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Further Evaluation of Saline Infusion for the Diagnosis of Primary Aldosteronism O. BRYAN HOLLAND, HELLE BROWN, LA VON KUHNERT, CAROL FAIRCHILD,
- Damian Hensley
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1 Clinical Studies Further Evaluation of Saline Infusion for the Diagnosis of Primary steronism O. BRYAN HOLLAND, HELLE BROWN, LA VON KUHNERT, CAROL FAIRCHILD, MARTIN RISK, AND CELSO E. GOMEZ-SANCHEZ SUMMARY Normal subjects, normal-renin hypertensive patients, and low-renin hypertensive patients were evaluated by intravenous saline infusion and with a fludrocortisone acetate (Florinef) protocol to clarify diagnostic criteria for primary aldosteronism that are recommended for the saline infusion protocol. The patients consumed a 200 meq sodium, 70 meq potassium diet for 6 days, and on the last 3 days received Florinef 5 mg orally twice daily. On Days 3 and 6, urinary aldosterone and tetrahydroaldosterone excretions were determined, and on Days 4 and 7 plasma aldosterone (PA) was determined at 0600 after overnight recumbency and at 0800 after 2 hours of walking. Although the level of normal PA by saline infusion has been commonly defined as 10 ng/dl, a value of 5 ng/dl was originally recommended. In 20 normal subjects and 45 normal-renin hypertensive patients, we found that the PA was almost always suppressed below 5 ng/dl. In 18 of 75 low-renin patients including five with aldosterone-producing adenoma (APA), the PA was never suppressed below 10 ng/ dl; thus, these 18 patients had classical primary aldosteronism by generally accepted criteria. The Florinef protocol was performed in eight of these 18 patients and was abnormal in all. An abnormal Florinef protocol was also found in seven of 15 patients studied with PA after saline infusion to between 5 and 10 ng/dl, but in only one of 24 patients studied with PA below 5 ng/dl. Additional studies in the subgroup with abnormal results from the Florinef protocol indicated that none of these patients had evidence of APA, so they had nontumorous primary aldosteronism (NTPA). Thus, failure to suppress PA to less than 10 ng/dl with saline infusion is characteristic of patients with APA. However, the normal level should be lowered to 5 ng/dl when screening is done for NTPA. Additional studies such as Florinef are necessary to gain confidence about the diagnosis of NTPA in those patients with PA of between 5 and 10 ng/dl after saline infusion. (Hypertension 6: , 1984) KEY WORDS aldosterone zona glomerulosa hyperplasia adrenal gland low-renin hypertension DIAGNOSTIC criteria for primary aldosteronism remain uncertain. Although patients with aldosterone-producing adenoma (APA) have autonomous aldosterone production in response From the Departments of Internal Medicine, University of Texas Medical Branch, Galveston, Texas; the University of Texas Health Science Center, Dallas; the University of South Florida College of Medicine, Tampa, Florida; and the James A. Haley Veterans Administration Hospital, Tampa, Florida. A preliminary report of the data was presented at the American Federation for Clinical Research meeting in Washington, D.C., April Supported by Grants HL and HL from the National Institutes of Health (NIH) and by Grants RR-633 and RR-73 from the General Clinical Research Centers Program of the Division of Research Resources, NIH; and by grants from the American Heart Association and its Texas affiliate. Dr. Gomez-Sanchez is the recipient of Research Career Development Award KO4-HL-OO921 from the NIH. Address for reprints: O. Bryan Holland, M.D., Hypertension 4.100OJSH, E72, University of Texas Medical Branch, Galveston Texas 7755 Received November 17, 1983; revision accepted June 6, to sodium loading, patients with bilateral zona glomerulosa hyperplasia (ZGHP) retain some feedback of aldosterone production. 1 " 4 Determination of plasma aldosterone (PA) with intravenous saline infusion has been widely used for the diagnosis of primary aldosteronism. 5 " 7 Originally, the normal level of PA was stated 3 to be below 5 ng/dl, but later 6 this level was raised to as high as 10 ng/dl. To clarify the diagnostic criteria for mild primary aldosteronism, we undertook the following study which compares the saline infusion protocol with an additional sodium loading protocol. Methods Patient Population History, physical examination, blood chemistry analysis with an automated multiple analysis system (SMA-12 or SMA-24), urinalysis, urinary metanephrine, and rapid sequence intravenous pyelogram were done to rule out secondary forms of hypertension other
