Aldosterone / Direct Renin Ratio (ADRR)
A calculated ratio of aldosterone to direct renin concentration. Clinicians use it as a first step when looking into primary aldosteronism in people with high blood pressure.
AI-verified against cited sources. Awaiting expert reviewAlso called ADRR, ARR-DRC, A/DRCLOINC 30894-0
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What it is
Aldosterone and renin normally move in step: when renin falls, aldosterone should fall too. This version of the ratio uses direct renin concentration, which is the amount of active renin in the blood, rather than renin activity. The two renin tests are not interchangeable, so a ratio made with one can't be compared with cut points made for the other. Labs get the ratio by dividing aldosterone by direct renin, so it depends on both measurements and on the units used.
Why it matters
The ratio is a first-step test, not a diagnosis. A result above the cut point is a reason for more testing. The Endocrine Society's 2025 guideline suggests testing aldosterone and renin in everyone with high blood pressure, because primary aldosteronism is often missed. The ratio can mislead. Medicines, potassium, salt intake and age can push it up or down. With direct renin, the menstrual cycle and estrogen also matter. Both false alarms and missed cases happen, so your own lab's cut point matters.
If it’s low
A low ratio is usually not a concern. It often reflects a high renin level, which low salt intake, dehydration, water pills, ACE inhibitors and angiotensin receptor blockers can cause. It can also be falsely reassuring. Low potassium or some medicines can hide a high ratio. A clinician may repeat the test on another day if there is a strong reason to suspect primary aldosteronism.
Common causes
- ACE inhibitors or angiotensin receptor blockers
- Water pills (diuretics) or aldosterone-blocking medicines
- Low potassium
- Low salt intake or dehydration
- Pregnancy
- Narrowed kidney arteries or very high blood pressure
What can help
- Ask whether your medicines or your potassium level could have affected the result
- Ask whether the test should be repeated if your clinician still has concerns
If it’s high
A high ratio means aldosterone is high compared with direct renin. Several everyday things can push it up, including the second half of the menstrual cycle, estrogen-containing medicines, beta-blockers, older age and kidney problems. A high ratio is a reason for more testing, not a diagnosis. If aldosterone is also high and renin is low, a clinician may suggest confirmation tests.
Common causes
- Being premenstrual or in the second half of the menstrual cycle, or taking estrogen-containing birth control or hormone therapy, which lower direct renin
- Beta-blockers, clonidine or NSAIDs
- Age 65 or older
- Reduced kidney function
- A high-salt diet
- Primary aldosteronism, where the adrenal glands make too much aldosterone on their own
What can help
- Ask whether your medicines, your cycle or estrogen could have changed the ratio, and don't stop any medicine on your own
- Ask whether a ratio made with renin activity would be a better fit for you
- Ask whether a repeat test or a confirmation test makes sense
Usual ranges
What labs print as the reference range, by who was tested. Ranges differ a little between labs, so the range on your own report is the one your result is judged against.
For adults: up to 4 ng/dL per pg/mL. Source: ARUP Laboratories, ARUP Consult, Cleveland Clinic Laboratories.
- Adults (this one applies)up to 4 ng/dL per pg/mL
Sources: ARUP Laboratories, ARUP Consult, Cleveland Clinic Laboratories
Endocrine Society 2025 first-step cut point for direct renin of 5.2 ng/L or less, aldosterone by immunoassay (also needs aldosterone of 10 ng/dL or more)
- 4.0 or lowerbelow 4 ng/dL per pg/mL
- Above 4.04 and above ng/dL per pg/mL
Endocrine Society 2025 first-step cut point for direct renin of 5.2 ng/L or less, aldosterone by LC-MS/MS (also needs aldosterone of 7.5 ng/dL or more)
- 2.8 or lowerbelow 2.8 ng/dL per pg/mL
- Above 2.82.8 and above ng/dL per pg/mL
What can affect your result
- Medicines that raise or lower aldosterone or renin
- Sex, cycle phase and estrogen: direct renin runs lower, which can inflate the ratio
- Potassium level and salt intake
- Age and kidney function
- Posture, time of day and sample handling (the renin tube should not be chilled)
- The renin test: direct renin and renin activity give ratios on different scales
- Direct renin must not be chilled. Cold activates prorenin and falsely raises renin, which lowers the ratio, so the tubes are kept and spun at room temperature and the plasma is frozen.
- Menstruating women and people taking estrogen-containing medicines have lower direct renin, which can make the ratio falsely high. ARUP suggests the renin-activity version of the ratio in those cases.
