed primary aldo-
steronism to assess the implications for real-life ambulatory
diagnostic evaluations for primary aldosteronism.
Study Design and Participants
This was a retrospective study design that only included
patients if:
1. They met conventional Endocrine Society criteria for the
confirmation of primary aldosteronism,21 either via a rec-
ommended dynamic confirmatory test or via a very high
aldosterone (ie, aldosterone concentration ≥20 ng/dL)
in the context of a suppressed renin, hypertension, and
hypokalemia.
2. They had 2 or more paired measurements of aldosterone
and renin, obtained on separate days. The underlying rea-
son for obtaining multiple measurements of aldosterone
and renin varied for each patient and included diagnos-
tic uncertainty after the first measurement and referral
from a primary care physician to a specialist who then
repeated the measurements. All samples were obtained
in the seated position, on an ad libitum diet, at the time of
the ambulatory clinic visit which could have occurred at
any time during the day.
Yozamp et al
3. All renin measurements were suppressed, defined as a
plasma renin activity less than or equal to 1.0 ng/mL·hour.
Patients were excluded from this study if:
1. They did not have confirmed primary aldosteronism based
on Endocrine Society criteria.
2. They had fewer than 2 serial aldosterone and renin
measurements.
3. They had any renin values that were >1.0 ng/mL·hour.
4. They were taking a mineralocorticoid receptor antagonist
or epithelial sodium channel inhibitor at the time of any
aldosterone or renin measurements. The use of all other
antihypertensive medication classes was permitted since
measurement and interpretation of screening aldosterone
and renin while on these medications is convention in
most of the United States. However, to eliminate the intro-
duction of new pharmacological variability on aldosterone
levels, if a patient initiated an ACE (angiotensin-convert-
ing enzyme) inhibitor or angiotensin receptor blocker in
between measurements, all subsequent measurements
were excluded.
A total of 51 patients, seen between 2005 and 2019, met all
of these inclusion criteria and represented the study population.
This study was approved by our institutional ethics and human
research committees.
Measurements
Paired aldosterone and renin measurements were obtained
using one of 3 pairs of assays, listed in the order of decreasing
frequency below:
1. LC-MS/MS assay for aldosterone and LC-MS/MS assay
for plasma renin activity from Mayo Clinic (Rochester,
MN). A total of 31 (61%) patients had values measured
with these assays. The coefficient of variation (CV) for the
aldosterone assay ranged from 8.7% at lower concentra-
tions to 3.9% at higher concentrations; the CV for the
renin assay was 18.8% at low concentrations.
2. Quantitative chemiluminescent immunoassay for aldoste-
rone concentration and ELISA for plasma renin activity
from ARUP Laboratories (Salt Lake City, UT). Fourteen
patients (27%) had values measured with these assays.
The CV for the aldosterone assay ranged from 10% at
lower concentrations to 6% at higher concentrations; the
CV for the renin assay was 15%.
3. LC-MS/MS assay for aldosterone and LC-MS/MS assay
for plasma renin activity from Quest Diagnostics (Chantilly,
VA). Six patients (12%) had values measured with these
assays. The CV for the aldosterone assay ranged from
2.7% to 4.4%; the CV for the renin assay was 11% at low
concentrations.
Analysis Plan and Statistical Methods
We first demonstrated the intraindividual variability in serial
aldosterone and ARR measurements by graphically display-
ing the data. Intraindividual coefficients of variation (defined
as the SD divided by the mean value) and the percent dif-
ference (the highest value in an individual minus the lowest
value, the result of which was divided by the mean value) were
calculated for each patient’s aldosterone and ARR measure-
ments as metrics of intraindividual variability. Subsequently,
we quantified the percentage of patients with single and
Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Aldosterone Variability in Primary Aldosteronism
mean aldosterone levels and single and mean ARR measure-
ments generally considered to be low for the diagnosis of
Original Article
primary aldosteronism using a variety of well-established and
traditional thresholds (<10, 15, and 20 ng/dL for aldoste-
rone; <20, 25, and 30 ng/dL per ng/mL·hour for the ARR).
We then divided patients into tertiles based on their aldoste-
rone and ARR values and assessed for any demographic or
diagnostic differences that could potentially predict underly-
ing reasons for these differences.
We conducted several sensitivity analyses to assess the
reproducibility and robustness of the findings. Most plasma
renin activity assays report only to a lower limit of 0.6 ng/
mL·hour; however, a minority report to 0.1 ng/mL·hour. To
mitigate any effect that the lower limit of the plasma renin
activity assays could have had on the perceived variability of
the ARR, we reanalyzed data in which the minimum plasma
renin activity was set at 0.6 ng/mL·hour. Additionally, since
it is known that aldosterone LC-MS/MS assays tend to be
more precise than immunoassays and report lower values,33
we performed a sensitivity analysis including only patients
who had LC-MS/MS measurements of aldosterone. Finally,
low-serum potassium levels are known to suppress aldoste-
rone secretion, and a minority of patients did not have a con-
comitant serum potassium measured. Thus, we performed
sensitivity analyses using only paired aldosterone and renin
measurements obtained with a concomitant potassium level
and also analyzed the data after eliminating all aldoste-
rone and renin measurements obtained at a time when the
serum potassium was <3.5 MEq/L, as recommended by the
Endocrine Society.21
For continuous variables, differences between 2 groups
were analyzed via Student t test if data were parametric and the
Wilcoxon rank-sum test if data were nonparametric; differences
