151
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Galve E, Martell-Claros N, Camafort-Babkowski M. [Renal denervation as treatment of resistant hypertension]. Med Clin (Barc) 2015; 145:131-5. [PMID: 25746610 DOI: 10.1016/j.medcli.2014.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/04/2014] [Accepted: 12/11/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Enrique Galve
- Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona, España.
| | | | - Miguel Camafort-Babkowski
- Departamento de Medicina Interna, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, España
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152
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Kochsalzrestriktion bei Menschen mit Hypertonie und kardiovaskulären Patienten. Internist (Berl) 2015; 56:784-90. [DOI: 10.1007/s00108-015-3674-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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153
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Salehpour F, Ghanian Z, Yang C, Zheleznova NN, Kurth T, Dash RK, Cowley AW, Ranji M. Effects of p67phox on the mitochondrial oxidative state in the kidney of Dahl salt-sensitive rats: optical fluorescence 3-D cryoimaging. Am J Physiol Renal Physiol 2015; 309:F377-82. [PMID: 26062875 DOI: 10.1152/ajprenal.00098.2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/09/2015] [Indexed: 02/07/2023] Open
Abstract
The goal of the present study was to quantify and correlate the contribution of the cytosolic p67(phox) subunit of NADPH oxidase 2 to mitochondrial oxidative stress in the kidneys of the Dahl salt-sensitive (SS) hypertensive rat. Whole kidney redox states were uniquely assessed using a custom-designed optical fluorescence three-dimensional cryoimager to acquire multichannel signals of the intrinsic fluorophores NADH and FAD. SS rats were compared with SS rats in which the cytosolic subunit p67(phox) was rendered functionally inactive by zinc finger nuclease mutation of the gene (SS(p67phox)-null rats). Kidneys of SS rats fed a 0.4% NaCl diet exhibited significantly (P = 0.023) lower tissue redox ratio (NADH/FAD; 1.42 ± 0.06, n = 5) than SS(p67phox)-null rats (1.64 ± 0.07, n = 5), indicating reduced levels of mitochondrial electron transport chain metabolic activity and enhanced oxidative stress in SS rats. When fed a 4.0% salt diet for 21 days, both strains exhibited significantly lower tissue redox ratios (P < 0.001; SS rats: 1.03 ± 0.05, n = 9, vs. SS(p67phox)-null rats: 1.46 ± 0.04, n = 7) than when fed a 0.4% salt, but the ratio was still significantly higher in SS(p67phox) rats at the same salt level as SS rats. These results are consistent with results from previous studies that found elevated medullary interstitial fluid concentrations of superoxide and H2O2 in the medulla of SS rats. We conclude that the p67(phox) subunit of NADPH oxidase 2 plays an important role in the excess production of ROS from mitochondria in the renal medulla of the SS rat.
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Affiliation(s)
- F Salehpour
- Biophotonics Lab, University of Wisconsin, Milwaukee, Wisconsin; and
| | - Z Ghanian
- Biophotonics Lab, University of Wisconsin, Milwaukee, Wisconsin; and
| | - C Yang
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - N N Zheleznova
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T Kurth
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - R K Dash
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A W Cowley
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - M Ranji
- Biophotonics Lab, University of Wisconsin, Milwaukee, Wisconsin; and
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154
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Wang G, Nauseef WM. Salt, chloride, bleach, and innate host defense. J Leukoc Biol 2015; 98:163-72. [PMID: 26048979 DOI: 10.1189/jlb.4ru0315-109r] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/27/2015] [Indexed: 12/17/2022] Open
Abstract
Salt provides 2 life-essential elements: sodium and chlorine. Chloride, the ionic form of chlorine, derived exclusively from dietary absorption and constituting the most abundant anion in the human body, plays critical roles in many vital physiologic functions, from fluid retention and secretion to osmotic maintenance and pH balance. However, an often overlooked role of chloride is its function in innate host defense against infection. Chloride serves as a substrate for the generation of the potent microbicide chlorine bleach by stimulated neutrophils and also contributes to regulation of ionic homeostasis for optimal antimicrobial activity within phagosomes. An inadequate supply of chloride to phagocytes and their phagosomes, such as in CF disease and other chloride channel disorders, severely compromises host defense against infection. We provide an overview of the roles that chloride plays in normal innate immunity, highlighting specific links between defective chloride channel function and failures in host defense.