2 718 HYPERTENSION VOL 6, No 5, SEPTEMBER-OCTOBER 1984 than possible primary aldosteronism. Patients with low- and normal-renin hypertension were initially identified by determination of plasma renin activity (PRA) during the intravenous furosemide test 8 or after 2 hours of ambulation, which produces about the same degree of renin stimulation. 9 Patients had been off antihypertensive medications for at least 3 weeks prior to these studies. An additional sodium depletion protocol 10 with 6 days of 10 meq sodium diet was used to confirm the diagnosis in most of the low-renin patients. With this protocol, a decreased PRA response after sodium depletion plus 4 hours of walking was defined as a PRA less than 7.0 ng/ml/hr for white patients and 5.5 ng/ml/hr for black patients. Those subjects who had been classified as outpatients as having low-renin hypertension and who later exhibited a normal PRA in response to the low-sodium diet were reclassified as having normal-renin hypertension. Saline Infusion Protocol Usually, we evaluated PA first by saline infusion. A 24-hour urine sample from normal subjects and hypertensive patients was refrigerated during the time of collection on the day before saline infusion. Urinary sodium, potassium, creatinine, aldosterone," and tetrahydroaldosterone 12 values were determined. It has been determined 12 that, when normal subjects consume a usual diet, the normal excretion rates for urinary aldosterone and tetrahydroaldosterone are less than 17 and 60 /Ag/24 hr, respectively. At0600 to 0700 on the day of the saline infusion, the patient walked or remained standing as much as possible. Shortly thereafter, the patient came to the General Clinical Research Center where, after 2 hours of walking, blood samples for PRA, 8 PA concentration, 13 and blood chemistry studies (SM A-12 or SMA-24) were col lected. The person then remained supine for the next 4 hours during which time 2000 ml of normal saline was infused intravenously. Blood samples for PRA and PA were obtained at 30, 60, 120, and 240 minutes during the infusion. No significant changes have been noted in the sensitivity and precision of the PA radioimmunoassay (RIA) 13 and urinary tetrahydroaldosterone RIA 12 since their original description. The sensitivity is 4 pg for the PA RIA and 6 pg for the tetrahydroaldosterone RIA. Over the last 7 years, the urinary aldosterone assay has had an interassay variation of about 8% and an interassay variation of about 15%, which is about the same as the assays for PA and urinary tetrahydroaldosterone. Florinef Suppression Protocol Normal subjects and hypertensive patients who agreed to participate in the additional protocol of aldosterone were admitted to the General Clinical Research Center. They were given a 200 meq sodium, 70 meq potassium metabolic diet for 6 days with 3000 ml of fluids per day. On the last 3 days, fludrocortisone acetate (Florinef) was administered by mouth at a dose of 5 mg twice daily. sterone, tetrahydroaldosterone, sodium, potassium, and creatinine levels were determined in 24 hour refrigerated urine samples from Days 3 and 6. On those nights, the patients retired to bed at 2230 to 2300 and remained at absolute bed rest from at least 0200 until 0600 the following morning, when blood was drawn. The fasting patient then walked from 0600 to 0800, and blood was again taken for determination of PA, PRA, and plasma cortisol. 14 All patients gave written informed consent to participate in these studies after explanation of the study in lay language. Study protocols were approved by the Human Research Review Committees of the University of Texas Health Science Center at Dallas and the University of Texas Medical Branch at Galveston. Statistical evaluation was performed with Student's t test. 15 Results Seventy-five patients with low-renin hypertension and 45 patients with normal-renin hypertension were studied with the saline infusion protocol. Saline infusion suppressed PA to 2.8 ± 1.6ng/dl (mean ± sd)or to less than 6 ng/dl (mean + 2 SD) in 19 of 20 normal subjects and to less than 5 ng/dl in 18 (Table 1). All but five of the 45 normal-renin patients had a PA below 5 ng/dl with saline infusion, and these five patients had a PA to between 5 and 6 ng/ dl. Definite of PA began within the first 30 minutes of saline infusion in all patients except those with an aldosterone-producing adenoma (APA). Normal subjects and normal-renin hypertensive patients also had a definite fall in PRA, whereas low-renin patients had only a slight change in PRA during the first 30 minutes of saline infusion. Normal results with the Florinef protocol were established by study of 21 age-matched normal subjects. This included a subgroup of 12 of the 20 normal subjects that participated in the saline infusion protocol. At the end of the baseline phase of the Florinef protocol in these normal subjects, 0600 supine PA was less than 13 ng/dl (mean + 2 SD), and PA after 2 hours of ambulation was less than 32 ng/dl. Normal urinary aldosterone excretion was less than 17 /ng/24 hr, and normal urinary tetrahydroaldosterone excretion was less than 60 /u.g/24 hr. Normal PA (mean + 2 SD) at the end of this protocol was found to be less than 6 ng/dl for 0600 PA and less than 11 ng/dl for 0800 PA after 2 hours of ambulation; the 24-hour urinary aldosterone was less than 6 /ig and the 24-hour urinary tetrahydroaldosterone less than 32 fig, respectively. The Florinef protocol was considered to have produced abnormal results if it failed to suppress normally supine or ambulatory PA, urinary aldosterone, and urinary tetrahydroaldosterone, or if all three of these determinations were elevated in the baseline phase. When these criteria were used, no normal subjects or normal-renin patients had abnormal testing with the Florinef protocol. Eighteen low-renin patients had primary aldosteronism by generally accepted criteria, 6 since they had hypokalemia and failure to suppress PA to less than 10