between tertiles were analyzed using ANOVA with parametric
data and the Kruskal-Wallis test with nonparametric data. The
χ2 test was used to compare categorical variables between 2
or more groups. Analyses were conducted using STATA version
15 (College Station, TX).
RESULTS
Study Population
Basic demographic and diagnostic data of the 51
patients with confirmed primary aldosteronism are dis-
played in Table 1. As expected, the study population was
hypertensive despite the average use of 3 antihyper-
tensive medications, and on average had a low-serum
potassium at the time of the first aldosterone and renin
blood draw. The mean number of paired aldosterone
and renin measurements was 3 (range 2–6 measure-
ments). The mean aldosterone and median ARR val-
ues across all patients were significantly elevated and
consistent with the diagnosis of primary aldosteronism.
The majority of patients had a unilateral adrenal nodule
on imaging and many underwent adrenal venous sam-
pling, in which adrenal vein measurements of cortisol
and aldosterone were obtained in triplicate both before
and after cosyntropin; unstimulated measurements
February 2021   3
 Yozamp et al
Table 1. Patient Demographic and Diagnostic Characteris-
tics
Original Article
Characteristic
Age, y
Male sex, %
Race, %
White
Black
Asian
Unknown/other
BMI, kg/m2
Systolic blood pressure at diagnosis, mm Hg
Diastolic blood pressure at diagnosis, mm Hg
Potassium at diagnosis, MEq/L
No. of blood pressure medications at first aldoste-
rone/renin measurement
No. of aldosterone measurements
Mean aldosterone, ng/dL
Median plasma renin activity, ng/mL·hour
Median ARR, [(ng/dL)/(ng/mL·hour)]
Imaging findings, %
Normal adrenal glands
Unilateral left adrenal nodule
Unilateral right adrenal nodule
Bilateral adrenal nodules
Lateralization at AVS (unstimulated, lateralization index ≥2), %
Bilateral disease
Unilateral disease
Lateralization at AVS (unstimulated, lateralization index ≥4), %
Bilateral disease
Unilateral disease
Treatment, %
Medical therapy
Unilateral adrenalectomy or ablation
ARR indicates aldosterone-to-renin ratio; AVS, adrenal venous sampling; BMI,
body mass index; and IQR, interquartile range.
were used to calculate the lateralization index and
stimulated measurements were used to enhance
selectivity, as previously described.34–38 At adrenal
venous sampling, the majority of patients lateralized
to one side regardless of the unstimulated lateraliza-
tion index threshold used, and most were treated with
a unilateral intervention rather than medical therapy.
Post-treatment outcomes with either medical therapy
or unilateral intervention (ie, surgical adrenalectomy or
radiofrequency ablation) are reported in Table S1 in the
Data Supplement and were no different between treat-
ment groups; clinical outcomes and biochemical out-
comes in the unilateral intervention group were defined
according to the PASO study (Primary Aldosteronism
Surgical Outcome).39
4   February 2021
Aldosterone Variability in Primary Aldosteronism
Intraindividual Variability of Aldosterone and
ARR
Mean (SD) or
Median [IQR] There were a total of 137 paired renin and aldosterone
52 (10) measurements performed on the 51 patients. Although
71
all patients had a confirmed diagnosis of primary aldo-
steronism, individual aldosterone measurements ranged
from a low of 4.9 ng/dL to a high of 51 ng/dL (Fig-
57
ure 1). The mean aldosterone for each individual patient
31
also varied considerably, from a low of 7.3 ng/dL to a
4
high of 37 ng/dL (Figure 1). The mean intraindividual
8 coefficient of variation for aldosterone was 31% (range
32 (6) 0%–81%), at least 3- to 6-fold greater than the variabil-
146 (21) ity of the aldosterone assays, and the mean intraindivid-
88 (11) ual percent difference for aldosterone was 52% (range
3.5 (0.4) 0%–137%). There was no association between imaging
3 (1) findings or lateralization at adrenal venous sampling and
aldosterone variability. Nearly half (49%) of all patients
3 (1) had a single aldosterone level <15 ng/dL, nearly one-
20.3 (7.8) third (29%) had at least 2 aldosterone levels <15 ng/dL,
0.6 [0.3–0.6] and precisely one-third (33%) had the average of all their
47.5 [31.6–77.3]
aldosterone levels <15 ng/dL (Table 2). More striking
was the observation that nearly 30% of patients had at
least one aldosterone concentration <10 ng/dL and 6%
26
of patients had at least 2 aldosterone levels below this
38
permissive threshold (Table 2).
28 ARR values also varied considerably from patient-to-
8 patient, with the 137 single ARR values ranging from a
low of 8.2 ng/dL per ng/mL·hour to a high of 427 ng/
25 dL per ng/mL·hour (Figure 2). The mean ARR for each
75 patient ranged from a low of 11 ng/dL per ng/mL·hour
to a high of 349 ng/dL per ng/mL·hour (Figure 2). The
39
mean intraindividual coefficient of variation for the ARR
61
was 45% (range 0%–123%) and the mean intraindi-
vidual percent difference for the ARR was 79% (range
0%–281%). ARR variability was also not associated
41
with imaging findings or lateralization at adrenal venous
59
sampling. Well over half of patients (57%) had at least
one ARR <30 ng/dL per ng/mL·hour, and over one-
quarter (27%) had at least 2 values below this threshold
(Table 3). Strikingly, 24% of patients had at least one
ARR value, and 8% of patients had at least 2 ARR values
that were <20 ng/dL per ng/mL·hour, which is the most
permissive threshold typically recommended (Table 3).40
Predictors of Variability
When divided into tertiles based on the average aldo-
sterone and ARR levels, and the single lowest aldoste-
rone and ARR levels, there were no clinically significant
attributes that were significantly associated with the
variability in aldosterone or ARR (Tables S2A, S2B,
S3A, and S3B). Although samples were obtained from
early morning until late afternoon, there was no asso-
ciation between the time of day at which the measure-
ments were obtained and either the aldosterone levels
Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Yozamp et al Aldosterone Variability in Primary Aldosteronism