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Affiliation(s)
- Guoshun Wang
- *Departments of Microbiology and Immunology, Genetics, and Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA; and Department of Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, and Veterans Administration Medical Center, Iowa City, Iowa, USA
| | - William M Nauseef
- *Departments of Microbiology and Immunology, Genetics, and Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA; and Department of Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, and Veterans Administration Medical Center, Iowa City, Iowa, USA
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Abstract
Sodium is an essential nutrient. Increasing sodium intake is associated with increasing blood pressure, whereas low sodium intake results in increased renin and aldosterone levels. Randomized controlled trials have reported reductions in blood pressure with reductions in sodium intake, to levels of sodium intake <1.5 g/d, and form the evidentiary basis for current population-wide guidelines recommending low sodium intake. Although low sodium intake (<2.0 g/d) has been achieved in short-term feeding clinical trials, sustained low sodium intake has not been achieved by any of the longer term clinical trials (>6-month duration). It is assumed that the blood pressure-lowering effects of reducing sodium intake to low levels will result in large reductions in cardiovascular disease globally. However, current evidence from prospective cohort studies suggests a J-shaped association between sodium intake and cardiovascular events, based on studies from >300 000 people, and suggests that the lowest risk of cardiovascular events and death occurs in populations consuming an average sodium intake range (3-5 g/d). The increased risk of cardiovascular events associated with higher sodium intake (>5 g/d) is most prominent in those with hypertension. A major deficit in the field is the absence of large randomized controlled trials to provide definitive evidence on optimal sodium intake for preventing cardiovascular events. Pending such trials, current evidence would suggest a recommendation for moderate sodium intake in the general population (3-5 g/d), with targeting the lower end of the moderate range among those with hypertension.
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Affiliation(s)
- Martin O'Donnell
- From the Department of Medicine (M.O.D., S.Y.), and Department of Clinical Epidemiology and Biostatistics (A.M.), Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada; and HRB-Clinical Research Facility Galway, NUI Galway, Galway, Ireland (M.O.D.).
| | - Andrew Mente
- From the Department of Medicine (M.O.D., S.Y.), and Department of Clinical Epidemiology and Biostatistics (A.M.), Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada; and HRB-Clinical Research Facility Galway, NUI Galway, Galway, Ireland (M.O.D.)
| | - Salim Yusuf
- From the Department of Medicine (M.O.D., S.Y.), and Department of Clinical Epidemiology and Biostatistics (A.M.), Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada; and HRB-Clinical Research Facility Galway, NUI Galway, Galway, Ireland (M.O.D.)
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156
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Rhee MY. High sodium intake: review of recent issues on its association with cardiovascular events and measurement methods. Korean Circ J 2015; 45:175-83. [PMID: 26023304 PMCID: PMC4446810 DOI: 10.4070/kcj.2015.45.3.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 11/11/2022] Open
Abstract
There has been a long-known association between high dietary sodium intake and hypertension, as well as the increased risk of cardiovascular disease. Reduction of sodium intake is a major challenge for public health. Recently, there have been several controversial large population-based studies regarding the current recommendation for dietary sodium intake. Although these studies were performed in a large population, they aroused controversies because they had a flaw in the study design and methods. In addition, knowledge of the advantages and disadvantages of the methods is essential in order to obtain an accurate estimation of sodium intake. I have reviewed the current literatures on the association between sodium intake and cardiovascular events, as well as the methods for the estimation of sodium intake.
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Affiliation(s)
- Moo-Yong Rhee
- Cardiovascular Center, Clinical Trial Center, Dongguk University Ilsan Hospital, Goyang, Korea
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157
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158
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The feasibility and acceptability of reducing salt in partially baked bread: a Spanish case study. Public Health Nutr 2015; 19:983-7. [PMID: 25945420 DOI: 10.1017/s1368980015000944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Bread is a staple of the Mediterranean diet but contributes substantially to its salt content (19 % in Spain). The objective of the present study was to assess the feasibility and acceptability of salt reduction in partially baked breads, partly replacing salt (NaCl) with a potassium salt, with subsequent follow-up. DESIGN During 2013, nine breads already on the market (1·8 % NaCl flour basis) had 0·5 % of NaCl replaced with potassium citrate (27·7 % reduction in sodium) and were commercialized in Spain. Later, breads were baked in bake-off stores and sold ready-to-eat to consumers. This market test was evaluated by comparing the sales between standard- v. reduced-salt breads and the complaints related to flavour attributes. The wholesalers involved in the market test were then surveyed. SETTING Spain. RESULTS The market test confirmed good acceptance of the reduced-salt breads, as 2013 sales were 3678 tonnes v. 2012 sales of 3577 tonnes for the same standard breads. No complaints were received. The wholesaler survey showed, in general, little awareness of salt reduction. CONCLUSIONS It is feasible that potassium citrate can reduce the salt content of bread without negatively affecting sales or complaints. This shows potential for introducing this type of bread on a larger scale.
