Cited by 886Sodium Intake and HealthBlood Pressure and Hypertension StudiesNutritional Studies and Diet

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Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events

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O'Donnell, Martin, Mente, Andrew, Rangarajan, Sumathy, McQueen, Matthew J., Wang, Xingyu, Liu, Lisheng, Yan, Hou, Lee, Shun Fu, Mony, Prem, Devanath, Anitha, Rosengren, Annika, Lopez-Jaramillo, Patricio, Diaz, Rafael, Avezum, Alvaro, Lanas, Fernando, Yusoff, Khalid, Iqbal, Romaina, Ilow, Rafal, Mohammadifard, Noushin, Gulec, Sadi, Yusufali, Afzal Hussein, Kruger, Lanthe, Yusuf, Rita, Chifamba, Jephat, Kabali, Conrad, Dagenais, Gilles, Lear, Scott A., Teo, Koon, Yusuf, Salim·2014·New England Journal of Medicine

DOI 10.1056/nejmoa1311889

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Abstract

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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Result
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Potassium Intake in India: Opportunity for Mitigating Risks of High-Sodium Diets
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Does Sodium Intake Induce Systemic Inflammatory Response? A Systematic Review and Meta-Analysis of Randomized Studies in Humans
Basdeki, E. D., Κόλλιας, Α., Mitrou, P., Tsirimiagkou, C., Georgakis, M. K., Chatzigeorgiou, A., Argyris, A., Karatzi, K., Μanios, Y., Sfikakis, P. P., et al. (2021) · Nutrients · doi:10.3390/nu13082632 · Cited by 13
Association between urinary sodium and potassium excretion and blood pressure and inflammation in patients with rheumatoid arthritis
Leon, D. A. C., Octaria, R., Ormseth, M. J., Oeser, A. M., Solus, J. F., Zhang, Y., Okafor, C., Titze, J. M., Stein, C. M., & Chung, C. P. (2017) · Clinical Rheumatology · doi:10.1007/s10067-017-3935-8 · Cited by 11
The Data Show a U-Shaped Association of Sodium Intake With Cardiovascular Disease and Mortality
Graudal, N. A. (2014) · American Journal of Hypertension · doi:10.1093/ajh/hpu236 · Cited by 11
Government Dietary Guidelines: Uncertain Science Leads to Questionable Public Health PolicyPreprint
Archer, E., Marlow, M. L., & Williams, R. A. (2018) · SSRN Electronic Journal · doi:10.2139/ssrn.3211651 · Cited by 11
Sodium and health: another challenge to the current dogma
Mente, A., O'Donnell, M. J., & Yusuf, S. (2020) · European Heart Journal · doi:10.1093/eurheartj/ehaa1093 · Cited by 11
Self-citation
Impact of dietary intake of sodium and potassium on short-term blood pressure variability
Chang, H., Wu, C., Lee, Y., Gu, Y.-H., Chen, Y., Tsai, Y., Chuang, S., Guo, C., Chen, C.-H., & Cheng, H. (2021) · Journal of Hypertension · doi:10.1097/hjh.0000000000002856 · Cited by 11
Kaliuresis and Intracellular Uptake of Potassium with Potassium Citrate and Potassium Chloride Supplements
Wouda, R. D., Gritter, M., Karsten, M., Michels, E. H. A., Nieuweboer, T. M., Danser, A. H. J., de Borst, M. H., Hoorn, E. J., Rotmans, J. I., & Vogt, L. (2023) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.0000000000000228 · Cited by 10
Renal K+ retention in physiological circumstances: focus on adaptation of the distal nephron and cross-talk with Na+ transport systems
Lasaad, S., & Crambert, G. (2023) · Frontiers in Physiology · doi:10.3389/fphys.2023.1264296 · Cited by 11
Utilization of Yeast Extract as a Flavor Enhancer and Masking Agent in Sodium-Reduced Marinated Shrimp
Yılmaz, E. B. Ş. (2023) · Molecules · doi:10.3390/molecules29010182 · Cited by 10
The Guidelines for use and promotion of low sodium salt in China
Yuan, Y., Gao, C., Yin, X., Zhang, X., Ji, Y., Zheng, X., Zhou, Q. X., & Wu, Y. (2024) · Journal of Evidence-Based Medicine · doi:10.1111/jebm.12621 · Cited by 10
Managing Hypertension in Chronic Kidney Disease: The Role of Diet and Guideline Recommendations
Stambolliu, E., Iliakis, P., Tsioufis, K. P., & Damianaki, A. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14113755 · Cited by 11
Relationship Between Salt Intake and Cardiovascular Disease
Han, F., Li, W., Duan, N., Hu, X., Yao, N., Yu, G., & Qu, J. (2025) · Journal of Clinical Hypertension · doi:10.1111/jch.70078 · Cited by 17
Sodium Intake Recommendations: A Subject that Needs to be Reconsidered
López-Jaramillo, P. A., López-López, J., & Lopez-Lopez, C. (2015) · Current Hypertension Reviews · doi:10.2174/1573402111666150530204311 · Cited by 10
Mean population salt intake in Iran: A systematic review and meta‐analysis
Pourkhajoei, S., Yazdi‐Feyzabadi, V., Amiresmaeili, M., Nakhaee, N., & Goudarzi, R. (2022) · Health Science Reports · doi:10.1002/hsr2.855 · Cited by 10