Original Article
Figure 1. Scatterplot of screening aldosterone concentrations.
Individual aldosterone levels (black dots) are displayed directly above each patient on the x axis and arranged in order of the mean aldosterone
concentration for each patient (red dot). All patients had at least 2, or more, aldosterone measurements.

(r=−0.04, P=0.66) or ARR values (r=0.08, P=0.40; Fig-
ure S1A and S1B).
Sensitivity Analyses for Robustness and
Reproducibility
When ARR values were recalculated after fixing the
lower limit of plasma renin activity at 0.6 ng/mL·hour,
the percentage of patients with ARR values below the
predetermined thresholds substantially increased and
the overall ARR variability remained high, although it was
predictably lower than in the original analysis (Table S4).
When restricting analyses to only those measurements
that were obtained using LC-MS/MS assays, the study
population declined from 51 to 37 and the number of
measurements decreased from 137 to 97. Despite this,
the aldosterone and ARR levels below the prespecified
diagnostic thresholds were similar to the original analy-
ses, as was the overall aldosterone and ARR variability
(Table S5A and S5B). When we eliminated all paired
aldosterone and renin measurements obtained without a
concomitant potassium, the number of patients declined
from 51 to 41 and the total number of measurements
decreased to 106, but the findings did not differ from the
original analysis (Table S6A and S6B). When we further
eliminated all potassium values <3.5 MEq/L, the num-
ber of patients decreased from 41 to 19, the number of
individual measurements fell to 45, and the mean potas-
sium was 3.8 MEq/L. In this setting of normokalemia,
the intraindividual variability of both aldosterone and the
ARR increased, while the number of patients below the
prespecified thresholds was higher for aldosterone and
similar for the ARR compared with the original analysis
(Table S7A and S7B).
DISCUSSION
In this study, we characterized the intraindividual vari-
ability of screening diagnostics for primary aldosteron-
ism by demonstrating that a relatively high percentage
of patients with bona fide primary aldosteronism can
have one or more aldosterone and ARR values below

Table 2. Intraindividual Variability of Aldosterone Concentrations in Relation to Conventional Diagnostic

Thresholds

At least one aldosterone, At least 2 aldosterone Mean aldosterone,

ng/dL % of patients levels, ng/dL % of patients ng/dL % of patients
<10 29% <10 6% <10 4%
<15 49% <15 29% <15 33%
<20 69% <20 47% <20 53%

Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429 February 2021   5

 Yozamp et al Aldosterone Variability in Primary Aldosteronism
Original Article

Figure 2. Scatterplot of screening aldosterone-to-renin ratios (ARRs).

Individual ARR values (black dots) are displayed directly above each patient on the x axis and arranged in order of the mean ARR for each
patient (red dot). All patients had at least 2 or more ARR measurements.

commonly accepted diagnostic thresholds. Nearly 30%
of patients with primary aldosteronism had at least
one aldosterone between 5 and 10 ng/dL and 24%
of patients had at least one ARR <20 ng/dL per ng/
mL·hour. Like many similar studies, this study has some
inherent bias since it could only retrospectively include
those patients who were ultimately confirmed to have
primary aldosteronism (rather than the many patients
whose diagnosis was missed due to lack of screening
or misinterpretation of screening); thus, it may be that
our observations represent only a conservative estimate
of the true variability that exists, as has been shown in
prior studies that conducted unbiased confirmatory test-
ing rather than relying on screening aldosterone and
ARR.27,41,42 From a clinical perspective, these findings
highlight the fact that many of these patients with con-
firmed primary aldosteronism may have not been diag-
nosed if their clinicians had relied on just a single, rather
than repeated, screening assessment.
This study extends the findings of several prior studies
demonstrating the limitations of the screening ARR due
to aldosterone variability and provides impetus for recali-
brating the interpretation of screening diagnostics. Siragy
et al24 showed that beyond diurnal variation, aldosterone
concentrations in primary aldosteronism exhibit a burst-
like pulsatility throughout the day, resulting in a range of
aldosterone values that span across a 4-fold magnitude.
Tanabe et al25 previously showed that among patients
with pathologically confirmed primary aldosteronism from
an adrenal adenoma, aldosterone, and ARR measured by
radioimmunoassay were highly variable, such that 63%
of their patients studied did not have consistently typical
profiles for primary aldosteronism (the typical profile was
defined as an ARR >35 ng/dL per ng/mL·hour, PAC>15
ng/dL, and plasma renin activity<0.5 ng/mL·hour). Kline
et al26 and Yozamp et al38 recently demonstrated that
patients with confirmed primary aldosteronism can fre-
quently have aldosterone concentrations at the time of
adrenal venous sampling that are below 5 ng/dL, and that
there exists large variability in adrenal venous aldosterone
concentrations (reflecting acutely variable aldosterone
production), with coefficients of variation for repeated