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159
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Matthews EL, Brian MS, Ramick MG, Lennon-Edwards S, Edwards DG, Farquhar WB. High dietary sodium reduces brachial artery flow-mediated dilation in humans with salt-sensitive and salt-resistant blood pressure. J Appl Physiol (1985) 2015; 118:1510-5. [PMID: 26078434 DOI: 10.1152/japplphysiol.00023.2015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/31/2015] [Indexed: 12/31/2022] Open
Abstract
Recent studies demonstrate that high dietary sodium (HS) impairs endothelial function in those with salt-resistant (SR) blood pressure (BP). The effect of HS on endothelial function in those with salt-sensitive (SS) BP is not currently known. We hypothesized that HS would impair brachial artery flow-mediated dilation (FMD) to a greater extent in SS compared with SR adults. Ten SR (age 42 ± 5 yr, 5 men, 5 women) and 10 SS (age 39 ± 5 yr, 5 men, 5 women) healthy, normotensive participants were enrolled in a controlled feeding study consisting of a run-in diet followed by a 7-day low dietary sodium (LS) (20 mmol/day) and a 7-day HS (300 mmol/day) diet in random order. Brachial artery FMD and 24-h BP were assessed on the last day of each diet. SS BP was individually assessed and defined as a change in 24-h mean arterial pressure (MAP) of >5 mmHg between the LS and HS diets (ΔMAP: SR -0.6 ± 1.2, SS 7.7 ± 0.4 mmHg). Brachial artery FMD was lower in both SS and SR individuals during the HS diet (P < 0.001), and did not differ between groups (P > 0.05) (FMD: SR LS 10.6 ± 1.3%, SR HS 7.2 ± 1.5%, SS LS 12.5 ± 1.7%, SS HS 7.8 ± 1.4%). These data indicate that an HS diet impairs brachial artery FMD to a similar extent in adults with SS BP and SR BP.
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Affiliation(s)
- Evan L Matthews
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Michael S Brian
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Meghan G Ramick
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - Shannon Lennon-Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware
| | - David G Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
| | - William B Farquhar
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware; and
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160
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McMahon EJ, Campbell KL, Bauer JD, Mudge DW. Altered dietary salt intake for people with chronic kidney disease. Cochrane Database Syst Rev 2015:CD010070. [PMID: 25691262 DOI: 10.1002/14651858.cd010070.pub2] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Salt intake shows great promise as a modifiable risk factor for reducing heart disease incidence and delaying kidney function decline in people with chronic kidney disease (CKD). However, a clear consensus of the benefits of reducing salt in people with CKD is lacking. OBJECTIVES This review evaluated the benefits and harms of altering dietary salt intake in people with CKD. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared two or more levels of salt intake in people with any stage of CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and conducted risk of bias evaluation. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Mean effect sizes were calculated using the random-effects models. MAIN RESULTS We included eight studies (24 reports, 258 participants). Because duration of the included studies was too short (1 to 26 weeks) to test the effect of salt restriction on endpoints such as mortality, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were applied. Three studies were parallel RCTs and five were cross-over studies. Selection bias was low in five studies and unclear in three. Performance and detection biases were low in two studies and unclear in six. Attrition and reporting biases were low in four studies and unclear in four. One study had the potential for high carryover effect; three had high risk of bias from baseline characteristics (change of medication or diet) and two studies were industry funded.There was a significant reduction in 24 hour sodium excretion associated with low salt interventions (range 52 to 141 mmol) (8 studies, 258 participants: MD -105.86 mmol/d, 95% CI -119.20 to -92.51; I(2) = 51%). Reducing salt intake significantly reduced systolic blood pressure (8 