3 DIAGNOSIS OF PRIMARY ALDOSTERONISM///0//W et al. 719 TABLE 1. Suppression of sterone and Renin Activity (PRA) with Saline Infusion in Normal Subjects and Hypertensive Patients Subjects Normal PA Low-renin hypertension PA Normal-renin hypertension PA Classical primary aldosteronism Hyperplasia PA Adenoma PA No. Age (yrs) potassium liter) 20 39± ± ±2 4 l.l 13 47± ±5 2.9 Minutes of saline infusion ± ± ± ± ± ±l.O ± ± ± ± ± ± ± ± Data are expressed as means ± SE. PA = plasma aldosterone; PRA = plasma renin activity l ± ±6.6 l ng/dl after saline infusion (Table 1). The Florinef protocol produced abnormal results in all eight of these patients in whom it was performed. Thirty-nine of the remaining 57 low-renin patients with PA after saline infusion to less than 10 ng/dl underwent the Florinef protocol. This group included 15 of 20 patients with PA to 5 to 10 ng/dl with saline infusion and 24 of 37 patients with PA to less than 5 ng/dl. Seven of the 15 patients with PA to between 5 and 10 ng/dl had abnormal results from the Florinef protocol (Table 2). In contrast, only one of 24 patients with PA to less than 5 ng/dl had an abnormal Florinef protocol. This latter patient had elevated excretion levels of PA, urinary aldosterone, and urinary tetrahydroaldosterone in the baseline phase of the Florinef protocol (Table 2, Patient 8). Thus, no patients with an abnormal Florinef protocol would have been missed if urinary aldosterone and tetrahydroaldosterone and plasma potassium had been evaluated at the time of saline infusion and if the normal level of PA was determined as less than 5 ng/dl. All of these eight patients with abnormal results from the Florinef protocol had elevated 0600 supine PA at the end of the baseline phase of the Florinef protocol, whereas only three had elevated ambulatory PA, three had elevated urinary aldosterone excretion, and six had elevated urinary tetrahydroaldosterone excretion at that time. TABLE 2. sterone and Urinary sterone and Tetrahydroaldosterone Results in Patients with sterone Suppression to Less Than 10 ng/dl With Saline Infusion But With an Abnormal Florinef Protocol Patient no Saline infusion K liter) aldosterone Supine meq sodium diet Ambulatory = aldosterone; TH = tetrahydroaldosterone. (Mg/ Urinary TH (Mg/ meq sodium diet and Florinef aldosterone Supine Walking (Mg/24 1<ir) Urinary TH (Mg/
4 720 HYPERTENSION VOL 6, No 5, SEPTEMBER-OCTOBER 1984 TABLE 3. Changes in Urinary sterone, Tetrahydroaldosterone, and Sodium, Body Weight, and Potassium with Sodium Loading Subjects Normal Low-renin Abnormal Normal Normal-renin Classical primary Hyperplasia Adenoma No Age (yrs) ±2 ±4 51 ±2 ±2 aldosteronism 5 49 ± ± ± ± ± meq sodium diet TH 25.2 ± ± ± ± ± ±49 Sodium 167 ±6 177 ± ±9 175 ± ± ±8 Weight (kg) 71 2 ±3.4 9 ± ± ± ± ±2.0 liter) ± ± ± meq sodium diet and Florinef TH 15.8 ± ±6.4 2 ± ± ± ±88 Sodium Data are expressed as means ± SE. = aldosterone; TH = tetrahydroaldosterone; PA = plasma aldosterone. 98 ±9 161 ±9 136 ±7 125 ±8 135 ±3 183 ±28 Weight (kg) 72.4 ± ± ± ± ± ±2.3 liter) Creatinine clearance averaged 95.0 ± 19 ml/min (mean ± SE) in normal-renin hypertensives; it was somewhat higher (105.6 ± 6.7 ml/min) in the subgroup of eight low-renin patients with abnormal results from the Florinef protocol than in the subgroup with normal aldosterone (86.0 ± 5.2 ml/min). This points to the possibility that subtle renal dysfunction with sodium retention may have led to the lowrenin state in many of these latter patients. In comparison to hypertensive patients, normal subjects had a greater weight gain by the end of the Florinef protocol, but they still had not come as close to restoring 24-hour urinary sodium to the baseline level and thus to achieving mineralocorticoid escape (Table 3). potassium was lower in patients with classical primary aldosteronism and in the subgroup of eight low-renin patients with abnormal Florinef results than in normal subjects. Furthermore, plasma potassium fell to a lower level in these two groups compared to normal subjects with Florinef administration (Table 3). cortisol remained essentially unchanged or fell slightly from 0600 (supine) to 0800 (ambulation) in normal subjects and in all hypertensive subgroups (Table 4). cortisol levels at 0600 were slightly higher in patients with classical primary aldosteronism due to bilateral ZGHP than in normal subjects,.although this difference was significant (p < 05) only at the end of the Florinef protocol (Table 4). These differences probably reflect the small sample size of TABLE 4. Changes m Renin Activity (PRA), Cortisol, and sterone (PA) with Sodium Loading Subjects Normal Low-renin Abnormal Normal Normal-renin Classical primary Hyperplasia Adenoma 200 meq sodium diet 200 meq sodium diet and Florinef sterone sterone Cortisol Cortisol Walk- Walk- Walk- Walk- Walk- Walk- Supine ing Supine ing Supine ing Supine ing Supine ing Supine ing ± aldosteronism Data are expressed as means ± SE ± ± ± ± ± ± ±11 70 ± ± ± ± ± ± ±2.0.. o.; ± ± ± ± ± ± ± ± ± ± ± ±