Table 3. Intraindividual Variability of ARR in Relation to Conventional Diagnostic Thresholds

At least one ARR, (ng/dL per At least 2 ARRs (ng/ Mean ARR, (ng/dL
ng/mL·hour) % of patients dL per ng/mL/h) % of patients per ng/mL·hour) % of patients
<20 24% <20 8% <20 6%
<25 41% <25 16% <25 18%
<30 57% <30 27% <30 20%

ARR indicates aldosterone-to-renin ratio.

6   February 2021 Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429

Yozamp et al
adrenal vein measurements ranging from 30% to 39%.38
Finally, Brown et al27,28 found that nearly 25% of patients
with resistant hypertension who had confirmed primary
aldosteronism had at least one aldosterone concentra-
tion <10 ng/dL. Collectively, these studies highlight the
fallibility of single aldosterone measurements and illus-
trate a need to recalibrate the thresholds for a positive
screen for primary aldosteronism, particularly since newer
LC-MS/MS aldosterone assays report aldosterone con-
centrations that can be 20% lower than immunoassays.33
These studies also underscore the point that a single nor-
mal or low screening aldosterone concentration should
not exclude the possibility of a primary aldosteronism
diagnosis.16
It is often advised that screening for primary aldo-
steronism be conducted after accounting for important
factors that may lower aldosterone and the ARR, includ-
ing hypokalemia, the time of day, characteristics of the
assays (the type of assay for aldosterone and the lower
limit of the renin assay), and antihypertensive medica-
tion classes.21 However, our findings suggest that there
is substantial, and clinically relevant, intraindividual vari-
ability in aldosterone and ARR values regardless of
serum potassium, time of day, type of assay, and even
after the potential effect of major medication interfer-
ence is accounted for. In other words, complex and
laborious efforts to minimize confounders may not be
necessary, and a more practical and simplified screening
approach can be recommended for front-line clinicians
who are responsible for the majority of screening efforts.
In this regard, if public health efforts to increase screen-
ing rates for primary aldosteronism above 3% to 8%17–20
are to be implemented, one approach may be to encour-
age screening for primary aldosteronism regardless of
the conditions, but with modifications of the interpreta-
tion of the results to reflect more liberalized criteria for
a positive screen.
For every chosen threshold for a positive screen for
primary aldosteronism, and approach to conducting
screening, there is a trade-off in the risk for false-positive
versus false-negative results. From a public health per-
spective, the risk of a false-positive result from an overly
sensitive test is an increase in health care expenditures
because of needless or potentially harmful testing. The
risk of a false-negative result from a poorly sensitive test
is untreated morbidity and mortality from the undiag-
nosed condition, which in the case of primary aldosteron-
ism, has targeted therapies. Although further studies are
needed to quantify the health care economics associated
with increased screening, it is likely that the cardiometa-
bolic morbidity and mortality associated with unrecog-
nized primary aldosteronism is far more costly than the
relatively inexpensive changes to screening interpreta-
tion that might identify more cases. Our results suggest
that a recalibration of screening thresholds could sub-
stantially improve the detection of primary aldosteronism
Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Aldosterone Variability in Primary Aldosteronism
cases by minimizing false-negative testing. Emphasis
on inappropriate aldosterone production in the context
Original Article
of suppressed renin, rather than solely on an arbitrarily
elevated ARR, is likely to increase the number of posi-
tive screening tests. Our results suggest that a single
aldosterone or ARR may not be reliable; rather, at least
2, or repeated measurements provide greater sensitiv-
ity. Further, liberalizing the definition of an inappropriate
aldosterone concentration to 5 or 6 ng/dL (measured by
modern LC-MS/MS assays), when renin is suppressed,
should be strongly considered to maximize detection of
true cases, especially when the pretest probability for the
diagnosis is high. Although it is advised that blood draws
be obtained in the morning,21 the time of day should not
preclude testing, and reliable interpretations can still be
made with the aforementioned approach. Although hypo-
