Prevalence of Primary Aldosteronism in Type 2 Diabetes Mellitus and Hypertension

A Prospective Study From Western India

Saba S. Memon; Anurag Lila; Rohit Barnabas; Manjunath Goroshi; Vijaya Sarathi; Vyankatesh Shivane; Virendra Patil; Nalini Shah; Tushar Bandgar


Clin Endocrinol. 2022;96(4):539-548. 

In This Article

Abstract and Introduction


Objective: Type 2 diabetes mellitus (T2DM) and hypertension commonly coexist; however, underlying primary aldosteronism (PA) can lead to worsening of hypertension, glycemia and cardiovascular risk. We aim to screen patients with T2DM and hypertension for PA by conducting a prospective monocentric study from Western India, which included adults with T2DM and hypertension from the outpatient diabetes clinic.

Design: Prospective study.

Patients and Measurements: Patients with an aldosterone renin ratio of ≥1.6 ng/dl/μIU/ml with plasma aldosterone concentration (PAC) ≥ 10 ng/dl were considered to be positive on a screening test. A PAC ≥ 6 ng/dl on seated saline suppression test (SST) was used to confirm the diagnosis of PA.

Results: Four hundred and eighty-six patients were included in this study. Seventy-six (15.6%, 95% confidence interval [CI]: 12.7%–19.1%) patients had a positive screening test with positive confirmatory test in 20 of the 36 (55.5%, 95% CI: 39.3%–71.7%) screen-positive patients who underwent SST. Patients with positive screening test had a higher proportion of females (65.8% vs. 50%; p = .011), frequent history of hypertensive crises (21.1% vs. 8%; p = .001), uncontrolled blood pressure (51.3% vs. 34.6%; p = .006), diagnosis of hypertension before diabetes (32.9% vs. 21.7%; p = .035) and higher systolic (137.6 ± 6.9 vs. 131.2 ± 17.8 mmHg; p = .004) and diastolic (85.3 ± 11.1 vs. 81.7 ± 10.7 mmHg; p = .007) blood pressures. Patients with positive confirmatory test had longer duration of diabetes (108 [60–162] vs. 42 [24–87] months; p = .012), hypertension (84 [42–153] vs. 36 [15–81] months; p = .038) and higher creatinine (1.16 [1.02–1.42] vs. 0.95 [0.84–1.12] mg/dl; p = .021).

Conclusions: PA is prevalent (at least 4.1%) in Asian Indian patients with T2DM and hypertension. Further studies are needed to assess the cost-effectiveness of routine screening.


Primary aldosteronism (PA) is characterized by excessive and autonomous aldosterone production, which classically manifests as hypertension and hypokalemia.[1] Excess level of aldosterone with sodium excess is associated with worse cardiovascular outcomes than essential hypertension at comparable blood pressure levels.[1] A recent meta-analysis suggests that PA is associated with an increased risk of coronary artery disease, stroke, atrial fibrillation, heart failure, diabetes mellitus, metabolic syndrome and left ventricular hypertrophy.[2]

The prevalence rates of PA in the routine hypertensive population in the two large series are 7.2%–19.5% and 3.9%–11.8%, using aldosterone renin ratio (ARR) as the screening test followed by confirmatory testing.[3,4] A recent study using oral sodium suppression test regardless of baseline aldosterone and renin levels showed the prevalence of 11.3%–22% across the spectrum from normotensives to resistant hypertension.[5]

Type 2 diabetes mellitus (T2DM) frequently coexists with hypertension. Patients with type 1 diabetes mellitus usually develop hypertension after nephropathy sets in, whereas hypertension in T2DM is due to associated obesity, higher risk of atherosclerosis, nephropathy and higher sympathetic drive due to insulin resistance.[6] The development of hypertension in T2DM increases cardiovascular risk, retinopathy, renal failure and other target organ damage. Underlying PA can lead to a worsening of hypertension and glycemia and may escalate cardiovascular risk.[7]

While screening for PA in severe hypertension is advised by the Endocrine Society, there are no recommendations for screening patients with T2DM and hypertension. Studies in T2DM patients with resistant or difficult to control hypertension have shown a higher prevalence of PA (13%–14%). The studies on the prevalence of PA in T2DM patients without resistant hypertension are a few with conflicting results; studies from Japan (n = 124) and China (n = 256) reported the disease burden of 11.3% and 19%, respectively, while other studies (n = 61, n = 551) have reported a very low prevalence (0%–0.93%).[8–13]

Thus, there are a few studies with varying evidence on PA in patients with T2DM and hypertension. A couple of studies from the Indian subcontinent show high PA prevalence in hypertensives, but none specifically investigated patients with T2DM and hypertension.[14,15] In addition, Asian Indians have a different phenotype with higher abdominal fat, insulin resistance and dyslipidemia, which predisposes them to an increased risk of T2DM and coronary artery disease.[16] Therefore, to elucidate the prevalence and contribution of possible underlying PA, we aimed to screen patients with T2DM and hypertension for PA.