- Medicines change the ratio. Beta-blockers, clonidine and NSAID pain relievers can raise it (a false positive). ACE inhibitors, angiotensin receptor blockers, water pills, aldosterone-blocking medicines and dihydropyridine calcium blockers can lower it (a false negative). Renin inhibitor medicines push the ratio in different directions depending on the renin test. Never stop a medicine on your own: your clinician decides whether to test as you are or to adjust some medicines first.
- Low potassium can lower the ratio. A low-salt diet can hide a high ratio, and a high-salt diet can inflate it.
- Age 65 or older and reduced kidney function tend to raise the ratio.
- Some immunoassays are affected by high-dose biotin supplements. Ask your lab whether to hold biotin before the draw.
Morning, seated, without a long tourniquet time (ARUP and the Endocrine Society 2025). If lying down, ARUP asks for at least 30 minutes in that position first. Fasting is recommended but not required (Cleveland Clinic Laboratories). Shows the moment of the draw. Medicines that interfere with the test can take 2 to 4 weeks to clear.
When to talk to a clinician
Contact the clinician who ordered the test if your lab flagged the result. Seek urgent care for severe muscle weakness, fainting, a racing or uneven heartbeat or confusion. If your blood pressure is very high and you have chest pain, trouble breathing, vision changes or a severe headache, call 911 or your local emergency number.
Questions you could ask
- Which renin test did my lab use, and what cut point does it use?
- Could my menstrual cycle, estrogen or my medicines have raised this ratio?
- Would a ratio made with renin activity be a better fit for me?
- Could my medicines or a low potassium level have hidden a high ratio?
Questions people ask
What is the difference between this ratio and the renin activity ratio?
They use two different renin tests. Direct renin measures the amount of active renin, while renin activity measures how much renin is doing its job. The numbers and cut points differ, and direct renin tends to read lower in menstruating women and people on estrogen. Don't compare a ratio from one with cut points from the other.
Why does my lab's range differ from the guideline's cut point?
A lab range describes where results from a group of people fall. A guideline cut point is chosen to balance missed cases against false alarms, and a positive first-step result also needs aldosterone to be high enough and renin to be low. The Endocrine Society says to use your own lab's cut points where possible. Neither one is a diagnosis.
Should I stop my blood pressure medicine before this test?
Please don't stop any medicine on your own. Some medicines change aldosterone and renin, and your clinician decides whether to test as you are, adjust a few medicines for a short time, or repeat the test later.
Show the science and sources
Units
- 1 ng/dL per pg/mL = 1 ng/dL per pg/mL
- 1 ng/dL per pg/mL = 27.75 pmol/L per ng/L
For clinicians and researchers
ADRR = aldosterone ÷ direct renin concentration (DRC). ARUP divides aldosterone in ng/dL by DRC in pg/mL (equal to ng/L) and prints the ratio without a unit. The Endocrine Society's 2025 guideline (Table 5) gives screening cut points for DRC of 5.2 ng/L or less: above 4.0 ng/dL per ng/L with aldosterone of 10 ng/dL or more by immunoassay, or above 2.8 with 7.5 ng/dL or more by LC-MS/MS. In pmol/L per ng/L these are above 111 and above 82. For DRC expressed as 8.2 mU/L or less the guideline lists above 2.5 ng/dL per mU/L (immunoassay) and above 1.8 (LC-MS/MS), or above 70 and above 52 pmol/L per mU/L. The mU/L and ng/L forms are not converted here because the relationship depends on the assay. The guideline says to rely on local laboratory cut points where possible. ARUP's current test page (effective April 2026) prints 4.0 or less, an earlier version printed 0.1 to 3.7, and ARUP Consult lists a 3.7 cut point when aldosterone is above 15 ng/dL. Direct renin is falsely raised by cold activation of prorenin, so ARUP and Cleveland Clinic Laboratories specify room-temperature processing and no ice. Direct renin runs lower in ovulating or premenstrual women and with estrogen, which inflates the ratio; screening in the luteal phase is better done with plasma renin activity. Renin inhibitors move PRA-based and DRC-based ratios in opposite directions. Medicine effects on aldosterone and renin follow the same pattern as for the renin-activity ratio.
LOINC 30894-0 (primary), 103560-9. Specimen: calculated.
Sources
- Aldosterone and Renin Direct, With Ratio (test 3005949), ARUP Laboratories
- Aldosterone/Direct Renin Ratio (test ALDREN), Cleveland Clinic Laboratories
- Aldosterone-Renin Ratio (Test Fact Sheet), ARUP Consult (2026)
- Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline, Journal of Clinical Endocrinology & Metabolism (2025)
- Aldosterone (PubChem CID 5839), NCBI PubChem
AI-verified against cited sources. Awaiting expert review. Last reviewed 2026-10-03. How we build and check these pages.