“The high salt intake appears to be harmful to humans and is a primary cause of several NCDs with a detrimental effect on blood pressure.(2)”
Background
Significance of adjusting salt intake by body weight in the evaluation of dietary salt and blood pressure
Hashimoto, T., Takase, H., Okado, T., Sugiura, T., Yamashita, S., Kimura, G., Ohte, N., & Dohi, Y. (2016) · Journal of the American Society of Hypertension · doi:10.1016/j.jash.2016.06.029 · Cited by 10
Red meat intake is positively associated with non-fatal acute myocardial infarction in the Costa Rica Heart Study
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Simple dietary advice reduces 24-hour urinary sodium excretion, blood pressure, and drug consumption in hypertensive patients
Musso, N. R., Carloni, B., Chiusano, M. C., & Giusti, M. (2018) · Journal of the American Society of Hypertension · doi:10.1016/j.jash.2018.06.012 · Cited by 10
Urinary sodium-to-potassium ratio and serum asymmetric dimethylarginine levels in patients with type 2 diabetes
Yokoro, M., Minami, M., Okada, S., Yano, M., Otaki, N., Ikeda, H., & Fukuo, K. (2018) · Hypertension Research · doi:10.1038/s41440-018-0098-1 · Cited by 10
Low-Salt Intake Suggestions in Hypertensive Patients Do not Jeopardize Urinary Iodine Excretion
Musso, N. R., Conte, L., Carloni, B., Campana, C., Chiusano, M. C., & Giusti, M. (2018) · Nutrients · doi:10.3390/nu10101548 · Cited by 10
“Recently, a J-shaped curve linking sodium intake to cardiovascular events has been proposed [9,10], pointing to a possible risk induced by a decreased sodium intake in the general population.”
Background
Validation of the prognostic performance in various nodal staging systems for gallbladder cancer: results of a multicenter study
Lee, W., Jeong, C., Kim, Y. H., Roh, Y. H., Yoon, M. H., Seo, H. I., Park, J.-I., Jung, B., Shin, D. H., Choi, Y. I., et al. (2019) · Langenbeck s Archives of Surgery · doi:10.1007/s00423-019-01807-9 · Cited by 10
Separating the effects of 24-hour urinary chloride and sodium excretion on blood pressure and risk of hypertension: Results from PREVEND
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Evidence-Based Policy Making for Public Health Interventions in Cardiovascular Diseases: Formally Assessing the Feasibility of Clinical Trials
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Capítulo 10 - Hipertensão na Criança e no Adolescente
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.20160160 · Cited by 9
Associations of 24-Hour Urinary Sodium and Potassium Excretion with Cardiac Biomarkers: The Maastricht Study
Martens, R. J. H., Henry, R. M. A., Bekers, O., Dagnelie, P. C., DONGEN, M. C. J. M. V., Eussen, S. J. P. M., van Greevenbroek, M. M. J., Kroon, A. A., Stehouwer, C. D. A., Wesselius, A., et al. (2020) · Journal of Nutrition · doi:10.1093/jn/nxaa080 · Cited by 9
Low Sodium Intake, Low Protein Intake, and Excess Mortality in an Older Dutch General Population Cohort: Findings in the Prospective Lifelines-MINUTHE Study
Hessels, N. R., Zhu, Y., Bakker, S. J. L., de Borst, M. H., Navis, G. J., & Riphagen, I. J. (2023) · Nutrients · doi:10.3390/nu15020428 · Cited by 9
Effects of a low-sodium diet in patients with idiopathic hyperaldosteronism: a randomized controlled trial
Zhou, L., Jiang, Y., Zhang, C., Su, T., Jiang, L., Zhou, W., Zhong, X., Wu, L., & Wang, W. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1124479 · Cited by 9
“Regulation of sodium and potassium homeostasis occurs primarily in the renal tubules, and high sodium intake determines increased renal excretion of potassium (30, 31).”
Background
Dietary Sodium: Where Science and Policy Conflict: Impact of the 2013 IOM Report on Sodium Intake in Populations
Graudal, N. A. (2015) · Current Hypertension Reports · doi:10.1007/s11906-014-0522-0 · Cited by 10
“The recently published Norfolk and PURE studies [7, 9] have provided further confirmation of the U-shaped relationship between sodium intake and cardiovascular morbidity and mortality.”
BackgroundResultInfluential
Salt and hypertension
DiNicolantonio, J. J., & O’Keefe, J. H. (2018) · Current Opinion in Cardiology · doi:10.1097/hco.0000000000000525 · Cited by 9
“The Prospective Urban Rural Epidemiology (PURE) study examined over 100 000 people in 17 countries and determined that the lowest risk of death or cardiovascular events was in those consuming between 3000 and 6000 mg of sodium per day [31].”
Background
Potassium: poison or panacea in chronic kidney disease?
