See Article page 1277.
Sodium consumption in the United States is approximately 3,500mg/day as estimated from urinary sodium collections.1 Although there is consensus that this is too much sodium, there remains lively debate as to what reduction in sodium is beneficial and safe. This is reflected in differences of opinion of knowledgeable consensus panels, such as those from the American Heart Association, which recommends restricting sodium to <1,500mg/day in many cases,2 and the Institute of Medicine, which concluded that there is not enough evidence to support this low goal.3 The Institute of Medicine recommendations take into account some studies that suggest that targeting 1,500mg/day can be harmful, at least in selected populations.4,5 Critiques of these studies have suggested that there is stratification within the studies, with the sickest patients having the lowest sodium intake. In many of the studies, the estimation of sodium intake was not ideal.6 However, there are short-term meta-analysis data indicating that low-salt diets increase plasma renin, plasma aldosterone, plasma catecholamines, cholesterol, and triglycerides.7 The long-term effects of these changes could potentially be harmful
In this issue of the Journal, Smyth et al. 8 have reviewed published data in an attempt to determine whether it is possible to define a level of sodium intake that slows the progression of kidney disease. The strict criteria used for this article, which required robust evidence for sodium intake, allowed inclusion of only 7 studies, 4 in chronic kidney disease (CKD) and 3 in normal populations. Heterogeneity in study design prohibited a meta-analysis. Review of the data shows that high sodium intake (>4,600mg/day) is deleterious compared with low intake (<2,300mg/day), but no conclusion could be drawn about whether moderate sodium intake (2,300–4,600mg/day) was harmful compared with low sodium intake. The strengths of this review are that it uses data from prospective studies with a renal outcome and that 5 of the 7 studies had multiple urinary sodium collections, 1 had multiple food frequency questionnaires, and only 1 relied on a single sodium collection. The weaknesses are that few studies were included and study design was heterogenous. In the end, it was not possible to define an ideal level of daily sodium intake to limit CKD progression.
There are data from other studies that suggest that sodium intake plays a role in progression of CKD. There are important epidemiologic data that relate incidence of cardiovascular disease9 and end-stage renal disease10 to levels of blood pressure: for every increment in blood pressure there is an increase in risk, without an apparent threshold. Because there are data that salt restriction can reduce blood pressure, as best shown in the Dietary Approaches to Stop Hypertension study,11 this has led to the call to reduce dietary sodium intake to decrease the incidence of cardiovascular and renal disease. There are also additional prospective studies that did not meet the criteria for the Smyth study that show a link between sodium intake and CKD progression. For example, in the African American Study of Kidney Disease and Hypertension, there was a significant association of increased sodium intake with renal events (halving of glomerular filtration rate, or end-stage renal disease, or death) in unadjusted analyses.12 However, this effect was lost after adjustment for proteinuria, which could be interpreted to indicate that higher sodium intake causes increased proteinuria.
Animal studies also provide evidence that high salt intake promotes renal disease and provide information as to mechanism. Many of these effects are not blood pressure dependent. For example, salt loading can diminish glomerular filtration rate, increase proteinuria, and cause renal hemodynamic changes independent of blood pressure in spontaneously hypertensive rats.13 Animal models that are commonly used to study CKD, including, for example, reduced renal mass14 and deoxycorticosterone acetate–salt15 require high salt intake to promote renal disease. These models have shown that high salt increases production of oxygen free radicals in the kidney, increases expression of enzymes that are pro-oxidant, and decreases antioxidant pathways.16 High salt also diminishes renal nitric oxide production.17 Nitric oxide donors and antioxidants can slow the progression of renal disease in this setting.14 An additional effect of high-salt diet is that despite the salt surfeit and increases in blood pressure, it may increase renal angiotensinogen production, which is an index of intrarenal angiotensin II concentration.18 This suggests that the salt load may paradoxically stimulate the renal renin-angiotensin system and limit salt excretion. It has also been shown that angiotensin II increases oxidative stress in the kidney,19 resulting in renal damage. Sodium loading impairs microvascular function independent of blood pressure in humans, also likely by increasing oxidative stress.20 Finally, it has been shown that transient pretreatment with angiotensin II predisposes to hypertension and kidney damage when followed by a high-salt diet in the absence of exogenous angiotensin II,21 suggesting that prior exposure to angiotensin II can condition the kidney to respond adversely to salt.