kalemia can suppress the secretion of aldosterone and
theoretically lead to a false-negative screening test,30
we found that aldosterone levels were just as variable,
if not more variable, when potassium was replete, with
even more patients falling below conventional thresholds
(Table S7A and S7B). Finally, in resource-poor settings
where screening tests are prohibitively expensive or dif-
ficult to perform but the pretest probability of primary
aldosteronism is high, empirical treatment with a miner-
alocorticoid receptor antagonist is reasonable.16
One potential limitation of this study is the relatively
small sample size, although it is doubtful that the percent-
age of patients with aldosterone and ARR values below
our prespecified cutoffs would drastically change if the
study population were larger. Another limitation is that
we retroactively searched for patients with confirmed pri-
mary aldosteronism who had multiple measurements of
aldosterone and renin. This is likely to have introduced a
bias favoring inclusion of patients with the most severe
disease since many patients with milder primary aldoste-
ronism were likely never diagnosed. A third limitation is
that 3 different assays were used for aldosterone and
renin (2 LC-MS/MS assays each and one immunoas-
say apiece), each with a different intrinsic coefficient
of variation. Nonetheless, the results did not substan-
tively change when only one type of assay (the LC-MS/
MS) was analyzed and the intraindividual coefficients of
variation for aldosterone we observed were substantially
higher than the intrinsic variability of the aldosterone
assays, suggesting an inherent in vivo biological contribu-
tion to the variability we observed. The presence of mul-
tiple assays is also reflective of the real-life experience of
clinicians, in which patients are frequently referred from
other institutions with a different clinical laboratory, and
where results are reported using assays the clinicians are
not always familiar with or knowledgeable about. A fourth
limitation is that most patients were on antihypertensive
medications, as is the practical standard for screening
in most parts of the United States; certain medications,
such as renin-angiotensin-aldosterone system inhibitors
February 2021   7
 Yozamp et al
and calcium channel blockers, have been implicated in
lowering aldosterone production and may have thus con-
Original Article
tributed to the aldosterone and ARR variability observed
in this study. However, we minimized the impact of this
clinical reality by excluding patients on mineralocorti-
coid receptor antagonists or potassium-sparing diuret-
ics and excluding any values obtained after a patient
started an ACE inhibitor or angiotensin receptor blocker,
after which one would expect a decrease in aldosterone
and increase in renin. A fifth limitation is that we did not
directly measure all the many possible intrinsic factors
that may have influenced aldosterone variability, includ-
ing posture-responsiveness,43,44 adrenocorticotropic
hormone-dependence associated with diurnal rhythm
or stress,45–47 and the presence of certain mutations in
genes, such as KCNJ5.48 Yet, it should be noted that all
patients were seated at the time of measurement (thus
controlling for posture), and aldosterone and ARR vari-
ability were no different regardless of the time of day.
Finally, many patient-specific factors, including dietary
sodium/potassium intake, race,49 and sex, may have con-
tributed to our findings, although it is unlikely that any
patients were on a sodium-restricted diet and no mean-
ingful differences in aldosterone and ARR levels by race
and sex were observed.
PERSPECTIVES
There is substantial intraindividual variability in PACs
and ARRs in patients with primary aldosteronism. Sin-
gle, and even multiple, aldosterone and ARR values are
frequently lower than the traditionally recommended
screening diagnostic thresholds for primary aldosteron-
ism and may incorrectly exclude the diagnosis. Given the
high prevalence of primary aldosteronism, the low rates
of diagnosis, and the cardiometabolic morbidity and
mortality associated with untreated disease, these find-
ings suggest that a recalibration towards more permis-
sive screening criteria, and reliance on more than one
screening assessment, could improve detection of more
true cases of primary aldosteronism and decrease false-
negative screening interpretations.
ARTICLE INFORMATION
Received September 30, 2020; accepted October 27, 2020.
Affiliations
