Improving primary aldosteronism detection and classification in the UK

4.05pm – 5.45pm BST, 9 June 2026 ‐ 1 hour 40 mins

Parallel session

Chair, Tejas Kalaria

Primary aldosteronism – 2026 update, Mark Gurnell

Primary aldosteronism (PA) is now recognised as a common and potentially curable cause of secondary hypertension, with prevalence estimates substantially higher than previously appreciated. Once thought to be rare, PA accounts for a significant proportion of patients with hypertension, particularly those with resistant disease or hypokalaemia. Nevertheless, the condition remains under-recognised and frequently undiagnosed in routine clinical practice.

Current diagnostic algorithms, typically based on screening with the aldosterone-to-renin ratio followed by confirmatory suppression testing, are often complex and inconsistently applied. In addition, rigid screening criteria may fail to identify patients with milder or normokalaemic disease. Improved understanding of the biological continuum of aldosterone excess has prompted reconsideration of established diagnostic thresholds and the traditional dichotomous classification into unilateral and bilateral subtypes.

Adrenal vein sampling (AVS) remains the reference standard for lateralisation and selection of surgical candidates, yet its technical complexity and limited availability restrict widespread use. Conventional anatomical imaging with CT or MRI frequently lacks sufficient discriminatory power, and interpretation may be confounded by the high prevalence of non-functioning adrenal incidentalomas. These limitations contribute to delays in definitive management and the underuse of potentially curative adrenalectomy.

Emerging non-invasive biomarkers and advances in molecular and functional imaging hold promise for simplifying diagnostic pathways and improving subtype classification. These developments may facilitate novel therapeutic approaches, including minimally invasive ablative techniques. Concurrently, there is increasing interest in broader and earlier screening strategies to mitigate the long-term cardiovascular and renal sequelae of sustained aldosterone excess.

As insights into the molecular and clinical spectrum of PA continue to expand, traditional diagnostic and management paradigms are being challenged. Integration of new technologies and revised strategies may be required to improve detection, personalise treatment, and optimise patient outcomes.
Learning outcomes: 

1. Understand the evolving epidemiology and clinical spectrum of primary aldosteronism, including reasons for its persistent underdiagnosis despite its high prevalence and potential curability.
2. Evaluate the limitations of current diagnostic and lateralisation strategies for primary aldosteronism and the implications these have for timely and appropriate treatment selection.
3. Recognise how emerging biomarkers, molecular imaging, and earlier screening approaches may reshape future diagnostic pathways and improve cardiovascular and renal outcomes in patients with primary aldosteronism.

Developing UK guidelines for biochemical investigation of Primary Aldosteronism, Sophie Barnes

The Renin Aldosterone Standardisation and Harmonisation group (RASH) are a collaborative group of Clinical Scientists, Chemical Pathologists, Clinical Endocrinologists, Endocrine Surgeons and Clinical Pharmacologists working to improve the detection of Primary Aldosteronism (PA) in the United Kingdom. This group was established in 2024 after a Lab Med Audit showed marked variation in UK practice.

Detection of PA can be problematic as patients are often on multiple antihypertensive agents when first tested. We have developed consensus guidelines to provide advice for non-specialists to ensure PA detection is as comprehensive and appropriate as possible.

Alongside the recently revised Endocrine Society guidelines, Sophie will present the first set of UK consensus guidelines and discuss some of the considerations around stability, medications, intra-individual variability, confounding factors etc. The talk will also share current and future areas for harmonisation that the RASH workstream intend to cover.
Learning outcomes:

1. Familiarity with latest evidence and best practice guidance for Primary Aldosteronism detection including sample stability, medications, intra-individual variability, confounding factors and more.
2. Presentation of RASH UK consensus guidelines.
3. Current and proposed activities of RASH workstream.

RASH-UK Workstream 1: Conn laboratories reduce variability in primary aldosteronism? Sarah Davies

RASH-UK (Renin and Aldosterone Standardisation and Harmonisation United Kingdom) group was established in 2024 following a LabMed United Kingdom-wide audit of the laboratory investigation of primary aldosteronism (doi: 10.1177/00045632251319984) which showed marked variation in practice across all stages of the diagnostic pathway. We are a multi-professional collaborative group of Clinical Scientists, Chemical Pathologists, Endocrinologists and other relevant specialists working to improve this.

