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Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events
Open accessAbstract
BACKGROUND: The optimal range of sodium intake for cardiovascular health is controversial. METHODS: We obtained morning fasting urine samples from 101,945 persons in 17 countries and estimated 24-hour sodium and potassium excretion (used as a surrogate for intake). We examined the association between estimated urinary sodium and potassium excretion and the composite outcome of death and major cardiovascular events. RESULTS: The mean estimated sodium and potassium excretion was 4.93 g per day and 2.12 g per day, respectively. With a mean follow-up of 3.7 years, the composite outcome occurred in 3317 participants (3.3%). As compared with an estimated sodium excretion of 4.00 to 5.99 g per day (reference range), a higher estimated sodium excretion (≥ 7.00 g per day) was associated with an increased risk of the composite outcome (odds ratio, 1.15; 95% confidence interval [CI], 1.02 to 1.30), as well as increased risks of death and major cardiovascular events considered separately. The association between a high estimated sodium excretion and the composite outcome was strongest among participants with hypertension (P=0.02 for interaction), with an increased risk at an estimated sodium excretion of 6.00 g or more per day. As compared with the reference range, an estimated sodium excretion that was below 3.00 g per day was also associated with an increased risk of the composite outcome (odds ratio, 1.27; 95% CI, 1.12 to 1.44). As compared with an estimated potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a reduced risk of the composite outcome. CONCLUSIONS: In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 g per day and 6 g per day was associated with a lower risk of death and cardiovascular events than was either a higher or lower estimated level of intake. As compared with an estimated potassium excretion that was less than 1.50 g per day, higher potassium excretion was associated with a lower risk of death and cardiovascular events. (Funded by the Population Health Research Institute and others.).
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“Studies have shown that high sodium intake is associated with increased blood pressure (25,26).”
Potassium – a scoping review for Nordic Nutrition Recommendations 2023
Toft, U., Riis, N. L., & Jula, A. (2024) · Food & Nutrition Research · doi:10.29219/fnr.v68.10365 · Cited by 15
Long-term potassium intake and associated renal and cardiovascular outcomes in the clinical setting
Engberink, R. O., van den Born, B. H., Sengers, H. P., & Vogt, L. (2020) · Clinical Nutrition · doi:10.1016/j.clnu.2020.03.026 · Cited by 15
Toft, U., Riis, N. L., Lassen, A. D., Trolle, E., Andreasen, A. H., Frederiksen, A. K. S., Joergensen, N. R., Munk, J. K., & Bjoernsbo, K. S. (2020) · Nutrients · doi:10.3390/nu12051467 · Cited by 15
Ishigami, T., Kino, T., Minegishi, S., Araki, N., Umemura, M., Ushio, H., Saigoh, S., & Sugiyama, M. (2020) · International Journal of Molecular Sciences · doi:10.3390/ijms21113871 · Cited by 16
Dietary intervention for the management of hypertension in Asia
Chang, H., Cheng, H., Chen, C., Wang, T., Soenarta, A. A., Turana, Y., Teo, B. W., Tay, J. C., Tsoi, K. K. F., Wang, J., et al. (2020) · Journal of Clinical Hypertension · doi:10.1111/jch.14116 · Cited by 17
Sari, D. W., Noguchi‐Watanabe, M., Sasaki, S., Sahar, J., & Yamamoto-Mitani, N. (2021) · British Journal Of Nutrition · doi:10.1017/s0007114521000271 · Cited by 17
Levels of dietary sodium intake: diverging associations with arterial stiffness and atheromatosis
Tsirimiagkou, C., Karatzi, K., Argyris, A., Chalkidou, F., Tzelefa, V., Sfikakis, P. P., Yannakoulia, M., & Protogerou, A. D. (2021) · Hellenic Journal of Cardiology · doi:10.1016/j.hjc.2021.02.005 · Cited by 16
Sun, H., Ma, B., Wu, X., Wang, H., & Zhou, B. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.645902 · Cited by 15
Re, F., Hammami, I., Littlejohns, T. J., Arnold, M., Lewington, S., Clarke, R., & Carter, J. L. (2021) · Hypertension · doi:10.1161/hypertensionaha.120.16549 · Cited by 15
Ito, T., Takeda, M., Hamano, T., Kijima, T., Yamasaki, M., Isomura, M., Yano, S., Shiwaku, K., & Nabika, T. (2015) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2015.10.013 · Cited by 16
“While 24-hour urinary sodium excretion estimated from a spot urine sample using Tanaka's formula only has a modest correlation with actual sodium excretion measured by 24-hour urine collection [14–16], this method is considered useful for evaluation of salt intake in epidemiological studies with a large population bec…”
MethodLanzani, C. L., Gatti, G., Citterio, L., Messaggio, E., Carpini, S. D., Simonini, M., Casamassima, N., Zagato, L., Brioni, E., Hamlyn, J. M., et al. (2015) · Hypertension · doi:10.1161/hypertensionaha.115.06415 · Cited by 15
Con: Reducing salt intake at the population level: is it really a public health priority?
