Effect of Dietary Sodium Restriction (<2 g/day) on Blood Pressure Variability and Proteinuria Levels in Patients with Stage 2–3 chronic kidney disease: A Structured Narrative Review
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Background: Excess dietary sodium contributes to extracellular volume expansion, hypertension, proteinuria, and reduced responsiveness to renin–angiotensin–aldosterone system inhibition in chronic kidney disease. However, its specific relationship with blood pressure variability remains uncertain. Objective: To critically synthesize evidence concerning dietary sodium restriction below 2 g/day and its effects on blood pressure variability, mean blood pressure, proteinuria, albuminuria, and related renal outcomes in adults with stage 2–3 chronic kidney disease. Methods: A structured narrative review was undertaken using literature identified through PubMed/MEDLINE, Scopus, Web of Science, the Cochrane Library, Embase, and Google Scholar. Controlled dietary interventions, longitudinal cohorts, observational studies, guidelines, and clinically relevant mechanistic literature were evaluated. Intervention evidence was interpreted separately from observational sodium-exposure studies, and mean blood pressure was distinguished from formally measured blood pressure variability. Results: Controlled trials generally demonstrated that sodium restriction reduced office and ambulatory blood pressure, extracellular fluid volume, proteinuria, and albuminuria. One crossover trial reported approximate reductions of 10 mmHg in systolic and 4 mmHg in diastolic blood pressure, while behavioural sodium-reduction support produced short-term reductions in ambulatory and office blood pressure and urinary protein excretion. Sodium restriction also enhanced the antiproteinuric effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Higher urinary sodium excretion was frequently associated with CKD progression and cardiovascular outcomes in observational cohorts, particularly among patients with greater proteinuria. Direct evidence regarding standardized blood pressure variability indices was limited. Conclusion: Sodium restriction is supported as an adjunctive strategy for improving mean blood pressure control and reducing proteinuria in non-dialysis CKD, but its independent effects on blood pressure variability and long-term clinical outcomes require further investigation
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1. Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013;382(9888):260–272.
2. Ku E, Lee BJ, Wei J, Weir MR. Hypertension in CKD: core curriculum 2019. Am J Kidney Dis. 2019;74(1):120–131.
3. Kotchen TA, Cowley AW Jr, Frohlich ED. Salt in health and disease—a delicate balance. N Engl J Med. 2013;368(13):1229–1237.
4. Titze J, Luft FC. Speculations on salt and the genesis of arterial hypertension. Kidney Int. 2017;91(6):1324–1335.
5. Remuzzi G, Bertani T. Pathophysiology of progressive nephropathies. N Engl J Med. 1998;339(20):1448–1456.
6. Ruggenenti P, Perna A, Remuzzi G. Retarding progression of chronic renal disease: the neglected issue of residual proteinuria. Kidney Int Suppl. 2003;(83):S65–S71.
7. Stevens SL, Wood S, Koshiaris C, Law K, Glasziou P, Stevens RJ, et al. Blood pressure variability and cardiovascular disease: systematic review and meta-analysis. BMJ. 2016;354:i4098.
8. Okada H, Fukui M, Tanaka M, Inada S, Mineoka Y, Nakanishi N, et al. Visit-to-visit blood pressure variability is a marker of renal function decline in patients with type 2 diabetes. Hypertens Res. 2012;35(5):469–475.
9. Kidney Disease: Improving Global Outcomes CKD Work Group. KDIGO clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1–150.
10. Smyth A, O’Donnell M, Yusuf S, Clase CM, Teo KK, Canavan M, et al. Sodium intake and renal outcomes: a systematic review. Kidney Int. 2014;86(2):344–352.
11. He FJ, Marciniak M, Visagie E, Markandu ND, Anand V, Dalton RN, et al. Effect of modest salt reduction on blood pressure, urinary albumin, and pulse wave velocity in white, black, and Asian mild hypertensives. J Hum Hypertens. 2009;23(6):363–384.
12. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension diet. N Engl J Med. 2001;344(1):3–10.
13. de Brito-Ashurst I, Perry L, Sanders TAB, Thomas JE, Dobbie H, Varagunam M, et al. The role of salt intake and salt sensitivity in the management of hypertension in chronic kidney disease. Nephron Clin Pract. 2013;123(1–2):53–60.