studies, 258 participants: MD -8.75 mm Hg, 95% CI -11.33 to -6.16; I(2) = 0%) and diastolic blood pressure (8 studies, 258 participants: MD -3.70 mm Hg, 95% CI -5.09 to -2.30; I(2) = 0%). One study reported restricting salt intake reduced the risk of oedema by 56%. Salt restriction significantly increased plasma renin activity (2 studies, 71 participants: MD 1.08 ng/mL/h, 95% CI 0.51 to 1.65; I(2) = 0%) and serum aldosterone (2 studies, 71 participants: 6.20 ng/dL (95% CI 3.82 to 8.58; I(2) = 0%). Antihypertensive medication dosage was significantly reduced with a low salt diet (2 studies, 52 participants): RR 5.48, 95% CI 1.27 to 23.66; I(2) = 0%). There was no significant difference in eGFR (2 studies, 68 participants: MD -1.14 mL/min/1.73 m(2), 95% CI -4.38 to 2.11; I(2) = 0%), creatinine clearance (3 studies, 85 participants): MD -4.60 mL/min, 95% CI -11.78 to 2.57; I(2) = 0%), serum creatinine (5 studies, 151 participants: MD 5.14 µmol/L, 95% CI -8.98 to 19.26; I(2) = 59%) or body weight (5 studies, 139 participants: MD -1.46 kg; 95% CI -4.55 to 1.64; I(2) = 0%). There was no significant change in total cholesterol in relation to salt restriction (3 studies, 105 participants: MD -0.23 mmol/L, 95% CI -0.57 to 0.10; I(2) = 0%) or symptomatic hypotension (2 studies, 72 participants: RR 6.60, 95% CI 0.77 to 56.55; I(2) = 0%). Salt restriction significantly reduced urinary protein excretion in all studies that reported proteinuria as an outcome, however data could not be meta-analysed. AUTHORS' CONCLUSIONS We found a critical evidence gap in long-term effects of salt restriction in people with CKD that meant we were unable to determine the direct effects of sodium restriction on primary endpoints such as mortality and progression to end-stage kidney disease (ESKD). We found that salt reduction in people with CKD reduced blood pressure considerably and consistently reduced proteinuria. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in ESKD incidence and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted, as is investigation into adherence to a low salt diet.
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Affiliation(s)
- Emma J McMahon
- Nutrition and Dietetics, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Queensland, Australia, 4102.
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161
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Park SM, Joung JY, Cho YY, Sohn SY, Hur KY, Kim JH, Kim SW, Chung JH, Lee MK, Min YK. Effect of high dietary sodium on bone turnover markers and urinary calcium excretion in Korean postmenopausal women with low bone mass. Eur J Clin Nutr 2015; 69:361-6. [DOI: 10.1038/ejcn.2014.284] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 12/03/2014] [Accepted: 12/09/2014] [Indexed: 11/09/2022]
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Cao W, Li A, Wang L, Zhou Z, Su Z, Bin W, Wilcox CS, Hou FF. A Salt-Induced Reno-Cerebral Reflex Activates Renin-Angiotensin Systems and Promotes CKD Progression. J Am Soc Nephrol 2015; 26:1619-33. [PMID: 25635129 DOI: 10.1681/asn.2014050518] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/10/2014] [Indexed: 12/30/2022] Open
Abstract
Salt intake promotes progression of CKD by uncertain mechanisms. We hypothesized that a salt-induced reno-cerebral reflex activates a renin-angiotensin axis to promote CKD. Sham-operated and 5/6-nephrectomized rats received a normal-salt (0.4%), low-salt (0.02%), or high-salt (4%) diet for 2 weeks. High salt in 5/6-nephrectomized rats increased renal NADPH oxidase, inflammation, BP, and albuminuria. Furthermore, high salt activated the intrarenal and cerebral, but not the systemic, renin-angiotensin axes and increased the activity of renal sympathetic nerves and neurons in the forebrain of these rats. Renal fibrosis was increased 2.2-fold by high versus low salt, but intracerebroventricular tempol, losartan, or clonidine reduced this fibrosis by 65%, 69%, or 59%, respectively, and renal denervation or deafferentation reduced this fibrosis by 43% or 38%, respectively (all P<0.05). Salt-induced fibrosis persisted after normalization of BP with hydralazine. These data suggest that the renal and cerebral renin-angiotensin axes are interlinked by a reno-cerebral reflex that is activated by salt and promotes oxidative stress, fibrosis, and progression of CKD independent of BP.