Graudal, N. A. (2016) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfw280 · Cited by 15
Vidal‐Petiot, E., Joseph, A., Resche‐Rigon, M., Boutten, A., Mullaert, J., d’Ortho, M., Vrtovsnik, F., Steg, P. G., & Flamant, M. (2017) · Journal of Hypertension · doi:10.1097/hjh.0000000000001609 · Cited by 16
“Several previous major population studies on the link between individual salt intake and outcome [6,12] were based on the Kawasaki formula, when the reference validation study to date, on which these studies relied, was based on an overnight urine [37].”
BackgroundMethodResultInfluentialJudge, C. S., O'Donnell, M. J., Hankey, G. J., Rangarajan, S., Chin, S. L., Ps, R., Ferguson, J. P., Smyth, A., Xavier, D., Lisheng, L., et al. (2020) · American Journal of Hypertension · doi:10.1093/ajh/hpaa176 · Cited by 18
Self-citationSerum Potassium and Cardiovascular Outcomes: The Highs and the Lows
Toto, R. D. (2017) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.00030117 · Cited by 16
Endothelin-1 signaling in the kidney: recent advances and remaining gaps
Brooks, A. J., Gallego‐López, M. D. C., & Miguel, C. D. (2025) · American Journal of Physiology-Renal Physiology · doi:10.1152/ajprenal.00304.2024 · Cited by 14
Chronic Kidney Disease Management in Developing Countries
Badro, D. A. (2023) · Springer eBooks · doi:10.1007/978-3-030-74786-2_27-1 · Cited by 18
Less sodium and more potassium to reduce cardiovascular risk
Muiesan, M. L., Buso, G., & Rosei, C. A. (2023) · European Heart Journal Supplements · doi:10.1093/eurheartjsupp/suad084 · Cited by 14
Is Fluid Overload as Measured by Bioimpedance Spectroscopy Harmful in CKD—If So, Why?
Hebert, L. A., & Parikh, S. M. (2014) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.11311114 · Cited by 14
What Determines Human Sodium Intake: Policy or Physiology?
McCarron, D. A. (2014) · Advances in Nutrition · doi:10.3945/an.114.006502 · Cited by 15
Association of Urinary Sodium Excretion With Insulin Resistance in Korean Adolescents
Chun, Y. H., Han, K., Kim, D., Park, Y. G., Cho, K.-H., Choi, Y. S., Kim, S. M., Kim, Y., & Nam, G. E. (2016) · Medicine · doi:10.1097/md.0000000000003447 · Cited by 14
Capítulo 6 - Tratamento não medicamentoso
Malachias, M. V. B., Souza, W., Plavnik, F. L., Rodrigues, C., Brandão, A., Neves, M. F., Bortolotto, L. A., Franco, R., Figueiredo, C., Jardim, P., et al. (2016) · Arquivos Brasileiros de Cardiologia · doi:10.5935/abc.20160156 · Cited by 15
The burden of hypertension in Ecuador: a systematic review and meta-analysis
Hajri, T., Cáceres, L. F., & Angamarca-Armijos, V. (2021) · Journal of Human Hypertension · doi:10.1038/s41371-020-00471-7 · Cited by 16
“It is well-established that excess sodium intake increases blood pressure [37].”