Yeung, S. M. H., Vogt, L., Rotmans, J. I., Hoorn, E. J., & de Borst, M. H. (2018) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfy329 · Cited by 9
What methods have been used to estimate salt intake? A systematic review
Perin, M. S., Gallani, M. C. B. J., Andrechuk, C. R. S., São‐João, T. M., Rhéaume, C., & Cornélio, M. E. (2019) · International Journal of Food Sciences and Nutrition · doi:10.1080/09637486.2019.1620185 · Cited by 9
“Over the last years, some prospective cohort studies have shown a J- or U-shaped relationship between sodium intake and cardiovascular diseases (O’Donnell et al. 2014; Pfister et al. 2014; Mente et al. 2016), as well as between higher risk of kidney failure (Ekinci et al. 2011; Stolarz-Skrzypek et…”
BackgroundInfluential
Familial genetic and environmental risk profile and high blood pressure event: a prospective cohort of cardio-metabolic and genetic study
Kolifarhood, G., DANESHPOUR, M. S., Zahedi, A. S., Khosravi, N., Sedaghati-khayat, B., Guity, K., Dehkordi, S. R., Roudbar, M. A., Ghanbari, F., Hadaegh, F., et al. (2021) · Blood Pressure · doi:10.1080/08037051.2021.1903807 · Cited by 9
“physiologic pathway of BP regulation [3].”
The Sweet and Salty Dietary Face of Hypertension and Cardiovascular Disease in Lebanon
Labban, M., Itani, M. M., Maaliki, D. S., Radwan, Z., Nasreddine, L., & Itani, H. A. (2022) · Frontiers in Physiology · doi:10.3389/fphys.2021.802132 · Cited by 11
Preventive Interventions for the Second Half of Life: A Systematic Review
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Emerging Trends in Clinical Research With Implications for Population Health and Health Policy
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Paucity of high‐quality studies reporting on salt and health outcomes from the science of salt: A regularly updated systematic review of salt and health outcomes (April 2017 to March 2018)
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Associations of estimated 24-h urinary sodium excretion with mortality and cardiovascular events in Chinese adults: a prospective cohort study
Liu, X., Bai, Y., Li, S., O'Donnell, M. J., Mente, A., Yin, L., Hu, B., Cheng, X., Liu, W., Bai, X., et al. (2020) · Journal of Hypertension · doi:10.1097/hjh.0000000000002647 · Cited by 10
Self-citation
Combined Salt and Caloric Restrictions: Potential Adverse Outcomes
Homma, T., Homma, M., Huang, Y., Mayurasakorn, K., Rodi, N. M., Hamid, A. A. A., Hurwitz, S., Yao, T. M., Adler, G. K., Pojoga, L. H., et al. (2017) · Journal of the American Heart Association · doi:10.1161/jaha.116.005374 · Cited by 9
“Reduction of salt intake is recognized as an effective nonpharmacological intervention to reduce BP and cardiovascular risk.(2,3,8,28) Although BP was reduced in the present study, ResS also impaired insulin sensitivity (Table 2) and increased proteinuria (Figure 6).”
Background
A Nutritional Strategy Based on Multiple Components for Glycemic Control in Type 2 Diabetes: A Multicenter Randomized Controlled Clinical Trial
Bersch-Ferreira, Â. C., Machado, R. H. V., de Oliveira, J. S., Santos, R. H. N., da Silva, L. R., Mota, L. G. S., Pagano, R., Sady, É. R. R., Miyada, D. H. K., Miranda, T. A., et al. (2024) · Nutrients · doi:10.3390/nu16223849 · Cited by 9
“…cholesterol (HDL-c, mg/dL), fasting triglycerides (mg/dL), serum creatinine (mg/dL), serum sodium (mEq/L), and serum potassium (mEq/L) were obtained directly from blood samples, and albuminuria (mg/d), urinary sodium (mEq/L), and urinary potassium (mEq/L) [32] were obtained from urine samples.”
Lowering Sodium Intake: Reduction and Substitution for Cardiovascular Health
Hu, N., & McLean, R. M. (2025) · International Journal for Vitamin and Nutrition Research · doi:10.31083/ijvnr36289 · Cited by 11
A New Understanding of Potassium's Influence Upon Human Health and Renal Physiology
McCormick, J. A., Topf, J. M., Tomacruz, I. D. V., & Grimm, P. R. (2023) · Advances in Kidney Disease and Health · doi:10.1053/j.akdh.2023.01.001 · Cited by 8

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: O'Donnell, Martin
Mente, Andrew
Rangarajan, Sumathy
Wang, Xingyu
Liu, Lisheng
Lee, Shun Fu
Mony, Prem
Devanath, Anitha
Rosengren, Annika
Lanas, Fernando
Yusoff, Khalid
Iqbal, Romaina
Mohammadifard, Noushin
Yusuf, Rita
Chifamba, Jephat
Kabali, Conrad
Dagenais, Gilles
Lear, Scott A.
Teo, Koon
Yusuf, Salim
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
DOI: 10.1056/nejmoa1311889
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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Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events

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