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Affiliation(s)
- Wei Cao
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Aiqing Li
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Liangliang Wang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Zhanmei Zhou
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Zhengxiu Su
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Wei Bin
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
| | - Christopher S Wilcox
- Center for Hypertension, Kidney, and Vascular Research, Georgetown University, Washington, DC
| | - Fan Fan Hou
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China; and
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163
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Geurts AM, Mattson DL, Liu P, Cabacungan E, Skelton MM, Kurth TM, Yang C, Endres BT, Klotz J, Liang M, Cowley AW. Maternal diet during gestation and lactation modifies the severity of salt-induced hypertension and renal injury in Dahl salt-sensitive rats. Hypertension 2014; 65:447-55. [PMID: 25452472 DOI: 10.1161/hypertensionaha.114.04179] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Environmental exposure of parents or early in life may affect disease development in adults. We found that hypertension and renal injury induced by a high-salt diet were substantially attenuated in Dahl SS/JrHsdMcwiCrl (SS/Crl) rats that had been maintained for many generations on the grain-based 5L2F diet compared with SS/JrHsdMcwi rats (SS/Mcw) maintained on the casein-based AIN-76A diet (mean arterial pressure, 116±9 versus 154±25 mm Hg; urinary albumin excretion, 23±12 versus 170±80 mg/d). RNAseq analysis of the renal outer medulla identified 129 and 82 genes responding to a high-salt diet uniquely in SS/Mcw and SS/Crl rats, respectively, along with minor genetic differences between the SS substrains. The 129 genes responding to salt in the SS/Mcw strain included numerous genes with homologs associated with hypertension, cardiovascular disease, or renal disease in human. To narrow the critical window of exposure, we performed embryo-transfer experiments in which single-cell embryos from 1 colony (SS/Mcw or SS/Crl) were transferred to surrogate mothers from the other colony, with parents and surrogate mothers maintained on their respective original diet. All offspring were fed the AIN-76A diet after weaning. Salt-induced hypertension and renal injury were substantially exacerbated in rats developed from SS/Crl embryos transferred to SS/Mcw surrogate mothers. Conversely, salt-induced hypertension and renal injury were significantly attenuated in rats developed from SS/Mcw embryos transferred to SS/Crl surrogate mothers. Together, the data suggest that maternal diet during the gestational-lactational period has substantial effects on the development of salt-induced hypertension and renal injury in adult SS rats.
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Affiliation(s)
- Aron M Geurts
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee.
| | - David L Mattson
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Pengyuan Liu
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Erwin Cabacungan
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Meredith M Skelton
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Theresa M Kurth
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Chun Yang
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Bradley T Endres
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Jason Klotz
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Mingyu Liang
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
| | - Allen W Cowley
- From the Departments of Physiology (A.M.G., D.L.M., P.L., M.M.S., T.M.K., C.Y., B.T.E., J.K., M.L., A.W.C.), Pediatrics (E.C.), and Cardiovascular Research Center (A.M.G.), Medical College of Wisconsin, Milwaukee
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 989] [Impact Index Per Article: 98.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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Kusche-Vihrog K, Schmitz B, Brand E. Salt controls endothelial and vascular phenotype. Pflugers Arch 2014; 467:499-512. [DOI: 10.1007/s00424-014-1657-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/11/2014] [Accepted: 11/14/2014] [Indexed: 01/11/2023]
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167
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MacLeod SM, Cairns JA. Controversial sodium guidelines: scientific solution or perpetual debate? CMAJ 2014; 187:95-96. [PMID: 25384648 DOI: 10.1503/cmaj.141011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Stuart M MacLeod
- Department of Pediatrics (MacLeod); Child and Family Research Institute (MacLeod); and Division of Cardiology, Department of Medicine (Cairns), University of British Columbia, Vancouver, BC
| | - John A Cairns
- Department of Pediatrics (MacLeod); Child and Family Research Institute (MacLeod); and Division of Cardiology, Department of Medicine (Cairns), University of British Columbia, Vancouver, BC
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168
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Engelen L, Soedamah-Muthu SS, Geleijnse JM, Toeller M, Chaturvedi N, Fuller JH, Schalkwijk CG, Stehouwer CDA. Higher dietary salt intake is associated with microalbuminuria, but not with retinopathy in individuals with type 1 diabetes: the EURODIAB Prospective Complications Study. Diabetologia 2014; 57:2315-23. [PMID: 25172228 PMCID: PMC4181505 DOI: 10.1007/s00125-014-3367-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/05/2014] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS High dietary salt intake has been associated with elevated BP and may also have a deleterious effect on microvascular complications. We studied the cross-sectional associations between dietary salt intake (estimated from 24 h urinary sodium excretion) and urinary potassium excretion on the one hand, and the prevalence of microvascular complications on the other, in individuals with type 1 diabetes. METHODS We measured sodium and potassium concentrations in two 24 h urine samples in 1,212 individuals with type 1 diabetes (40 ± 10 years old, 51% men) who participated in the EURODIAB Prospective Complications Study. We used multiple logistic regression analyses to investigate associations between dietary salt intake and microvascular complications adjusted for age and sex, and additionally for BMI, smoking, urinary potassium excretion, antihypertensive medication and physical activity, and total energy, protein, alcohol, saturated fat and fibre intake. RESULTS After full adjustment, 1 g/day higher dietary salt intake was positively associated with the presence of microalbuminuria (OR 1.06 [95% CI 1.01, 1.10]), but not macroalbuminuria (OR 0.99 [95% CI 0.94, 1.05]), non-proliferative retinopathy (OR 1.00 (95% CI 0.96, 1.04]) or proliferative retinopathy (OR 1.02 (95% CI 0.95, 1.08]). After excluding individuals with cardiovascular disease and/or antihypertensive medication (n = 418), we found a non-significant association with microalbuminuria (OR 1.04 [95% CI 0.99, 1.10]) and macroalbuminuria (OR 1.05 [95% CI 0.96, 1.16]). The association between dietary salt intake and microalbuminuria was stronger in individuals with a BMI above 25 kg/m(2) (OR 1.11 [95% CI 1.04, 1.18]) than in those with BMI below 25 kg/m(2) (OR 1.03 [95% CI 0.97, 1.09]). No significant associations were found between urinary potassium excretion and microvascular complications. CONCLUSIONS/INTERPRETATION In individuals with type 1 diabetes, higher dietary salt intake, as determined by 24 h urinary sodium excretion, may be positively associated with microalbuminuria, particularly in overweight individuals.
