What is it about?

We already know that primary aldosteronism (PA) accounts for 10% of newly diagnosed hypertension and is a significant cause of secondary or refractory hypertension. We also know that PA could result in both macro- and microvascular complications. Thus, the recent American Endocrine Society recommends screening for the Aldosterone-to-Renin Ratio (ARR) in newly diagnosed hypertensive Patients. However, the aberrant ARR in diabetic patients with or without hypertension has been associated with microvascular lesions, while the cut-off of ARR and its mechanism are undergoing investigation. In this real-world retrospective study, we analyzed the ARR under the PA cut-off. We tried to simulate the real model of ARR dynamic evolution and to reveal its ability to predict renal micro-vasculopathy, as marked by UACR, a biomarker of DKD.

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Why is it important?

Beyond the chronic hyperglycemic lesion in the pathophysiology of diabetic kidney disease (DKD), hyperaldosteronism may also contribute to renal micro-lesions. However, the ARR is recommended as an initial screening tool for hypertension refractoriness in some diabetic patients or those with metabolic syndrome (Met), who may have elevated or abnormal Renin-Angiotensin-Aldosterone System (RAAS) activation. Many patients may have an ARR below the diagnostic cutoff for primary aldosteronism (PA). In diagnosing and treating PA, the ARR serves only as a preliminary screening tool, as numerous physiological and pathophysiological factors can influence it. In a clinical setting, withdrawing and replacing antihypertensive medications in diabetic patients can be challenging for both PA diagnosis and ARR evaluation. In this study, we aimed to assess the dynamic evolution of ARR in a real clinical environment, including patients without a history or evidence of PA, to reflect actual ARR profiles. We found that, in addition to hypertension-related parameters, other indices, such as calcium homeostasis and insulin requirements, may assist in developing a more comprehensive understanding; thus, in future studies, when building an accurate ARR model, we should consider a multi-parameter model paradigm. We employed two assessment methods, direct renin concentration (PDC) and plasma renin activity (PRA), both of which showed generally consistent results in dynamic population profiles and in their relationships with DKD, potentially aiding in evaluating DKD progression.

Perspectives

Basic studies have elucidated the multifactorial nature of the RAAS and its aberrancy in many metabolic disorders, such as CKD, hypertension, HF, Obesity, stroke, myocardial remodeling, Osteoporosis, etc. The relationship between the systemic and local aldosterone system may require further investigation in the pathophysiology of many human metabolic disorders and organ lesions. In a clinical setting, an early elevated ARR should be evaluated as a risk factor in some rare early-onset hypertension, stroke, and ACS, where other traditional risk factors or family history could be excluded.

Dr. Song Wen
Shanghai Pudong Hospital, Fudan University

Read the Original

This page is a summary of: The Renal Micro-Vasculopathy and Systemic Aldosterone-Renin Ratio (ARR) in Type 2 Diabetic Patients—A Retrospective Real-World Study, Diabetes Metabolic Syndrome and Obesity, November 2025, Taylor & Francis,
DOI: 10.2147/dmso.s557805.
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