RASH-UK Workstream One is principally focussed on analytical improvements. To this end, it has produced and distributed specimens (pooled patient material from both males and females across the analytical measuring interval) with Birmingham Quality for replicate analysis by liquid chromatography tandem mass spectrometry and chemiluminescence immunoassay on the major analytical platforms at assorted clinical laboratories within the UK. This aims to increase understanding of analytical differences and comparability between methods as a starting point for further harmonisation/standardisation efforts. Data from the first phase of experimental work will be presented as well as possible next steps for this working group.
Learning outcomes:

1. Obtain an overview of Renin and Aldosterone Standardisation and Harmonisation United Kingdom (RASH-UK) Workstream 1 activities to date.
2. Understand the implications of analytical variation across the primary aldosteronism diagnostic pathway.
3. Discuss further work required to progress harmonisation/standardisation efforts.

Speakers

Tejas Kelaria

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Sarah Davies

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Sophie Barnes

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Mark Gurnell

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Tejas Kelaria

Tejas Kalaria is a Consultant in Chemical Pathology and Metabolic Medicine at Black Country Pathology Services, The Royal Wolverhampton NHS Trust, and Member young scientist on the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) post-analytical phase working group.

Dr Kalaria’s areas of interest include endocrine biochemistry and post-analytics.

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Sarah Davies

Sarah Davies is a Principal/HSST clinical scientist & EQA scheme manager at Birmingham Quality. She’s a Fellow of the Royal College of Pathologists working towards a DClinSci. She’s an honorary lecturer at the University of Manchester, with active interests in publication/peer review (ORCHID ID: 0000-0003-1689-7134).

Between 2021–2025, Sarah developed significant expertise in adrenal biochemistry (particularly Primary aldosteronism) and cardiovascular disease (particularly lipids and high-sensitivity cardiac troponin) through membership of the Adrenal multidisciplinary team, participating in lipid service improvements and working on the MACROS2 trial at University Hospitals Liverpool Group. This created a drive to apply clinical insights for quality improvements, notably through the Renin and Aldosterone Standardisation and Harmonisation (RASH-UK) group.

In 2025, Sarah moved into External Quality Assessment where she combines her analytical/clinical insights in analytical performance monitoring activities. She is developing experience in traceability through appointment to the JCTLM database Review Team for Non-Peptide Hormones and Corresponding Membership of the IFCC Committee on Traceability in Laboratory Medicine. Sarah was appointed as joint Clinical lead for Guideline Adjudication (Royal College of Pathologists). These roles emphasise commitment to reducing unwarranted analytical variability to allow consistent clinical decision making with maximal patient benefit.

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Sophie Barnes

Sophie is a Consultant clinical scientist in Clinical Biochemistry at North West London Pathology.

Although she covers all areas of Clinical Biochemistry, Sophie specialises in aldosterone and renin analysis and interpretation.

She was appointed as Director of the Supra-Regional Assay Service (SAS) for renin and aldosterone in 2008 and chairs the SAS Endocrinology SubGroup.

More recently, she has been part of the Renin and Aldosterone Standardisation and Harmonisation group and had the pleasure of leading the clinical workstream.

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Mark Gurnell

Mark Gurnell holds several senior appointments in Cambridge:

• Professor of Clinical Endocrinology, University of Cambridge
• Clinical lead, Endocrine Services, Addenbrooke's Hospital
• Head of section, Department of Medicine
• Clinical subdean, School of Clinical Medicine

His clinical & research interests are focused on pituitary, adrenal & thyroid disorders.

He serves on several national & international committees including:

• Council, UK Society for Endocrinology
• Education Committee, European Society of Endocrinology
• Board of directors, Professional Education & Career Development Committees, Pituitary Society

He currently holds several senior appointments in medical education, including:

• Chair, Executive Board, UK Medical Schools Council Assessment Alliance
• Chair, Exam Board, UK Medical Licensing Assessment (MLA) Applied Knowledge Test
• Co-chair, European Board Examination in Endocrinology, Diabetes & Metabolism