5 DIAGNOSIS OF PRIMARY ALDOSTERONISM///0//W et al. Ill the ZGHP group (five patients). During the 2 hours of ambulation in the baseline phase of the Florinef protocol, there was an increase in PA in normal subjects, normal-renin hypertensive patients, and low-renin hypertensive patients, except for two of three patients with APA who showed a fall in PA during this time (Table 4). All but one of the eight low-renin patients with abnormal Florinef increased PA with ambulation (Table 2, Patient 1). Discussion Classical primary aldosteronism with definite hypokalemia and elevated urinary aldosterone excretion is generally considered to occur in less than 1 % of hypertensive patients. 16 However, these estimates have been derived with diagnostic criteria that have led to a predominance of patients with APA instead of ZGHP. sterone secretion in patients with APA appears to be relatively autonomous in response to sodium loading since adrenocorticotrophic hormone (ACTH) commonly regulates acute changes. 17 In contrast, patients with ZGHP have intact, though abnormal, feedback regulation of aldosterone secretion in response to sodium loading. 1 "' Although part of this feedback is mediated by changes in circulating angiotensin II, there is evidence that other sodium-sensing mechanisms are important. 18 As a consequence of this intact feedback regulation, these patients tend to have decreased aldosterone secretion as they become progressively sodium loaded, so random aldosterone determinations based on the usual normal ranges may not identify these patients correctly. In our study, a steady-state increase in total body sodium during the Florinef protocol was suggested by the lack of weight gain and earlier achievement of mineralocorticoid escape in patients with primary aldosteronism in comparison to normal subjects and normal-renin hypertensives. Patients with NTPA were also noted to have a rapid fall in PA levels with saline infusion. Thus, sensitive diagnostic methodology for ZGHP should provide for quantification of aldosterone after sodium loading. Until diagnostic methodology for ZGHP is clarified, it will be difficult to evaluate the postulate that low-renin "essential" hypertension is a subtle form of primary aldosteronism. 19 Determination of PA concentration during the saline infusion test is utilized widely for the diagnosis of primary aldosteronism. 5 " 7 However, the normal level of has been reported to be from 5 ng/dl 3 to 10 ng/dl. 6 Undoubtedly, some of this ambiguity about the normal level of results from slight differences in PA RIA techniques. As noted by previous investigators, 6-7 we found that patients with APA invariably failed to suppress PA to less than 10 ng/dl with saline infusion. However, the appropriate level of to use for the diagnosis of ZGHP is less clear. Unlike the case with APA, surgical correction of the disease cannot be used to confirm the diagnosis. Thus, definition of abnormal PA must be derived through the study of the response of normal subjects and patients with normal-renin essential hypertension. We would presume that the Florinef protocol would be more accurate for the diagnosis of ZGHP than the saline infusion protocol since it provides more complete evaluation of both basal aldosterone production and its response to sodium loading through three determinations (PA, urinary aldosterone, urinary tetrahydroaldosterone) instead of just PA determination alone with the saline infusion protocol. All low-renin patients who failed to suppress PA below 10 ng/dl with saline infusion also had abnormal Florinef. However, we noted a certain lack of correlation of the results from saline infusion and Florinef in those patients with PA below 10 ng/dl with saline infusion. Seven of 15 low-renin patients with PA with saline infusion to between 5 and 10 ng/dl had abnormal Florinef. In contrast, only one of 24 patients with PA with saline infusion to less than 5 ng/dl had abnormal Florinef. Thus, when normal PA with the saline infusion protocol was set at 10 ng/dl, some patients with primary aldosteronism appeared to be missed. Those seven patients who after saline infusion had PA to between 5 and 10 ng/dl and who also had an abnormal Florinef provided excellent evidence for primary aldosteronism. In the baseline phase of the Florinef protocol, five of these patients had elevated urinary aldosterone or tetrahydroaldosterone excretion, and all had elevated 0600 supine PA levels (Table 2). Thus, the normal level of PA with saline infusion would need to be set at 5 ng/dl to avoid an appreciable rate of falsenegative testing for primary aldosteronism. However, when normal was set at this level, we noted that eight of 15 patients had a normal Florinef protocol. Therefore, additional testing appears indicated in those patients with PA to between 5 and 10 ng/dl with saline infusion, to obtain better evidence for a diagnosis of primary aldosteronism. It should also be noted that occasional patients with primary aldosteronism may have PA below 5 ng/dl. This has been reported by others, 7 and we found one such patient. Our patient had elevated PA and urinary aldosterone and tetrahydroaldosterone in the baseline phase of the Florinef protocol, but had normal of all three of these values with Florinef. Thus, determination of urinary aldosterone and/or tetrahydroaldosterone on the day before saline infusion is desirable to provide greater sensitivity in screening for primary aldosteronism. A more difficult question concerns those patients with abnormal of PA, urinary aldosterone, or urinary tetrahydroaldosterone at the end of the Florinef protocol but wi f h normal urinary aldosterone and tetrahydroaldosterone excretion in the baseline phase. Abnormalities in aldosterone during sodium loading have been noted previously in a significant percentage of hypertensive patients, 20 " 22 but the percentage of these patients who might have had subtle primary aldosteronism was not determined. We identi-
