Prevalence, clinical characteristics and management of low-renin hypertension: a real-world cohort study

Emerging evidence suggests that patients with low-renin hypertension (LRH) benefit from targeted treatment with mineralocorticoid receptor antagonists (MRA). With broader screening for primary aldosteronism (PA), clinicians are increasingly identifying patients with low renin levels who do not meet current diagnostic criteria for PA. In the absence of specific management guidelines, these patients are often treated as having primary hypertension. This study aimed to assess the prevalence, clinical characteristics, and real-world management of LRH in a tertiary endocrine hypertension clinic. We conducted a retrospective audit of patients evaluated between 2016 and 2021. PA was diagnosed based on saline suppression test (SST) results. LRH and normal renin hypertension (NRH) were classified using a direct renin concentration below or above 10mU/L, respectively. Among 409 eligible patients, 82 (20%) had LRH, 221 (54%) had PA, and 106 (26%) had NRH. Compared to NRH, patients with LRH were older despite a similar duration of hypertension, more likely to be female, and non-Caucasian. They also had a lower 24-h urinary aldosterone excretion compared to both PA and NRH. Automated office blood pressure, urinary sodium, and potassium excretion were similar across groups. Only 25 patients with LRH (31%) were prescribed an MRA; others were prescribed conventional antihypertensive agents and/or discharged to their primary care physician. LRH was present in one-fifth of patients referred to for endocrine hypertension assessment. Management was inconsistent, underscoring the need for evidence-based diagnostic and treatment strategies for this under-recognized subtype of hypertension.