The data presented herein and cogent arguments of others6 provide evidence that salt intake should be reduced in most populations to prevent cardiovascular disease and CKD progression. However, there are not enough data to determine the optimal target sodium consumption. There are very few studies that provide any data about sodium intake and CKD progression,8 and some studies, although criticized for potential methodological flaws, suggest harmful effects of very low sodium targets in selected populations.4,6 Furthermore, many of the arguments for sodium reduction are based on the resultant blood pressure reduction, regardless of the baseline blood pressure. However, several major treatment studies have not shown significant benefit of blood pressure targets <140/90 in hypertensive populations.22,23 This finding, in conjunction with the lack of good prospective studies, argues that appropriate outcome-based clinical trials should be planned to assess current sodium consumption goals for benefits and risks in broad-based populations, across a wide range of age, renal function, racial/ethnic, and comorbidity groups, as is being done for hypertension therapy (Systolic Blood Pressure Intervention Trial; https://www.sprinttrial.org/public/dspSprintScience.cfm). At the same time, public health efforts to reduce sodium content, particularly in prepared foods, should continue because the ubiquitous presence of high salt content in foods makes achieving even moderate levels of sodium consumption a challenge.
DISCLOSURE
The author declared no conflict of interest.
REFERENCES
- 1. Bernstein AM, Willett WC. Trends in 24-h urinary sodium excretion in the United States, 1957–2003: a systematic review. Am J Clin Nutr 2010; 92:1172–1180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Appel LJ, Frohlich ED, Hall JE, Pearson TA, Sacco RL, Seals DR, Sacks FM, Smith SC, Jr., Vafiadis DK, Van Horn LV. The importance of population-wide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation 2011; 123:1138–1143. [DOI] [PubMed] [Google Scholar]
- 3. Institute of Medicine. Sodium Intake in Populations: Assessment of Evidence. Washington DC: National Research Council, 2013. [Google Scholar]
- 4. O’Donnell MJ, Yusuf S, Mente A, Gao P, Mann JF, Teo K, McQueen M, Sleight P, Sharma AM, Dans A, Probstfield J, Schmieder RE. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA 2011; 306:2229–2238. [DOI] [PubMed] [Google Scholar]
- 5. Alderman MH, Cohen HW. Dietary sodium intake and cardiovascular mortality: controversy resolved? Curr Hypertens Rep 2012; 14:193–201. [DOI] [PubMed] [Google Scholar]
- 6. Whelton PK, Appel LJ, Sacco RL, Anderson CA, Antman EM, Campbell N, Dunbar SB, Frohlich ED, Hall JE, Jessup M, Labarthe DR, MacGregor GA, Sacks FM, Stamler J, Vafiadis DK, Van Horn LV. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation 2012; 126:2880–2889. [DOI] [PubMed] [Google Scholar]
- 7. Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens 2012; 25:1–15. [DOI] [PubMed] [Google Scholar]
- 8. Smyth A, O’Donnell MJ, Yusuf S, Clase C, Teo K, Canavan M, Reddan DN, Mann JF. Sodium intake and renal outcomes: a systematic review. Am J Hypertens 2014; 27:1277–1284. [DOI] [PubMed] [Google Scholar]
- 9. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903–1913. [DOI] [PubMed] [Google Scholar]