6 722 HYPERTENSION VOL 6, No 5, SEPTEMBER-OCTOBER 1984 fled seven patients who failed to suppress two of the three aldosterone determinations but who had normal basal urinary aldosterone and tetrahydroaldosterone excretion. Six of these seven patients had borderline abnormal or elevated PA levels in the baseline phase of the Florinef protocol. Thus, many of these patients may have exceedingly mild primary aldosteronism. potassium determinations were also somewhat suggestive that these patients had subtle primary aldosteronism in that most of these patients had borderline hypokalemia. In addition, some of these patients demonstrated an enhanced aldosterone response to ACTH, 23 which is generally a characteristic of patients with classical primary aldosteronism but not of patients with low-renin hypertension. 17 But, although there are some suggestions that these patients with abnormal of one or more aldosterone determinations with Florinef have primary aldosteronism, we cannot rule out the possibility that an abnormality in may not reflect enhanced aldosterone secretion. Thus, additional studies of the aldosterone secretory rate and 24-hour integrated PA will be needed to clarify this question. All of our five patients with APA failed to suppress PA below 10 ng/dl with saline infusion and had marked abnormalities in aldosterone with the Florinef protocol. None of the patients with PA below 10 ng/dl and abnormal Florinef appeared to have APA. This was established by additional studies in these patients incuding adrenal venography, bilateral adrenal vein sampling with PA determination, adrenal scanning during dexamethasone with NP-59, 24 and adrenal CT scanning. Thus, these patients had presumed NTPA. Most of these patients had been documented in previous reports to have bilateral ZGHP. However, we did not perform adrenal biopsy to confirm the diagnosis since this is no longer clinically indicated. We cannot rule out the possibility that some of these patients had small unilateral or bilateral APA. Other protocols of sodium loading for the diagnosis of primary aldosteronism have included the use of a high sodium diet by itself 3 ' 20 " 22 or the administration of exogenous mineralocorticoids such as deoxycorticosterone 1 ' 2-7 or fiudrodhydrocortisone. 23 " 28 A regular sodium diet was utilized in all but two 7 - n of these latter protocols involving mineralocorticoid administration. Although all of these sodium loading studies have proved useful for the diagnosis of primary aldosteronism, the small number of their normal subjects and their way of determining aldosterone to establish the normal response have been considerably more limited than in our study. These factors would tend to decrease the confidence with which a diagnosis of primary aldosteronism could be made. In one study, 28 determination of PA changes with ambulation after sodium loading with Florinef was said to provide totally accurate differentiation of APA from ZGHP. Although we performed ambulation at a slightly different time ( vs ), we noted that one of our three patients with APA evaluated with the Florinef protocol had a clear increase in PA with ambulation in both the basal and Florinef phases. Thus, the differentiation of APA from NTPA should be based on several methods. The saline infusion protocol with 24-hour urinary aldosterone and tetrahydroaldosterone done, if possible, on the day before would appear better suited than the Florinef protocol for initial evaluation of patients with possible primary aldosteronism. Patients with APA should only rarely have a PA below 10 ng/dl with saline infusion. In contrast, patients with NTPA may frequently have a PA of 5 ng/ dl. In those patients with PA between 5 and 10 ng/dl, additional studies should be done to provide better evidence for a diagnosis of primary aldosteronism. Acknowledgments We thank Linda Pietrzyk and Rebecca Hicks for secretarial assistance; Marci Shaw, Lynn Hurst, Yvonne Hillier, and Deborah Schindewolf for technical assistance in performing the assays; and Judy Norris, Jeanne Pollard, and the staff nurses of the General Clinical Research Centers of the University of Texas Health Science Center at Dallas and the University of Texas Medical Branch at Galveston for assistance with the patient studies. The anti-aldosterone serum was provided by the National Institute of Arthritis, Metabolism, and Digestive Diseases. References 1. Biglieri EG, Slaton PE, Jr, Kronfield SJ, Schambelan M. Diagnosis of an aldosterone-producing adenoma in primary aldosteronism. JAMA 1967; Rodriguez JA, Lopez JM, Biglieri EG. DOCA test for aldosteronism: its usefulness and implications. Hypertension 1981; 3(suppl I1):1I-1O2-I1-1O6 3. Bravo EL, Tarazi RC, Dustan HP, et al. The changing clinical spectrum of primary aldosteronism. Am J Med 1983;74: Holland OB, Gomez-Sanchez C. Mineralocorticoids and hypertension. Am J Nephrol 1983;3: Kern DC, Weinberger MH, Mayes DM, Nugent CA. Saline of plasma aldosterone in hypertension. Arch Intern Med 1971;128.38O Weinberger MH, Grim CE, Hollifield JW, et al. Primary aldosteronism: diagnosis, localization, and treatment. Ann Intern Med 1979;90: Streeten DHP, Tomycz N, Anderson GH. Reliability of screening methods for the diagnosis of primary aldosteronism. Am J Med 1979;67: Kaplan NM, Kern DC, Holland OB, Kramer NJ, Higgins J, Gomez-Sanchez C. The intravenous furosemide test: a simple way to evaluate renin responsiveness. Ann Intern Med 1976; 84: Holland OB, Gomez-Sanchez CE, Fairchild C, Kaplan NM. Role of renin classification for diuretic treatment of black hypertensive patients. Arch Intern Med 1979; 139: Holland OB, Chud JM, Braunstein H. Urinary kallikrein excretion in essential and mineralocorticoid hypertension. J Clin Invest 1980;65: Langan J, Jackson R, Adlin EV, Channick BJ. A simple radioimmunoassay for urinary aldosterone. J Clin Endocrinol Metab 1974;38: Gomez-Sanchez CE, Holland OB. Urinary tetrahydroaldosterone and aldosterone-18-glucuronide excretion in white and black normal subjects and hypertensive patients. J Clin Endocrinol Metab 1981;52: Gomez-Sanchez C, Milewich L, Holland OB. A radioimmunoassay for plasma aldosterone by immunologic purification. J Clin Endocnnol Metab 1973;36:
7 DIAGNOSIS OF PRIMARY ALDOSTERONISM///0//W et al Gomez-Sanchez C, Milewich L, Holland OB. Radio-iodinated derivatives for steroid radioimmunoassay: application to the radioimmunoassay of cortisol. J Lab Clin Med 1977;89: Goldstein A. Biostatistics: an introductory text. New York: Macmillan, 1969: Kaplan NM. Hypokalemia in the hypertensive patient with observations on the incidence of primary aldosteronism. Ann Intern Med 1967 ;66: Kern DC, Weinberger MH Jr, Higgins JR, Kramer NJ, Gomez-Sanchez C, Holland OB. aldosterone response to ACTH in primary aldosteronism and in patients with low renin hypertension. J Clin Endocrinol Metab 1978;46:552-56O 18. Shoback DM, Williams GH, Hollenberg NK, Davies RO, Moore TJ, Dluhy RG. Endogenous angiotensin II as a determinant of sodium-modulated changes in tissue responsiveness to angiotensin II in normal man. J Clin Endocrinol Metab 1983;57: Grim CE. Low renin "essential" hypertension. Arch Intern Med 1975;135: Collins RD, Weinberger MH, Dowdy AJ, Nokes GW, Gonzales CM, Luetscher JA. Abnormally sustained aldosterone secretion during salt loading in patients with various forms of benign hypertension; relation to plasma renin activity. J Clin Invest 1970;49: Luetscher JA, Weinberger MH, Dowdy AJ, Nokes GW. Effects of sodium loading, sodium depletion and posture on plasma aldosterone concentration and renin activity in hypertensive patients. J Clin Endocrinol Metab 1969;29: Helber A, Wamback G, Hummerick W, Bonner G, Meurer KA, Kaufmann W. Evidence for a subgroup of essential hypertensives with non-suppressible exretion of aldosterone during sodium loading. Klin Wochenschr 1980;58: Holland OB, Thomas C, Brown H, Schindewolf D, Hillier Y, Gomez-Sanchez C. sterone with dopamine infusion in low-renin hypertension. J Clin Invest 1983;72: Sarkar SD, Cohen EL, Beierwaltes WH, Ice RD, Copper R, Gold EN. A new superior adrenal imaging agent, 1: "l-6/3-iodomethyl-19-nor cholesterol (NP-59): evaluation in humans. J Clin Endocrinol Metab 1977;45: Horton R. Stimulation and of aldosterone in plasma of normal man and in primary aldosteronism. J Clin Invest 1969;:123O Horton R, Finck E. Diagnosis and localization in primary aldosteronism. Ann Intern Med 1972;76:885-89O 27. Lund JO, Nielson MD. Fludrocortisone test in normal subjects, in patients with essential hypertension and in patients with various forms of aldosteronism. Acta Endocrinol 1980;93: Vaughan NJA, Slater JDH, Lightman SL, et al. The diagnosis of primary hyperaldosteronism. Lancet 1981; 1:
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A MP has been sacked from his job as a parliamentary aide after he was pictured attending a Nazi-themed bachelor party where one of the guests wore an SS uniform, the Conservative Party said on Sunday.
Aidan Burley, 31, who was Parliamentary Private Secretary at the Department of Transport, had behaved in a manner which is offensive and foolish, a Conservative Party spokesman said in a statement.
In light of information received the prime minister has asked for a fuller investigation into the matter to be set up and to report to him, the spokesman added.
Burley had apologised last week after the Mail Sunday newspaper published photos of him at the party in a French ski resort where some of the revellers were said to have toasted Adolf Hitler and his Third Reich regime.
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Posted by ESPN.com's Mike Sando
Darren Urban of azcardinals.com says the Cardinals are looking for their first 2-0 start since 1991. That is truly amazing.
Bob McManaman of the Arizona Republic says Cardinals coach Ken Whisenhunt isn't afraid to dial up trick plays. We saw that Sunday when he sent cornerback Dominique Rodgers-Cromartie on a deep pass route.
Also from McManaman: Arizona's 18-play drive in the fourth quarter was its longest in 12 years.
Bill Coats of the St. Louis Post-Dispatch says the Rams are expected to work out free-agent receiver Eddie Kennison as they seek help following Drew Bennett's injury. Also, the Rams' season opener drew a poor TV rating in the St. Louis market.
Jeff Gordon of stltoday.com wonders if the Rams will respond to coach Scott Linehan after losing for the 14th time in 17 games.
Jim Thomas of the St. Louis Post-Dispatch says Linehan entered this season determined to handle defeats more effectively. Now's his chance.
Steve Korte of the Belleville News-Democrat says the Rams' lack of enthusiasm in the opener stemmed from their inability to execute, according to Linehan.
Dave Boling of Seahawks Insider breaks down Mike Holmgren's day-after-game news conference. The Bills' fake field goal might have stretched the rulebook, but that was the least of the Seahawks' concerns following a horrendous opener.