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Affiliation(s)
- Lian Engelen
- Department of Internal Medicine, Maastricht University Medical Centre, Universiteitssingel 50, 6200 MD, Maastricht, the Netherlands,
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Cowley AW, Abe M, Mori T, O'Connor PM, Ohsaki Y, Zheleznova NN. Reactive oxygen species as important determinants of medullary flow, sodium excretion, and hypertension. Am J Physiol Renal Physiol 2014; 308:F179-97. [PMID: 25354941 DOI: 10.1152/ajprenal.00455.2014] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The physiological evidence linking the production of superoxide, hydrogen peroxide, and nitric oxide in the renal medullary thick ascending limb of Henle (mTAL) to regulation of medullary blood flow, sodium homeostasis, and long-term control of blood pressure is summarized in this review. Data obtained largely from rats indicate that experimentally induced elevations of either superoxide or hydrogen peroxide in the renal medulla result in reduction of medullary blood flow, enhanced Na(+) reabsorption, and hypertension. A shift in the redox balance between nitric oxide and reactive oxygen species (ROS) is found to occur naturally in the Dahl salt-sensitive (SS) rat model, where selective reduction of ROS production in the renal medulla reduces salt-induced hypertension. Excess medullary production of ROS in SS rats emanates from the medullary thick ascending limbs of Henle [from both the mitochondria and membrane NAD(P)H oxidases] in response to increased delivery and reabsorption of excess sodium and water. There is evidence that ROS and perhaps other mediators such as ATP diffuse from the mTAL to surrounding vasa recta capillaries, resulting in medullary ischemia, which thereby contributes to hypertension.
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Affiliation(s)
- Allen W Cowley
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michiaki Abe
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Takefumi Mori
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul M O'Connor
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yusuke Ohsaki
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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170
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Wainford RD, Carmichael CY, Pascale CL, Kuwabara JT. Gαi2-protein-mediated signal transduction: central nervous system molecular mechanism countering the development of sodium-dependent hypertension. Hypertension 2014; 65:178-86. [PMID: 25312437 DOI: 10.1161/hypertensionaha.114.04463] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Excess dietary salt intake is an established cause of hypertension. At present, our understanding of the neuropathophysiology of salt-sensitive hypertension is limited by a lack of identification of the central nervous system mechanisms that modulate sympathetic outflow and blood pressure in response to dietary salt intake. We hypothesized that impairment of brain Gαi2-protein-gated signal transduction pathways would result in increased sympathetically mediated renal sodium retention, thus promoting the development of salt-sensitive hypertension. To test this hypothesis, naive or renal denervated Dahl salt-resistant and Dahl salt-sensitive (DSS) rats were assigned to receive a continuous intracerebroventricular control scrambled or a targeted Gαi2-oligodeoxynucleotide infusion, and naive Brown Norway and 8-congenic DSS rats were fed a 21-day normal or high-salt diet. High salt intake did not alter blood pressure, suppressed plasma norepinephrine, and evoked a site-specific increase in hypothalamic paraventricular nucleus Gαi2-protein levels in naive Brown Norway, Dahl salt-resistant, and scrambled oligodeoxynucleotide-infused Dahl salt-resistant but not DSS rats. In Dahl salt-resistant rats, Gαi2 downregulation evoked rapid renal nerve-dependent hypertension, sodium retention, and sympathoexcitation. In DSS rats, Gαi2 downregulation exacerbated salt-sensitive hypertension via a renal nerve-dependent mechanism. Congenic-8 DSS rats exhibited sodium-evoked paraventricular nucleus-specific Gαi2-protein upregulation and attenuated hypertension, sodium retention, and global sympathoexcitation compared with DSS rats. These data demonstrate that paraventricular nucleus Gαi2-protein-gated pathways represent a conserved central molecular pathway mediating sympathoinhibitory renal nerve-dependent responses evoked to maintain sodium homeostasis and a salt-resistant phenotype. Impairment of this mechanism contributes to the development of salt-sensitive hypertension.