From the Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and
Hypertension, Brigham and Women’s Hospital (N.Y., A.V.) and Department of
Radiology, Beth Israel Deaconess Medical Center (M.M., J.U., T.F., B.S.), Harvard
Medical School, Boston, MA; and Division of Nephrology, The Ottawa Hospital,
University of Ottawa, Canada (G.L.H.).
Acknowledgments
We thank the clinical research center staff that assisted with specimen process-
ing and storage.
8   February 2021 Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Aldosterone Variability in Primary Aldosteronism
Sources of Funding
We thank our funding sources for supporting this work: R01 DK115392 (A.
Vaidya), R01 HL153004 (A. Vaidya), R01 DK16618 (A. Vaidya), and 2T32
HL007609-32 (N. Yozamp).
Disclosures
A. Vaidya reports consulting fees unrelated to the contents of this work from
Corcept Therapeutics, CatalysPacific, and HRA Pharma. The other authors report
no conflicts.
REFERENCES
1. Markou A, Pappa T, Kaltsas G, Gouli A, Mitsakis K, Tsounas P, Prevoli A,
Tsiavos V, Papanastasiou L, Zografos G, et al. Evidence of primary aldoste-
ronism in a predominantly female cohort of normotensive individuals: a very
high odds ratio for progression into arterial hypertension. J Clin Endocrinol
Metab. 2013;98:1409–1416. doi: 10.1210/jc.2012-3353
2. Monticone S, Burrello J, Tizzani D, Bertello C, Viola A, Buffolo F, Gabetti L,
Mengozzi G, Williams TA, Rabbia F, et al. Prevalence and clinical manifesta-
tions of primary aldosteronism encountered in primary care practice. J Am
Coll Cardiol. 2017;69:1811–1820. doi: 10.1016/j.jacc.2017.01.052
3. Mosso L, Carvajal C, González A, Barraza A, Avila F, Montero J, Huete A, Gederlini A,
Fardella CE. Primary aldosteronism and hypertensive disease. Hypertension.
2003;42:161–165. doi: 10.1161/01.HYP.0000079505.25750.11
4. Mulatero P, Stowasser M, Loh KC, Fardella CE, Gordon RD, Mosso L,
Gomez-Sanchez CE, Veglio F, Young WF Jr. Increased diagnosis of pri-
mary aldosteronism, including surgically correctable forms, in centers from
five continents. J Clin Endocrinol Metab. 2004;89:1045–1050. doi:
10.1210/jc.2003-031337
5. Omura M, Saito J, Yamaguchi K, Kakuta Y, Nishikawa T. Prospective study
on the prevalence of secondary hypertension among hypertensive patients
visiting a general outpatient clinic in Japan. Hypertens Res. 2004;27:193–
202. doi: 10.1291/hypres.27.193
6. Rossi E, Regolisti G, Negro A, Sani C, Davoli S, Perazzoli F. High preva-
lence of primary aldosteronism using postcaptopril plasma aldosterone to
renin ratio as a screening test among Italian hypertensives. Am J Hypertens.
2002;15(10 pt 1):896–902. doi: 10.1016/s0895-7061(02)02969-2
7. Rossi GP, Bernini G, Caliumi C, Desideri G, Fabris B, Ferri C,
Ganzaroli C, Giacchetti G, Letizia C, Maccario M, et al; PAPY Study Inves-
tigators. A prospective study of the prevalence of primary aldosteronism in
1,125 hypertensive patients. J Am Coll Cardiol. 2006;48:2293–2300. doi:
10.1016/j.jacc.2006.07.059
8. Vaidya A, Mulatero P, Baudrand R, Adler GK. The expanding spectrum
of primary aldosteronism: implications for diagnosis, pathogenesis,
and treatment. Endocr Rev. 2018;39:1057–1088. doi: 10.1210/er.
2018-00139
9. Yozamp N, Vaidya A. The prevalence of primary aldosteronism and evolv-
ing approaches for treatment. Curr Opin Endocr Metab Res. 2019;8:30–39.
doi:10.1016/j.coemr.2019.07.001
10. Calhoun DA, Nishizaka MK, Zaman MA, Thakkar RB, Weissmann
P. Hyperaldosteronism among black and white subjects with resis-
tant hypertension. Hypertension. 2002;40:892–896. doi: 10.1161/01.
hyp.0000040261.30455.b6
11. Calhoun DA, Nishizaka MK, Zaman MA, Harding SM. Aldosterone excretion
among subjects with resistant hypertension and symptoms of sleep apnea.
Chest. 2004;125:112–117. doi: 10.1378/chest.125.1.112
12. Milliez P, Girerd X, Plouin PF, Blacher J, Safar ME, Mourad JJ. Evi-
dence for an increased rate of cardiovascular events in patients with
primary aldosteronism. J Am Coll Cardiol. 2005;45:1243–1248. doi:
10.1016/j.jacc.2005.01.015
13. Monticone S, D’Ascenzo F, Moretti C, Williams TA, Veglio F, Gaita F,
Mulatero P. Cardiovascular events and target organ damage in primary aldo-
steronism compared with essential hypertension: a systematic review
and meta-analysis. Lancet Diabetes Endocrinol. 2018;6:41–50. doi:
10.1016/S2213-8587(17)30319-4
14. Reincke M, Fischer E, Gerum S, Merkle K, Schulz S, Pallauf A,
Quinkler M, Hanslik G, Lang K, Hahner S, et al. Observational study mortality
in treated primary aldosteronism: the German Conn's registry. Hypertension.