Also from Boling: Nate Burleson was stunned to find out he'll miss the rest of the season. Meanwhile, Matt Hasselbeck is no longer receiving treatment for his back.
And this: "Embarrassing" is the word to describe Seattle's opening-week performance.
Clare Farnsworth of the Seattle Post-Intelligencer says Burleson's injury was of the non-contact variety. He simply planted on the leg.
Also from Farnsworth: A breakdown of the Seahawks' injury situation.
Greg Johns of the Seattle Post-Intelligencer says backup quarterback Seneca Wallace might need to play receiver for the Seahawks. If not now, when?
Matt Barrows of the Sacramento Bee says the 49ers are considering their options at quarterback while backup Alex Smith awaits word on his shoulder.
Larry Weisman of USA Today assesses the lack of quality receivers in the NFL, something John Clayton touched upon in June.


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Adventure Carribean cruise
Sail Date: March 04, 2012
Reviewed: 5 years ago
Traveled As: Singles/Friends
Room Type: Oceanview
Pros: The service and my room's shower (had a handicap room.
Cons: the steak on the alternate menu, two too toughies.
Recommends Adventure of the Seas? No.
Category Ratings
Click table then swipe to view all columns.
Click table then swipe to view all columns.
|Ship Quality
|Seems as if the invited entertainers are getting less expensive as time goes by although I did enjoy Julie Kolba quite a lot. I've also seen more elaborate production shows although these were quite good.
|Food and Dining
|As a diabetic, it would be nice to have more sugar-free choices.
|Cabin / Stateroom
|Service and Staff


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it's an internet thing!
19:59 23 February 2010
Prince is being sued for 1.7 Euros, it has been reported.
A High Court action has been started against the singer after he cancelled a Dublin gig.
Promoter MCD are suing Prince for compensation after he cancelled the event in 2008 at the city's Croke Park concert.
The court heard that he is claiming his agents did not have the authorisation to enter into an agreement for him to perform at the event.
However, the agents maintain that Prince gave 'no reason of substance' to back out of the music event.
The Dublin date had been heavily advertised as the last time Prince would play greatest hits like Diamonds And Pearls and Little Red Corvette in Ireland.
Over 55,000 tickets had been sold, and thousands of angry fans demanded refunds when it was cancelled.
The 'Purple Rain' star, whose real name is Prince Rogers Nelson, is being sued for financial loss and damage to commercial reputation by MCD.
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Maimonides Medical Center, Brooklyn, NY
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Plasmapheresis is a modality used frequently in the treatment of TTP. It has improved the outcomes associated with TTP, however it is not a benign modality as it involves placement of invasive catheters and the risk of infections. We present a case of catheter related right-sided staphylococcus aureus endocarditis that mimicked symptoms of TTP.
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text: All India UPSC Ranker's GS answers compilation 2015 is a treasury of GS tests which top rankers had given while preparing for UPSC. This compilation will allow you to understand how to write answer when you know the concepts. It will drag your mind to the direction which ends in scoring good marks. You will understand how writing makes the difference not just knowledge about a particular topic. This compilation will come at your place as hard copy with 2 booklets . It has total 652 pages.


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Finish your dining room look with an area rug! >
This dining set was Inspired by the French countryside but its perfectly suited to add a pinch of farmhouse charm to any home decor. The quaint and traditionally picturesque table design is countered with modern functionality in the form of a galvanized metal table top sealed with a zinc finish for maximum usability. Mix and match the upholstered side chairs, bench, and woven side chairs for a look that's totally yours.
The Matisse Six Piece Dining Set with Upholstered Bench and Woven Chairs by Coaster at Del Sol Furniture in the Phoenix, Glendale, Tempe, Scottsdale, Avondale, Peoria, Goodyear, Litchfield, Arizona area. Product availability may vary. Contact us for the most current availability on this product.
Nowadays people want their furniture to look more naturally curated and less matchy-matchy. This rustic dining group inspired by the French countryside is perfect for people who want their kitchen or dining room to have a more eclectic and organic feel. Featuring a mix of complementing colors on the table, dining server, and side chairs you can mix and match to find the set that works best for your home. Includes rustic, industrial table tops of galvanized metal and a matching server for dining and silverware storage.
The Matisse collection is a great option if you are looking for Cottage furniture in the Phoenix, Glendale, Tempe, Scottsdale, Avondale, Peoria, Goodyear, Litchfield, Arizona area.
These images are representative of this group as a whole and may differ from this item.
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Why to have your certificate reissued as SHA2
Google and Microsoft initiatives have caused the web industry to update the SSL certificate security standard. As a result, someone using Chrome and Internet Explorer will get a warning when they visit a site that uses an SHA1 generated security certificate.
To prevent your customers from seeing these warnings, you will need to reissue your certificate as SHA2.
Where to go
When requesting a reissue, the same contacts and domain name associated with the original SSL Certificate must be used for the new SSL Certificate. To get a reissue on an SSL Certificate, go to the SSL certificate provider's site:
- GeoTrust: https://products.geotrust.com/orders/orderinformation/authentication.do
- Symantec: https://products.websecurity.symantec.com/orders/orderinformation/authentication.do
- thawte: https://products.thawte.com/orders/orderinformation/authentication.do
- Trustwave: https://ssl.trustwave.com/controlcenter/login.php
Comodo certificates are reissued through OpenSRS. To start that process just send us an email at email@example.com.