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Affiliation(s)
- Richard D Wainford
- From the the Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute, Boston University School of Medicine, MA (R.D.W., C.Y.C., J.T.K.); and Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans (R.D.W., C.L.P.).
| | - Casey Y Carmichael
- From the the Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute, Boston University School of Medicine, MA (R.D.W., C.Y.C., J.T.K.); and Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans (R.D.W., C.L.P.)
| | - Crissey L Pascale
- From the the Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute, Boston University School of Medicine, MA (R.D.W., C.Y.C., J.T.K.); and Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans (R.D.W., C.L.P.)
| | - Jill T Kuwabara
- From the the Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute, Boston University School of Medicine, MA (R.D.W., C.Y.C., J.T.K.); and Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans (R.D.W., C.L.P.)
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171
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172
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Thuesen BH, Toft U, Buhelt LP, Linneberg A, Friedrich N, Nauck M, Wallaschofski H, Jørgensen T. Estimated daily salt intake in relation to blood pressure and blood lipids: the role of obesity. Eur J Prev Cardiol 2014; 22:1567-74. [PMID: 25281483 DOI: 10.1177/2047487314553201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 09/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Excessive salt intake causes increased blood pressure which is considered the leading risk for premature death. One major challenge when evaluating associations between daily salt intake and markers of non-communicable diseases is that a high daily salt intake correlates with obesity, which is also a well described risk factor for poor cardiometabolic outcome. The aim of this study was to evaluate the relationship of estimated daily salt intake with blood pressure and blood lipids and to investigate the effect of taking different measures of obesity into account. METHODS We included 3294 men and women aged 18-69 years from a general population based study in Copenhagen, Denmark. Estimated 24-hour sodium excretion was calculated by measurements of creatinine and sodium concentration in spot urine in combination with information of sex, age, height and weight. The relations of estimated 24-hour sodium excretion with blood pressure and blood lipids were evaluated by linear regression models. RESULTS The daily mean estimated intake of salt was 10.80 g and 7.52 g among men and women, respectively. Daily salt intake was significantly associated with blood pressure (β-estimates 1.18 mm Hg/g salt (systolic) and 0.74 mm Hg/g salt (diastolic), p < 0.0001) - however this association was markedly affected by adjustment for obesity (β-estimates around 0.60 mm Hg/g salt (systolic) and around 0.25 mm Hg/g salt (diastolic), p < 0.05). Also associations between daily salt intake and blood lipids were highly affected by adjustment for obesity. CONCLUSIONS Associations of estimated daily salt intake with blood pressure and blood lipids were highly affected by adjustment for obesity.
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Affiliation(s)
- Betina H Thuesen
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark
| | - Ulla Toft
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark
| | - Lone P Buhelt
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark
| | - Allan Linneberg
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Denmark Department of Clinical Experimental Research, Glostrup University Hospital, Denmark
| | - Nele Friedrich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Germany
| | - Henri Wallaschofski
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Germany
| | - Torben Jørgensen
- Research Centre for Prevention and Health, Glostrup University Hospital, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Denmark Faculty of Medicine, Aalborg University, Denmark
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173
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Wang G, Yang E, Smith KJ, Zeng Y, Ji G, Connon R, Fangue NA, Cai JJ. Gene expression responses of threespine stickleback to salinity: implications for salt-sensitive hypertension. Front Genet 2014; 5:312. [PMID: 25309574 PMCID: PMC4160998 DOI: 10.3389/fgene.2014.00312] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/20/2014] [Indexed: 01/11/2023] Open
Abstract
Despite recent success with genome-wide association studies (GWAS), identifying hypertension (HTN)-susceptibility loci in the general population remains difficult. Here, we present a novel strategy to address this challenge by studying salinity adaptation in the threespine stickleback, a fish species with diverse salt-handling ecotypes. We acclimated native freshwater (FW) and anadromous saltwater (SW) threespine sticklebacks to fresh, brackish, and sea water for 30 days, and applied RNA sequencing to determine the gene expression in fish kidneys. We identified 1844 salt-responsive genes that were differentially expressed between FW sticklebacks acclimated to different salinities and/or between SW and FW sticklebacks acclimated to full-strength sea water. Significant overlap between stickleback salt-responsive genes and human genes implicated in HTN was detected (P < 10−7, hypergeometric test), suggesting a possible similarity in genetic mechanisms of salt handling between threespine sticklebacks and humans. The overlapping genes included a newly discovered HTN gene—MAP3K15, whose expression in FW stickleback kidneys decreases with salinity. These also included genes located in the GWAS loci such as AGTRAP-PLOD1 and CYP1A1-ULK3, which contain multiple potentially causative genes contributing to HTN susceptibility that need to be prioritized for study. Taken together, we show that stickleback salt-responsive genes provide valuable information facilitating the identification of human HTN genes. Thus, threespine sticklebacks may be used as a model, complementary to existing animal models, in human HTN research.
