European journal of internal medicine · 2026
Low-renin hypertension in incidental adrenal adenomas and response to aldosterone-targeted therapy: a prospective study.
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Uslar Thomas, Sanfuentes Benjamín, Olmos Roberto, Burnier Alberth, Böhm Pauline, Guarda Francisco J, Huete Álvaro, Mertens Nicolás, Besa Cecilia, Andía Marcelo, Majerson Alejandro, Cartes Jaime, Tapia Alejandra, Carvajal Cristian A, Fardella Carlos E, Allende Fidel, Solari Sandra, Vaidya Anand, Baudrand Rene
Аннотация
BACKGROUND: Incidental adrenal adenomas are common, yet renin status is infrequently assessed in hypertensive patients. Emerging evidence supports a spectrum of renin-independent aldosterone excess associated with adverse cardiovascular risk.
OBJECTIVE AND METHODS: To determine the frequency of a low-renin phenotype in a prospective cohort of hypertensive patients with adrenal adenomas and to evaluate the clinical response to aldosterone-targeted therapy across baseline aldosterone categories. Low-renin phenotype was defined as suppressed renin (PRA <1.0 ng/mL/h or DRC <10 µIU/mL). Among these patients, plasma aldosterone concentration (PAC) was categorized as 5-10 ng/dL (Group 1), 10-15 ng/dL (Group 2), and >15 ng/dL (Group 3). Patients with suppressed renin were treated with MR antagonists or adrenalectomy and followed longitudinally using PAMO/PASO criteria.
RESULTS: Low renin was present in 47% (138/290) of hypertensive patients. Increasing aldosterone levels were associated with higher systolic blood pressure (SBP), resistant hypertension, higher antihypertensive treatment burden, lower potassium, and reduced eGFR (p-trend <0.001). After a mean follow-up of 24±18 months (n = 121), aldosterone-targeted therapy (75% medical, 25% surgical) led to significant reductions in SBP (-18, -26, and -30 mmHg across Groups 1-3; all p < 0.001), decreased medication and significant increases in renin (all p < 0.001), irrespective of aldosterone category.
CONCLUSIONS: Nearly half of hypertensive patients with adrenal incidentalomas exhibit suppressed renin levels associated with greater blood pressure burden and favorable response to aldosterone-targeted therapy, even in lower aldosterone levels categories. These findings support systematic renin assessment in hypertensive patients with incidental adrenal adenomas and provide a rationale for testing aldosterone-targeted therapy in broader hypertensive populations beyond adrenal adenomas.
OBJECTIVE AND METHODS: To determine the frequency of a low-renin phenotype in a prospective cohort of hypertensive patients with adrenal adenomas and to evaluate the clinical response to aldosterone-targeted therapy across baseline aldosterone categories. Low-renin phenotype was defined as suppressed renin (PRA <1.0 ng/mL/h or DRC <10 µIU/mL). Among these patients, plasma aldosterone concentration (PAC) was categorized as 5-10 ng/dL (Group 1), 10-15 ng/dL (Group 2), and >15 ng/dL (Group 3). Patients with suppressed renin were treated with MR antagonists or adrenalectomy and followed longitudinally using PAMO/PASO criteria.
RESULTS: Low renin was present in 47% (138/290) of hypertensive patients. Increasing aldosterone levels were associated with higher systolic blood pressure (SBP), resistant hypertension, higher antihypertensive treatment burden, lower potassium, and reduced eGFR (p-trend <0.001). After a mean follow-up of 24±18 months (n = 121), aldosterone-targeted therapy (75% medical, 25% surgical) led to significant reductions in SBP (-18, -26, and -30 mmHg across Groups 1-3; all p < 0.001), decreased medication and significant increases in renin (all p < 0.001), irrespective of aldosterone category.
CONCLUSIONS: Nearly half of hypertensive patients with adrenal incidentalomas exhibit suppressed renin levels associated with greater blood pressure burden and favorable response to aldosterone-targeted therapy, even in lower aldosterone levels categories. These findings support systematic renin assessment in hypertensive patients with incidental adrenal adenomas and provide a rationale for testing aldosterone-targeted therapy in broader hypertensive populations beyond adrenal adenomas.