Is It Time to Retire Aldosterone Suppression Testing?
Bibliographic record
Abstract
Primary aldosteronism (PA) is the most common endocrine hypertension. For decades, PA diagnosis has required proving nonsuppressibility of aldosterone following maneuvers modulating the renin-angiotensin-aldosterone pathway. This includes oral salt suppression, intravenous saline suppression, captopril suppression, and others. Grounded in rational first principles from pathophysiologic considerations and small, early pathophysiologic studies following Conn's initial PA description, such testing has been widely recommended. However, a modern understanding of PA pathophysiology and critical appraisal of diagnostic test studies suggest that traditional suppression testing is not suited to diagnosis or disease definition. There are four main problems recently raised regarding aldosterone suppression testing: (i) PA is now known to exist along a continuous biochemical spectrum and it is scientifically impossible to draw a single, diagnostic threshold within this continuum. (ii) Aldosterone assay uncertainty is sufficiently large to yield contradictory final diagnoses when applied to a threshold during suppression testing. (iii) The pathophysiology of PA is multifactorial with multiple mechanisms not necessarily relevant to salt and volume loading tests. (iv) Finally, meta-analysis of suppression testing studies demonstrated extensive biases and confounders, which have overestimated the diagnostic value. A recent prospective, blinded study of saline suppression for PA diagnosis defined by medical or surgical response to PA-targeted therapy showed no discrimination according to nadir aldosterone level. Given the clinical value of a PA diagnosis and the high prevalence of the disease, modern evidence suggests that aldosterone suppression testing should now be retired from the diagnostic pathway; new ways of approaching the definition of PA are provided to spur further discussion.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.037 | 0.109 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.002 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.002 | 0.009 |
| Scholarly communication | 0.007 | 0.014 |
| Open science | 0.004 | 0.003 |
| Research integrity | 0.009 | 0.026 |
| Insufficient payload (model declined to judge) | 0.008 | 0.007 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".