A 34-year-old woman presents with hypertension, hypokalemia, and suppressed plasma renin activity. CT abdomen reveals a 1.8 cm left adrenal nodule. Aldosterone-to-renin ratio (ARR) is 40 (ng/dL)/(ng/mL/h). Which confirmatory test is recommended by Endocrine Society guidelines before proceeding to adrenal vein sampling?
- A Any of the above; choice depends on local expertise and contraindications ✓
- B Saline infusion test (2L IV NaCl over 4 hours)
- C Captopril challenge test
- D Fludrocortisone suppression test
Correct answer: A. Any of the above; choice depends on local expertise and contraindications
Explanation
The 2016 Endocrine Society Clinical Practice Guideline on primary aldosteronism recommends confirmatory testing with any one of four tests: oral sodium loading, saline infusion, fludrocortisone suppression, or captopril challenge. No single test is mandated; the choice depends on local expertise, cost, patient factors, and contraindications (e.g., saline infusion is avoided in severe hypertension or heart failure). Following confirmation, adrenal vein sampling distinguishes unilateral from bilateral disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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