摘要
目的 探讨卡托普利试验（CCT）在原发性醛固酮增多症（PA）诊断中的意义。方法 分析2000—2015年在北京协和医院内分泌科诊治的高血压患者674例的临床资料。674例患者的年龄（45.0±13.7）岁，男341例，女333例，其中原发性高血压222例、嗜铬细胞瘤28例、特发性醛固酮增多症246例及醛固酮分泌瘤178例。所有受试对象均行CCT，部分患者并在试验前日留取24 h尿钠。结果 PA组在CCT前后的血浆肾素活性[PRA, 0.1（0.1，0.2） μg·L－1·h－1、0.1（0.1，0.2） μg·L－1·h－1]显著低于原发性高血压组[0.5（0.2，0.9）μg·L－1·h－1、0.8（0.4，1.5）μg·L－1·h－1]和嗜铬细胞瘤组[0.3（0.1，0.9）μg·L－1·h－1、0.4（0.1，1.6）μg·L－1·h－1]，CCT前后血浆醛固酮水平[（468±216） pmol/L、（457±199）pmol/L]及醛固酮肾素比值[ARR，129（75，212）、106（63，176）]显著高于原发性高血压组[（393±122） pmol/L、（360±97） pmol/L及30（15，67）、17（8，30）]和嗜铬细胞瘤组[（396±108） pmol/L、（374±114） pmol/L及56（14，140）、31（7，106）]，CCT后的醛固酮下降率[2.8%（－8.8%，15.4%）]和血浆肾素活性上升率[0（0，50%）]明显低于原发性高血压组[6.6%（－4.3%，17.6%）和50%（0，200%）]。原发性高血压组坐位CCT前后的醛固酮水平均高于卧位，但服药后ARR无明显变化。PA患者坐位CCT前后的醛固酮水平及服药后的ARR均无明显变化。与高尿钠组对比，正常尿钠组醛固酮分泌瘤、特发性醛固酮增多症和原发性高血压组CCT前后血浆醛固酮水平和PRA差异无统计学意义，但高尿钠组原发性高血压患者CCT后的ARR有低于正常尿钠组的趋势。血管紧张素Ⅱ（AngⅡ）有反应组醛固酮分泌瘤在CCT前血浆醛固酮水平和CCT后的ARR均低于AngⅡ无反应组。CCT后的ARR水平诊断PA的最适值为46.2[醛固酮单位ng/dl（换算为pmol/L需×27.7）；血浆肾素活性单位ng·ml－1·h－1]，其敏感度为88.7%，特异度为84.8%。结论 CCT后的ARR有较高敏感性和特异性，46.2可作为其切点，坐位CCT可取代卧位，作为PA的诊断指标。诊断PA时还应注意PRA的上升情况。
Objective To evaluate the value of captopril challenge test （CCT） in the diagnosis of primary aldosteronism （PA）.Methods A total of 674 patients [（45.0±13.7） years, men 341, women 333] admitted to Peking Union Medical College Hospital from 2000 to 2015 were analyzed. Among them, 222 subjects were with essential hypertension （EH）, 28 were with pheochromocytoma （PHEO）, 246 were with idiopathic hyperaldosteronism （IHA） and 178 were with aldosterone producing adenoma （APA）. All patients received CCT. 24 h urine sodium was measured in partial patients. Plasma renin activity （PRA）, aldosterone （ALD） were detected.Results Compared with EH [PRA： before 0.5（0.2, 0.9） μg·L-1·h-1, after 0.8（0.4, 1.5） μg·L-1·h-1; ALD： before （393±122） pmol/L, after （360±97） pmol/L] and PHEO [PRA： before 0.3（0.1, 0.9） μg·L-1·h-1, after 0.4（0.1, 1.6） μg·L-1·h-1; ALD： before （396±108） pmol/L, after （374±114） pmol/L], lower levels of PRA and higher levels of ALD before and after CCT were observed in PA patients [PRA： before 0.1 （0.1, 0.2） μg·L-1·h-1, after 0.1 （0.1, 0.2） μg·L-1·h-1; ALD： before （468±216） pmol/L; after （457±199） pmol/L]. After CCT, the suppression rate of ALD [2.8% （-8.8%, 15.4%） vs 6.6% （-4.3%, 17.6%）] and increasing rate of PRA [0（0, 50%） vs 50%（0, 200%）] in PA patients were lower than those in EH patients. The ALD/PRA ratio （ARR） were higher in PA than that in EH or PHEO patients. In the EH subjects, ALD levels of seated posture were higher than those of recumbent posture both before and after receiving captopril, but with no changes in ARR after CCT. No significant differences in ALD and ARR （before and after receiving captopril） were observed between seated and recumbent position in the PA group. The ARR after CCT tended to decrease in EH subjects with elevated urine-sodium compared with those with normal urine-sodium. No changes could be viewed in ALD and PRA levels between normal urine-sodium and elevated urine-sodium groups among APA, IHA and EH patients either before or after CCT. Among patients with APA, the ALD levels before CCT and the ARR after CCT were lower in the patients with AngiotensionⅡ（AngⅡ） reactive than those without. A ROC curve analysis suggested that the optimal cutoff value was 46.2 （ALD unit： ng/dl; PRA unit： μg·L-1·h-1） for ARR after challenge in diagnosing PA, with the sensitivity of 88.7% and specificity of 84.8%.Conclusions ARR after 25 mg captopril had high sensitivity and specificity in diagnosis of PA with the cutoff of 46.2. Seated CCT could replace recumbent CCT as a more confirmatory test. The PRA increasing rate should be taken into consideration when diagnosis of PA.
作者
陈适
曾正陪
宋爱羚
朱立
卢琳
童安莉
石穿
李汉忠
Chen Shi Zeng Zhengpei Song Ailing Zhu Li Lu Lin Tong Anli Shi Chuan Li Hanzhong(Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China)
出处
《中华内科杂志》
CAS
CSCD
北大核心
2017年第6期402-408,共7页
Chinese Journal of Internal Medicine