2012;60:618–624. doi: 10.1161/HYPERTENSIONAHA.112.197111
15. Hundemer GL, Curhan GC, Yozamp N, Wang M, Vaidya A. Cardiometabolic
outcomes and mortality in medically treated primary aldosteronism: a Ret-
rospective Cohort Study. Lancet Diabetes Endocrinol. 2018;6:51–59. doi:
10.1016/S2213-8587(17)30367-4
Yozamp et al
16. Vaidya A, Carey RM. Evolution of the primary aldosteronism syndrome:
updating the approach. J Clin Endocrinol Metab. 2020;105:dgaa606. doi:
10.1210/clinem/dgaa606
17. Ruhle BC, White MG, Alsafran S, Kaplan EL, Angelos P, Grogan RH. Keep-
ing primary aldosteronism in mind: deficiencies in screening at-risk hyper-
tensives. Surgery. 2019;165:221–227. doi: 10.1016/j.surg.2018.05.085
18. Jaffe G, Gray Z, Krishnan G, Stedman M, Zheng Y, Han J, Chertow GM,
Leppert JT, Bhalla V. Screening rates for primary aldosteronism in resistant
hypertension: a Cohort Study. Hypertens Dallas Tex 1979. 2020;75:650–
659. doi: 10.1161/HYPERTENSIONAHA.119.14359
19. Mulatero P, Monticone S, Burrello J, Veglio F, Williams TA, Funder J. Guidelines
for primary aldosteronism: uptake by primary care physicians in Europe. J
Hypertens. 2016;34:2253–2257. doi: 10.1097/HJH.0000000000001088
20. Reincke M, Beuschlein F, Williams TA. Progress in primary aldosteronism
2019: new players on the block? Horm Metab Res Horm Stoffwechselforsc-
hung Horm Metab. 2020;52:345–346. doi: 10.1055/a-1156-9926
21. Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H,
Stowasser M, Young WF Jr. The management of primary aldosteronism:
case detection, diagnosis, and treatment: an endocrine society clinical
practice guideline. J Clin Endocrinol Metab. 2016;101:1889–1916. doi:
10.1210/jc.2015-4061
22. Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocri-
nol (Oxf). 2007;66:607–618. doi: 10.1111/j.1365-2265.2007.02775.x
23. Vieweg WV, Veldhuis JD, Carey RM. Temporal pattern of renin and aldoste-
rone secretion in men: effects of sodium balance. Am J Physiol. 1992;262(5
pt 2):F871–F877. doi: 10.1152/ajprenal.1992.262.5.F871
24. Siragy HM, Vieweg WV, Pincus S, Veldhuis JD. Increased disorderliness
and amplified basal and pulsatile aldosterone secretion in patients with
primary aldosteronism. J Clin Endocrinol Metab. 1995;80:28–33. doi:
10.1210/jcem.80.1.7829626
25. Tanabe A, Naruse M, Takagi S, Tsuchiya K, Imaki T, Takano K. Variability in
the renin/aldosterone profile under random and standardized sampling con-
ditions in primary aldosteronism. J Clin Endocrinol Metab. 2003;88:2489–
2494. doi: 10.1210/jc.2002-021476
26. Kline GA, Darras P, Leung AA, So B, Chin A, Holmes DT. Surprisingly low
aldosterone levels in peripheral veins following intravenous sedation dur-
ing adrenal vein sampling: implications for the concept of nonsuppress-
ibility in primary aldosteronism. J Hypertens. 2019;37:596–602. doi:
10.1097/HJH.0000000000001905
27. Brown JM, Siddiqui M, Calhoun DA, Carey RM, Hopkins PN, Williams GH,
Vaidya A. The unrecognized prevalence of primary aldosteronism: a cross-
sectional study. Ann Intern Med. 2020;173:10–20. doi: 10.7326/M20-0065
28. Funder JW. Primary aldosteronism: at the tipping point. Ann Intern Med.
2020;173:65–66. doi: 10.7326/M20-1758
29. Byrd JB, Turcu AF, Auchus RJ. Primary aldosteronism: practical approach
to diagnosis and management. Circulation. 2018;138:823–835. doi:
10.1161/CIRCULATIONAHA.118.033597
30. Stowasser M, Ahmed AH, Pimenta E, Taylor PJ, Gordon RD. Factors affect-
ing the aldosterone/renin ratio. Horm Metab Res. 2012;44:170–176. doi:
10.1055/s-0031-1295460
31. Gordon RD, Stowasser M, Klemm SA, Tunny TJ. Primary aldosteronism and
other forms of mineralocorticoid hypertension. In: Swales JD, ed. Textbook
of Hypertension. London, UK: Blackwell Scientific; 1994:865–892.
32. Rossi GP, Gioco F, Fassina A, Gomez-Sanchez CE. Normoaldosterone-
mic aldosterone-producing adenoma: immunochemical characteriza-
tion and diagnostic implications. J Hypertens. 2015;33:2546–2549. doi:
10.1097/HJH.0000000000000748
33. Thuzar M, Young K, Ahmed AH, Ward G, Wolley M, Guo Z, Gordon RD,
McWhinney BC, Ungerer JP, Stowasser M. Diagnosis of primary aldoste-
ronism by seated saline suppression test-variability between immunoas-
say and HPLC-MS/MS. J Clin Endocrinol Metab. 2020;105:dgz150. doi:
10.1210/clinem/dgz150
34. Yatabe M, Bokuda K, Yamashita K, Morimoto S, Yatabe J, Seki Y,
Watanabe D, Morita S, Sakai S, Ichihara A. Cosyntropin stimulation in adre-
nal vein sampling improves the judgment of successful adrenal vein cathe-