BackgroundHorikawa, C., Aida, R., Tanaka, S., Kamada, C., Tanaka, S., Yoshimura, Y., Kodera, R., Fujihara, K., Kawasaki, R., Moriya, T., et al. (2021) · Nutrients · doi:10.3390/nu13020689 · Cited by 15
“A previous prospective study in 17 countries reported that mortality and cardiovascular events are greater on both a high sodium excretion, as well as on a low sodium excretion [25], and some populations demonstrate an increase in blood pressure on a low sodium diet and are considered to be inverse salt sensitive [26].”
BackgroundHigh Adherence to Mediterranean Diet Is Not Associated with an Improved Sodium and Potassium Intake
Viroli, G., Gonçalves, C., Pinho, O., Silva-Santos, T., Padrão, P., & Moreira, P. A. M. (2021) · Nutrients · doi:10.3390/nu13114151 · Cited by 16
“It has been associated with lower blood pressure and a lower risk of death and CV events [20,49] as well as Mediterranean diet [25].”
BackgroundThe effect of sodium restriction on iodine prophylaxis: a review
Nista, F., Bagnasco, M., Gatto, F., Albertelli, M., Vera, L., Boschetti, M., Musso, N. R., & Ferone, D. (2022) · Journal of Endocrinological Investigation · doi:10.1007/s40618-022-01749-y · Cited by 14
Dietary Sodium: Where Science and Policy Diverge
Alderman, M. H. (2014) · American Journal of Hypertension · doi:10.1093/ajh/hpu256 · Cited by 14
“(4) Recommend that physicians of patients at CVD risk determine sodium intake and provide appropriate care.”
BackgroundSugimoto, M., Asakura, K., Masayasu, S., & Sasaki, S. (2015) · Nutrition Research · doi:10.1016/j.nutres.2015.12.012 · Cited by 14
“health risks, such as hypertension and cardiovascular disease [1-3].”
Background
Metadata
- Authors
- O'Donnell, M., Mente, A., Rangarajan, S., McQueen, M. J., Wang, X., Liu, L., Yan, H., Lee, S. F., Mony, P., Devanath, A., Rosengren, A., Lopez-Jaramillo, P., Diaz, R., Avezum, A., Lanas, F., Yusoff, K., Iqbal, R., Ilow, R., Mohammadifard, N., Gulec, S., Yusufali, A. H., Kruger, L., Yusuf, R., Chifamba, J., Kabali, C., Dagenais, G., Lear, S. A., Teo, K., & Yusuf, S.
- Affiliations
- Ollscoil na Gaillimhe – University of Galway (IE)
- Population Health Research Institute (CA)
- Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
- St. John's Research Institute (IN)
- University of Gothenburg (SE)
- Universidad de La Frontera (CL)
- UCSI University (MY)
- Aga Khan University (PK)
- Isfahan University of Medical Sciences (IR)
- Independent University, Bangladesh (BD)
- University of Zimbabwe (ZW)
- Institut universitaire de cardiologie et de pneumologie de Québec (CA)
- Providence Health Care (CA)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2014-08-14
- Volume
- 371
- Issue
- 7
- Pages
- 612-623
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2106445408
- Cited by
- 886
- References
- 43
- Citations by year
- 2026: 29 · 2025: 37 · 2024: 55 · 2023: 60 · 2022: 73 · 2021: 84 · 2020: 82 · 2019: 68 · 2018: 81 · 2017: 76 · 2016: 100 · 2015: 98 · 2014: 41
- FWCI
- 95.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, cc-by-nc-nd)
- Omeka S (Universidad de La Frontera) (submittedVersion, cc-by-nc-nd)
- Boloka Institutional Repository (North-west University) (submittedVersion)
- Funders
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Keywords
- sodium excretion, potassium excretion, sodium intake, potassium intake, mortality, cardiovascular events, hypertension
- MeSH terms
- Adult, Cardiovascular Diseases, Diet, Female, Follow-Up Studies, Humans, Male, Middle Aged, Mortality, Potassium, Sodium, Sodium, Dietary, Linear Models
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