Oral Presentation ESA-SRB-ANZOS 2025 in conjunction with ENSA

Post-treatment renin status and cardiovascular, renal and mortality outcomes in medically treated primary aldosteronism: a systematic review and meta-analysis (125760)

Sho Katsuragawa 1 2 , Minh V Le 3 4 , Peter J Fuller 1 2 , Jun Yang 1 2
  1. Hudson Institute of Medical Research, Clayton, VIC, Australia
  2. Department of Molecular and Translational Science, Monash University, Clayton, VIC, Australia
  3. Royal Melbourne Hospital, Parkville, VIC, Australia
  4. Western Health, St Albans, VIC, Australia

Renin suppression persists in many patients with primary aldosteronism (PA) despite targeted medical treatment, which may indicate suboptimal mineralocorticoid receptor blockade. Hence renin is a suggested biomarker for medication titration in the Primary Aldosteronism Medical Treatment Outcome (PAMO) criteria. This study systematically reviewed the evidence on the association between post-treatment renin status and cardiovascular, renal, and mortality outcomes in medically treated patients with PA.

A systematic search of MEDLINE, Embase, CENTRAL and Web of Science was conducted on May 5th, 2025. Studies that investigated the association between post-treatment renin and clinical outcomes among medically treated patients with PA were included. The primary outcomes were the incidence of cardiovascular events, renal events, and mortality. Risk-of-bias was assessed using the QUIPS tool. Random-effects models were employed to estimate pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Certainty-of-evidence was rated using the GRADE framework.

Twenty-four studies involving 6621 patients with PA on mineralocorticoid receptor antagonists were included. Most studies used plasm renin activity with a cut-off of 1.0 ng/mL/h to classify post-treatment renin as suppressed or unsuppressed. A meta-analysis demonstrated that unsuppressed post-treatment renin was associated with a lower risk of cardiovascular events with ≥5 years follow-up (pooled HR 0.33 [95%CI, 0.19–0.57], I2=0%, three studies, 756 patients; moderate certainty). No significant association was found with renal events (pooled HR 0.95 [95%CI, 0.51–1.77], two studies, I2=0%, very low certainty). One study reported a lower risk of mortality in patients with unsuppressed vs. suppressed post-treatment renin (HR 0.29 [95%CI, 0.09–0.98], 201 patients; moderate certainty).

In conclusion, unsuppressed renin following targeted medical therapy for PA is associated with a reduced risk of cardiovascular events, suggesting that normalisation of renin should serve as a therapeutic target. Prospective studies are warranted to confirm that medication titration to normalise renin improves clinical outcomes.