terization and outcome prediction for primary aldosteronism. Hypertens Res.
2020;43:1105–1112. doi: 10.1038/s41440-020-0445-x
Hypertension. 2021;77:00–00. DOI: 10.1161/HYPERTENSIONAHA.120.16429
Aldosterone Variability in Primary Aldosteronism
35. Rossitto G, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimsky J,
Naruse M, Deinum J, Schultzekool L, et al. Subtyping of primary aldosteron-
ism in the AVIS-2 Study: assessment of selectivity and lateralization. J Clin
Original Article
Endocrinol Metab. 2020;105:dgz017. doi: 10.1210/clinem/dgz017
36. St-Jean M, Bourdeau I, Therasse É, Lacroix A. Use of peripheral plasma
aldosterone concentration and response to ACTH during simultaneous
bilateral adrenal veins sampling to predict the source of aldosterone secre-
tion in primary aldosteronism. Clin Endocrinol (Oxf). 2020;92:187–195. doi:
10.1111/cen.14137
37. Wannachalee T, Zhao L, Nanba K, Nanba AT, Shields JJ, Rainey WE,
Auchus RJ, Turcu AF. Three discrete patterns of primary aldosteron-
ism lateralization in response to cosyntropin during adrenal vein sam-
pling. J Clin Endocrinol Metab. 2019;104:5867–5876. doi: 10.1210/jc.
2019-01182
38. Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A.
Variability of aldosterone measurements during adrenal venous sampling for
primary aldosteronism. Am J Hypertens. 2020; doi:10.1093/ajh/hpaa151
39. Williams TA, Lenders JW, Mulatero P, Burrello J, Rottenkolber M,
Adolf C, Satoh F, Amar L, Quinkler M, Deinum J, et al. Outcome of adre-
nalectomy for unilateral primary aldosteronism: international consensus
and remission rates. Lancet Diabetes Endocrinol. 2017;5:689–699. doi:
10.1016/S2213-8587(17)30135-3
40. Baudrand R, Guarda FJ, Torrey J, Williams G, Vaidya A. Dietary sodium
restriction increases the risk of misinterpreting mild cases of primary
aldosteronism. J Clin Endocrinol Metab. 2016;101:3989–3996. doi:
10.1210/jc.2016-1963
41. Parasiliti-Caprino M, Lopez C, Prencipe N, Lucatello B, Settanni F, Giraudo G,
Rossato D, Mengozzi G, Ghigo E, Benso A, et al. Prevalence of primary aldo-
steronism and association with cardiovascular complications in patients with
resistant and refractory hypertension. J Hypertens. 2020;38:1841–1848.
doi: 10.1097/HJH.0000000000002441
42. Tsiavos V, Markou A, Papanastasiou L, Kounadi T, Androulakis II,
Voulgaris N, Zachaki A, Kassi E, Kaltsas G, Chrousos GP, et al. A new
highly sensitive and specific overnight combined screening and diagnostic
test for primary aldosteronism. Eur J Endocrinol. 2016;175:21–28. doi:
10.1530/EJE-16-0003
43. Tunny TJ, Klemm SA, Stowasser M, Gordon RD. Angiotensin-responsive
aldosterone-producing adenomas: postoperative disappearance of aldoste-
rone response to angiotensin. Clin Exp Pharmacol Physiol. 1993;20:306–
309. doi: 10.1111/j.1440-1681.1993.tb01690.x
44. Guo Z, Nanba K, Udager A, McWhinney BC, Ungerer JPJ, Wolley M,
Thuzar M, Gordon RD, Rainey WE, Stowasser M. Biochemical, histopath-
ological and genetic characterization of posture responsive and unre-
sponsive APAs. J Clin Endocrinol Metab. 2020;105:e3224–e3235. doi:
10.1210/clinem/dgaa367
45. Daimon M, Kamba A, Murakami H, Takahashi K, Otaka H, Makita K,
Yanagimachi M, Terui K, Kageyama K, Nigawara T, et al. Association between
pituitary-adrenal axis dominance over the renin-angiotensin-aldosterone
system and hypertension. J Clin Endocrinol Metab. 2016;101:889–897. doi:
10.1210/jc.2015-3568
46. El Ghorayeb N, Bourdeau I, Lacroix A. Role of ACTH and other hormones
in the regulation of aldosterone production in primary aldosteronism. Front
Endocrinol (Lausanne). 2016;7:72. doi: 10.3389/fendo.2016.00072
47. Markou A, Sertedaki A, Kaltsas G, Androulakis II, Marakaki C, Pappa T,
Gouli A, Papanastasiou L, Fountoulakis S, Zacharoulis A, et al. Stress-induced
aldosterone hyper-secretion in a substantial subset of patients with essen-
tial hypertension. J Clin Endocrinol Metab. 2015;100:2857–2864. doi:
10.1210/jc.2015-1268
48. Eisenhofer G, Durán C, Cannistraci CV, Peitzsch M, Williams TA, Riester A,
Burrello J, Buffolo F, Prejbisz A, Beuschlein F, et al. Use of steroid profiling
combined with machine learning for identification and subtype classifica-
tion in primary aldosteronism. JAMA Netw Open. 2020;3:e2016209. doi:
10.1001/jamanetworkopen.2020.16209
49. Tu W, Eckert GJ, Hannon TS, Liu H, Pratt LM, Wagner MA, Dimeglio LA,
Jung J, Pratt JH. Racial differences in sensitivity of blood pressure to aldo-
sterone. Hypertens Dallas Tex 1979. 2014;63:1212–1218. doi: 10.1161/
HYPERTENSIONAHA.113.02989
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