Stable Serum Potassium After Intracerebral Hemorrhage Is Predictive of Primary Aldosteronism
Stable Serum Potassium After Intracerebral Hemorrhage Is Predictive of Primary Aldosteronism
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DOI：
10.1210/jendso/bvab048.607
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发表时间：
2021-05-03
影响因子：
4.1
通讯作者：
Oya S
中科院分区：
文献类型：
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作者：
Arai M;Kiko K;Oya S
背景：原发性醛固酮增多症（PA）是包括脑出血（ICH）在内的心血管并发症的一个众所周知的危险因素。尽管如此，似乎有许多PA患者甚至在中风后也错过了PA诊断的机会。然而，在所有中风患者中进行PA筛查测试是低效的。在这里，我们专注于ICH，其中高血压有很大的贡献，并寻找在ICH患者中进行PA筛查试验的适应症。研究方法：1）在2016年6月至2017年2月期间我院收治的181例ICH患者中，126例高血压ICH患者入组本研究。于入院后第2天清晨测定血浆醛固酮浓度（PAC）、血浆肾素活性（PRA）等激素水平。2)结果：1）排除入院时服用过可干预PAC或PRA的药物的患者后，9例患者PA筛查阳性（PAC/PRA比值>200，PAC >120 pg/mL），46例为阴性。两组之间的年龄（68.6 vs 67.1岁）、性别（男性66.7 vs 67.3%）和血压（172/97 vs 177/100 mmHg）相似。阳性组入院时血清钾稍低（3.6 vs 3.9 mmol/L; P=0.108），两天后差异更明显（3.7 vs 4.0 mmol/L; P=0.042）。第2天皮质醇和儿茶酚胺等其他激素无差异。PA阳性患者有更严重的运动或认知障碍（功能独立性测量58比95; P=0.015）。2)在收集了1,242例高血压脑出血患者的25项临床参数后，使用t-SNE的降维程序确实将这些患者分为与PA筛选试验相容的聚类。PA阳性组入院时血钾低于3.5mmol/L者仅占4%（敏感性97%），且PA阳性组入院后2天内血钾升高较轻（P=0.001）。讨论：这是迄今为止调查ICH患者PA临床特征的最大规模研究。我们发现，在脑出血发作后血清钾的过渡性变化是决定谁应该继续PA筛查试验的有效标志物。脑出血后交感神经活动增强，继而引起肾素分泌增加，导致低血钾，即使PA阴性组也是如此。PA阴性组血清钾浓度在2天左右达到峰值，PA阳性组由于醛固酮的组成性分泌，血清钾浓度基本稳定。由于伴有PA的ICH患者复发性出血和其他并发症的风险较高，因此即使在ICH发生后，PA的诊断也很重要。PA筛查不应仅仅因为他们发生了ICH而等待。
Background: Primary aldosteronism (PA) is a well-known risk factor for cardiovascular complications including intracerebral hemorrhage (ICH). Still, there seem to be many PA patients who have been missing the opportunities for the diagnosis of PA even after stroke. PA screening tests in all stroke patients are, however, inefficient. Here we focused on ICH, where hypertension has a great contribution, and searched for the indications of performing PA screening tests in ICH patients. Methods: 1) Out of 181 ICH patients admitted to our hospital between June 2016 and February 2017, 126 patients of hypertensive ICH were enrolled in this study. Plasma aldosterone concentration (PAC), plasma renin activity (PRA) and other hormones were measured in the morning two days after admission. 2) 1,242 hypertensive ICH patients admitted to our hospital after January 2013 were retrospectively reviewed Results: 1) After excluding those who had been taking medications which could intervene with PAC or PRA on admission, nine patients were positive for PA screening (PAC/PRA ratio >200 and PAC >120 pg/mL) and 46 were negative. Age (68.6 vs 67.1 y), sex (male 66.7 vs 67.3 %) and blood pressure (172/97 vs 177/100 mmHg) were similar between these two groups. Serum potassium was slightly lower in positive group on admission (3.6 vs 3.9 mmol/L; P=0.108), and the difference became more evident two days later (3.7 vs 4.0 mmol/L; P=0.042). There were no differences in other hormones including cortisol and catecholamine on day 2. PA positive patients had more severe motor or cognitive impairments (Functional independence measure 58 vs 95; P=0.015). 2) After collecting 25 clinical parameters in 1,242 hypertensive ICH patients, dimension reduction procedure using t-SNE certainly divided these patients into clusters compatible with PA screening tests. Only 4% of PA positive group showed serum potassium lower than 3.5 mmol/L on admission (sensitivity 97%), and the increase in serum potassium during the first 2 days were milder in PA positive group (P=0.001). Discussion: This is the largest study ever that investigated the clinical features of PA in ICH patients. We uncovered that transitional changes of serum potassium after the onset of ICH were efficient markers to decide who should go on to PA screening tests. ICH increases sympathetic activity and subsequent renin secretion, resulting in low serum potassium even in PA negative group. But about two days later, when its activity peaked out, serum potassium in PA negative group restores to their original states while that in PA positive group are stable due to constitutive secretion of aldosterone. Since ICH patients with PA are at higher risk for recurrent hemorrhage and other complications, diagnosis of PA is important even after the occurrence of ICH. PA screening should not be awaited just because they have developed ICH.