You will need to provide us with the following information:
- Domain name on the certificate
- Supplier order ID
- CSR (Certificate Signing Request)
- NOTE: The CSR does not have to be generated using the SHA2 hash; you can use the same CSR that was used to last issue/reissue the certificate.
- Message stating you wish to reissue the certificate using SHA2
We will then reissue the certificates with Comodo on your behalf. Please allow 1-3 business days for these to be processed.
What you need
In order to get your SSL certificate reissued for all suppliers besides Comodo, make sure you have the following information ready:
For GeoTrust, Symantec and thawte:
- Domain or subdomain name - The domain for which the original SSL certificate was issued
- Email address - an email address used on the original order
- Order ID - this corresponds to the Supplier Order ID in your Reseller Control Panel
- To find the Supplier Order ID, go to Trust > the specific SSL Order > Status > Supplier Order ID
For Trustwave:
- Username and password
- The Admin contact email address you used to set up your SSL certificate
How to get your SSL certificate reissued
1. To log in:
- Enter the domain name OR order ID
- NOTE: The order ID corresponds to the Supplier Order ID listed in your Reseller Control Panel
- Enter one of the email addresses you used on your order
- In the Image number field, enter the number in the box below
2. Click Request Access; this will prompt the system to send you an email with the vendor login url.
3. Check your email and click on the vendor login url. You will see the following control panel.
Click the Reissue Certificate link in the top left menu.
4. In the Hashing Algorithm drop-down menu, select SHA2 with a 256-bit Digest (or reissue it with SHA1, if required).
Then enter your CSR in the provided field. This can be the existing CSR (SHA1 or 2) or a new CSR.
Lastly, review and agree to the Subscriber Agreement and then click Submit.
5. When the information is submitted, an approval email will be sent to the Domain Approver email address. Once approval completed the certificate will be sent to the Tech Contact email address.


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7108 Roslindale Trail, Kalamazoo MI, 49009
Sold Price:
4 beds , 2 Full/1 Half baths
2,326 sqft
Status: Closed
Last Updated: 6/26/2017 1:55 AM
Description for 7108 Roslindale Trail Kalamazoo, MI 49009
New colonial construction in the Applegate Trails community of Texas twp. This home is energy efficient and covered by a ten year structural warranty. Exterior features include a large covered front porch, and a two car garage with opener and remotes as well as a 14x20 patio. This home has a partially finished basement that includes a huge rec room. Home has been upgraded to include craftsman trim and hand rails. Kitchen includes designer cabinetry and stainless steel appliances. Off the front entry is a den with french doors and designer wainscoting as well as a formal dining room with laminate flooring and designer wainscoting. As you leave the entry and walk down the hall there is a mud room and powder room to your left and the kitchen to your right. Upper level has four bedrooms.
Sold Price:
Sold Date:06/26/2015
Texas Twp
2 Full/1 Half
2,326 (approx)
Listing Information
Texas Twp
Public Sewer
School Information
Room Information
Eat-In Kitchen
Interior Features
Humidifier, Dishwasher, Microwave, Range
Central Air
Gas Heat, Forced Air
Basement, Full
Insulated, Screened
Home Warranty Plan
Exterior / Lot Features
Attached Garage, 2 Car Garage
Patio, Porch
Paved Road, Level
Driving Directions
South on 10th St. to Ashland blvd.
Financial Considerations
Listing Price History
Kalamazoo Real Estate
Kalamazoo is located in Michigan. Kalamazoo, Michigan 49009 has a population of 76,041.
The median household income in Kalamazoo, Michigan 49009 is $32,959. The median household income for the surrounding county is $46,356 compared to the national median of $53,482. The median age of people living in Kalamazoo 49009 is 25.7 years.
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Product Code: AKPERCEPTION120
Manufacturer: AKG
Free mainland UK shipping available for this product
Our Price £96.99INC
Available within 2-5 working days
The Perception 120 is a 2/3-inch diaphragm true condenser microphone that offers solid build quality, outstanding performance, and excellent value. The low-mass diaphragm delivers a clear sound with accurate sonic detail. A switchable 20 dB preattenuation pad and bass cut filter make the Perception 120 an excellent choice for a wide range of recording and live sound applications.
Backed by AKG's six decades of experience in making microphones and input from sound engineers around the world, the Perception 120 now brings AKG studio quality to musicians and project studio applications.
With years of experience supplying Businesses, Government Organisations, Charities, Schools, Colleges and Universities, we invite you to take advantage of our knowledge to help you make an informed choice, ensuring you are purchasing the best music products for your needs. With specialists in PA Systems, Pro Audio & Live Sound equipment on hand to answer calls and emails, you're in the best possible hands.
Contact us now to discuss your requirements or to request a quotation. Additional discounts may apply for educational establishments or size and value of order.
Purchase orders can be sent directly to firstname.lastname@example.com or apply for your cash or credit account here. Terms and conditions will apply.
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XRAY Aluminum Rear Wing Mount Brace (2)
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This is set of optional CNC-machined aluminum rear wing mount braces for the Xray XB8 line of buggies.
This product was added to our catalog on October 5, 2006.