Pathology. 2026 May 30:S0031-3025(26)00529-5. doi: 10.1016/j.pathol.2026.04.003. Online ahead of print.
ABSTRACT
Primary aldosteronism (PA) is a prevalent yet under-recognised condition affecting up to 14% of patients with hypertension in primary care and up to 30% with resistant hypertension. PA is associated with an increased rate of cardiovascular disease compared to patients with similar blood pressure. The diagnosis of PA involves multiple steps; first, screening with the aldosterone-to-renin ratio (ARR), then if indicated, confirmatory dynamic function testing, and depending on the outcome of confirmation testing, subtyping with imaging and adrenal vein sampling (AVS). The United States Endocrine Society published an updated clinical practice guideline for the diagnosis and management of patients with PA in 2025 to provide a practical approach to improve rates of diagnosis and reduce the risk of adverse cardiovascular events through targeted treatment. This review highlights the significant changes contained in the 2025 guideline and outlines the impact on the clinical laboratory of those changes. Universal screening for PA in all patients with hypertension with an ARR test is now recommended, with the objective to improve the detection rate of PA. However, this will result in a significant increase in screening and subsequent diagnostic testing. The revised guideline focuses on the use of confirmatory testing to streamline patients for AVS based on the probability that the patient has lateralised PA, which is potentially surgically curable, as well as recognition of methodological differences in aldosterone measurement, reflected in method-specific thresholds. This guideline provides an updated strategy to optimise and streamline the diagnostic pathway for PA; however, the clinical laboratory will have an important role in the implementation and support of these changes.
PMID:42362393 | DOI:10.1016/j.pathol.2026.04.003