- 10. Klag MJ, Whelton PK, Randall BL, Neaton JD, Brancati FL, Ford CE, Shulman NB, Stamler J. Blood pressure and end-stage renal disease in men. N Engl J Med 1996; 334:13–18. [DOI] [PubMed] [Google Scholar]
- 11. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336:1117–1124. [DOI] [PubMed] [Google Scholar]
- 12. Norris KC, Greene T, Kopple J, Lea J, Lewis J, Lipkowitz M, Miller P, Richardson A, Rostand S, Wang X, Appel LJ. Baseline predictors of renal disease progression in the African American Study of Hypertension and Kidney Disease. J Am Soc Nephrol 2006; 17:2928–2936. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Matavelli LC, Zhou X, Varagic J, Susic D, Frohlich ED. Salt loading produces severe renal hemodynamic dysfunction independent of arterial pressure in spontaneously hypertensive rats. Am J Physiol Heart Circ Physiol 2007; 292:H814–H819. [DOI] [PubMed] [Google Scholar]
- 14. Carlstrom M, Brown RD, Yang T, Hezel M, Larsson E, Scheffer PG, Teerlink T, Lundberg JO, Persson AE. l-Arginine or tempol supplementation improves renal and cardiovascular function in rats with reduced renal mass and chronic high salt intake. Acta Physiol (Oxford) 2013; 207:732–741. [DOI] [PubMed] [Google Scholar]
- 15. Artunc F, Amann K, Nasir O, Friedrich B, Sandulache D, Jahovic N, Risler T, Vallon V, Wulff P, Kuhl D, Lang F. Blunted DOCA/high salt induced albuminuria and renal tubulointerstitial damage in gene-targeted mice lacking SGK1. J Mol Med (Berlin) 2006; 84:737–746. [DOI] [PubMed] [Google Scholar]
- 16. Kitiyakara C, Chabrashvili T, Chen Y, Blau J, Karber A, Aslam S, Welch WJ, Wilcox CS. Salt intake, oxidative stress, and renal expression of NADPH oxidase and superoxide dismutase. J Am Soc Nephrol 2003; 14:2775–2782. [DOI] [PubMed] [Google Scholar]
- 17. Tojo A, Kimoto M, Wilcox CS. Renal expression of constitutive NOS and DDAH: separate effects of salt intake and angiotensin. Kidney Int 2000; 58:2075–2083. [DOI] [PubMed] [Google Scholar]
- 18. Kobori H, Nishiyama A, Abe Y, Navar LG. Enhancement of intrarenal angiotensinogen in Dahl salt-sensitive rats on high salt diet. Hypertension 2003; 41:592–597. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Chabrashvili T, Kitiyakara C, Blau J, Karber A, Aslam S, Welch WJ, Wilcox CS. Effects of ANG II type 1 and 2 receptors on oxidative stress, renal NADPH oxidase, and SOD expression. Am J Physiol Regul Integr Comp Physiol 2003; 285:R117–R124. [DOI] [PubMed] [Google Scholar]
- 20. Greaney JL, DuPont JJ, Lennon-Edwards SL, Sanders PW, Edwards DG, Farquhar WB. Dietary sodium loading impairs microvascular function independent of blood pressure in humans: role of oxidative stress. J Physiol 2012; 590:5519–5528. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Lombardi D, Gordon KL, Polinsky P, Suga S, Schwartz SM, Johnson RJ. Salt-sensitive hypertension develops after short-term exposure to angiotensin II. Hypertension 1999; 33:1013–1019. [DOI] [PubMed] [Google Scholar]
- 22. Arguedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database Syst Rev 2009; 2009:CD004349. [DOI] [PubMed] [Google Scholar]
- 23. ACCORD Study Group, Cushman WC, Evans GW, Byington RP, Goff DC, Jr., Grimm RH, Jr., Cutler JA, Simons-Morton DG, Basile JN, Corson MA, Probstfield JL, Katz L, Peterson KA, Friedewald WT, Buse JB, Bigger JT, Gerstein HC, Ismail-Beigi F. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362: 1575–1585. [DOI] [PMC free article] [PubMed] [Google Scholar]