Greetings from Dr. Grim in Milwaukee.

[Guest guest]

I was just re-reading the important article you first authored on the prevalence of PA using the A/R ratio.I have some questions and some historical comments and some suggestions. Please feel free to pass these along to your coauthors.1. Salt is never mentioned in your article as necessary exposure which must be present before aldosterone causes hypertension, hypokalemia, fibrosis etc. This has been apparent since the DOCA salt model and ALDO salt models and even early studies in PA (Conn, Bravo and Schamelkamph (sp)) showed that one can control HTN and hypokalemia by using a very low sodium diet. The issue is how low does the Na need to be to control both and this seems to be an individual thing. I can tell you that recommending the DASH eating plan (1500 mg Na, 4700 mg K) eating plan has a remarkable effect on the need for BP meds, hypokalemia and its symptoms and BP in many patients with severe PA. Compliance is easily checked with a spot urine Na and K and creatinine. If the K is not higher than the Na (in mM/L) they are not DASHing.I have been doing this for at least 5 years on a yahoo Group I host that has over 550 PA patients on it. I can only give testimonials from the patients and their Drs. on the impressive effects on BP, K and need for BP meds including spiro and epeler. We would be interested in working with your group to set up an online data base for pts with PA. We get a new pt about every 3 days at this site. Many have had to suggest the Dx to their Dr in order to get tested. Despite years of drug resistant HNT and hypokalemia. But I am sure others in your group have seen the same thing. 2. I will present a poster at ASH in May (Grim CE, Hall S, V and the 500+ members of hyperaldosteronism a Support Group at Yahoo.com. Delayed Diagnosis of Primary Aldosteronism-help from the Web: a Yahoo support group for patients struggling with diagnosis and long-term management.) on this experience and perhaps will see you and some other members there. 3. Even the Endo Guidelines fail to mention diet salt and K as an adjunct to therapy. They should discuss the role of diet in the management of PA.I would urge your group to begin testing the effect of the DASH diet in pts with PA in a systematic fashion as this has a key role in the long term management of the problem. Even in post ADx pts who still have some HTN it helps. I suspect they have bilateral disease. 4. I note till 1985 almost no pts at Mayo were normokalemic. This is because they only worked up pts if they were hypokalemic until that time. I had several discussion with Jim Hunt about this long before 85 and his response was if there was no hypokalemia there is no PA so they screened only by doing K. This seems to be a commonly held belief in practice today still at least in the US. It is important that your group get this message to the practitioners. I have been doing this for almost 40 years and have seem to have had little impact.5. I have also noted and historical "creep" in the numbers used to Dx PA: I would make a nice review by someone in your group. For example when I was in Dr. Conn's lab the urine aldo have to be above 20 to the Dx to be made. At Indiana we used the post saline aldo of 13 as a cut off. It looks like. I just saw a ref that now uses 6.6. It has now been 5 years since you publication and it is time for a BP and K follow up and updating of failure rates over the long term. I trust your team has a new pub coming or I missed it.7. I may have sent you my review article below before FYI

See you in May? May your salt intake and pressure be low!Clarence Grim BS, MS, MD

Senior Consultant to Shared Care Research and Education Consulting, Inc.Clarence Grim BS, MS, MD FACP, FACCBoard Certified in Internal Medicine, Geriatrics and Hypertension. Training and faculty positions in past in Cardiology, Endocrinology and Nephrology