14. Saran R, Padilla RL, Gillespie BW, Heung M, Hummel SL, Derebail VK, et al. A randomized crossover trial of dietary sodium restriction in stage 3–4 chronic kidney disease. Clin J Am Soc Nephrol. 2017;12(3):399–407.
15. Garofalo C, Borrelli S, Provenzano M, De Stefano T, Vita C, Chiodini P, et al. Dietary salt restriction in chronic kidney disease: a meta-analysis of randomized clinical trials. Nutrients. 2018;10(6):732.
16. Smyth A, Dunkler D, Gao P, Teo KK, Yusuf S, O’Donnell MJ, et al. The relationship between estimated sodium and potassium excretion and subsequent renal outcomes. Kidney Int. 2014;86(6):1205–1212.
17. Fan L, Tighiouart H, Levey AS, Beck GJ, Sarnak MJ. Urinary sodium excretion and kidney failure in nondiabetic chronic kidney disease. Kidney Int. 2014;86(3):582–588.
18. Slagman MCJ, Waanders F, Hemmelder MH, Woittiez AJ, Janssen WMT, Lambers Heerspink HJ, et al. Moderate dietary sodium restriction added to angiotensin-converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: a randomized controlled trial. Kidney Int. 2011;80(10):1092–1099.
19. Vogt L, Waanders F, Boomsma F, de Zeeuw D, Navis G. Effects of dietary sodium and hydrochlorothiazide on the antiproteinuric efficacy of losartan. J Am Soc Nephrol. 2008;19(5):999–1007.
20. McMahon EJ, Bauer JD, Hawley CM, Isbel NM, Stowasser M, Johnson DW, et al. A randomized trial of dietary sodium restriction in chronic kidney disease. BMC Nephrol. 2013;14:36.
21. Konishi Y, Ohashi N, Suzuki K, Takahashi K, Nishiyama A, Nagata D, et al. Sodium intake and blood pressure variability in patients with chronic kidney disease. Clin Exp Nephrol. 2018;22(6):1362–1369.
22. Lambers Heerspink HJ, Holtkamp FA, Parving HH, Navis GJ, Lewis JB, Ritz E, et al. Moderation of dietary sodium potentiates the renal and cardiovascular protective effects of angiotensin receptor blockers. Kidney Int. 2012;82(3):330–337.
23. Meuleman Y, Hoekstra T, Dekker FW, van der Boog PJM, van Dijk S, Group E-S. Sodium restriction in patients with chronic kidney disease: a randomized controlled trial. Am J Kidney Dis. 2017;69(5):576–586.
24. Trakarnvanich T, Praditpornsilpa K, Tiranathanagul K, Eiam-Ong S, Sitprija V. Effect of a low-salt diet on the progression of chronic kidney disease. Kidney Dis. 2024;10(1):45–53.
25. Nerbass FB, Pecoits-Filho R, McIntyre NJ, McIntyre CW, Taal MW. Reduction in sodium intake is independently associated with improved blood pressure control in people with chronic kidney disease. Br J Nutr. 2015;114(6):936–944.
26. He J, Mills KT, Appel LJ, Yang W, Chen J, Lee BT, et al. Urinary sodium and potassium excretion and chronic kidney disease progression. J Am Soc Nephrol. 2016;27(4):1202–1212.
27. Mills KT, Chen J, Yang W, Appel LJ, Kusek JW, Alper A, et al. Sodium excretion and the risk of cardiovascular disease in patients with chronic kidney disease. JAMA. 2016;315(20):2200–2210.
28. Kang M, Kang E, Ryu H, Kim YC, Lee H, Kim DK, et al. Measured sodium excretion is associated with chronic kidney disease progression: results from the KNOW-CKD study. Nephrol Dial Transplant. 2021;36(3):512–519.
29. Kim HJ, Jung CY, Kim HW, Lee H, Kang E, Park JT, et al. Proteinuria modifies the relationship between urinary sodium excretion and adverse kidney outcomes. Kidney Int Rep. 2023;8(5):1022–1033.
30. Ogata S, Akashi Y, Sakusabe T, Ito Y, Akiyama S, Miura K, et al. Kidney function decline is related to urinary sodium and potassium excretion in patients with chronic kidney disease. Clin Exp Nephrol. 2021;25(11):1198–1208.
31. Humalda JK, Navis GJ, Bakker SJL, de Borst MH. Salt intake and progression of chronic kidney disease: an overlooked modifiable exposure? Nephrol Dial Transplant. 2012;27(9):3435–3442.