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Affiliation(s)
- Gang Wang
- Department of Veterinary Integrative Biosciences, Texas A&M University College Station, TX, USA
| | - Ence Yang
- Department of Veterinary Integrative Biosciences, Texas A&M University College Station, TX, USA
| | - Kerri J Smith
- Interdisciplinary Program in Genetics, Texas A&M University College Station, TX, USA
| | - Yong Zeng
- Department of Veterinary Integrative Biosciences, Texas A&M University College Station, TX, USA ; Department of Automation, Xiamen University Xiamen, China
| | - Guoli Ji
- Department of Automation, Xiamen University Xiamen, China
| | - Richard Connon
- Department of Anatomy, Physiology and Cell Biology, School of Veterinary Medicine, University of California Davis, CA, USA
| | - Nann A Fangue
- Department of Wildlife, Fish, and Conservation Biology, University of California Davis, CA, USA
| | - James J Cai
- Department of Veterinary Integrative Biosciences, Texas A&M University College Station, TX, USA ; Interdisciplinary Program in Genetics, Texas A&M University College Station, TX, USA
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174
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Fan L, Tighiouart H, Levey AS, Beck GJ, Sarnak MJ. Urinary sodium excretion and kidney failure in nondiabetic chronic kidney disease. Kidney Int 2014; 86:582-8. [PMID: 24646858 PMCID: PMC4149837 DOI: 10.1038/ki.2014.59] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/02/2013] [Accepted: 01/02/2014] [Indexed: 11/08/2022]
Abstract
Current guidelines recommend under 2 g/day sodium intake in chronic kidney disease, but there are a few studies relating sodium intake to long-term outcomes. Here we evaluated the association of mean baseline 24-h urinary sodium excretion with kidney failure and a composite outcome of kidney failure or all-cause mortality using Cox regression in 840 participants enrolled in the Modification of Diet in Renal Disease Study. Mean 24-h urinary sodium excretion was 3.46 g/day. Kidney failure developed in 617 participants, and the composite outcome was reached in 723. In the primary analyses, there was no association between 24-h urine sodium and kidney failure (HR 0.99 (95% CI 0.91-1.08)) nor on the composite outcome (HR 1.01 (95% CI 0.93-1.09)), each per 1 g/day higher urine sodium. In exploratory analyses, there was a significant interaction of baseline proteinuria and sodium excretion with kidney failure. Using a two-slope model, when urine sodium was under 3 g/day, higher urine sodium was associated with increased risk of kidney failure in those with baseline proteinuria under 1 g/day and with lower risk of kidney failure in those with baseline proteinuria of ⩾ 1 g/day. There was no association between urine sodium and kidney failure when urine sodium was ⩾ 3 g/day. Results were consistent using first baseline and time-dependent urinary sodium excretion. Thus, we noted no association of urine sodium with kidney failure. Results of the exploratory analyses need to be verified in additional studies and the mechanism explored.
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Affiliation(s)
- Li Fan
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Hocine Tighiouart
- Research Design Center/Biostatistics Research Center, Tufts Clinical and Translational Science Institute (CTSI), Tufts Medical Center, Boston, MA
| | - Andrew S. Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Gerald J. Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, OH
| | - Mark J. Sarnak
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
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175
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Sinnakirouchenan R, Kotchen TA. Role of Sodium Restriction and Diuretic Therapy for “Resistant” Hypertension in Chronic Kidney Disease. Semin Nephrol 2014; 34:514-9. [DOI: 10.1016/j.semnephrol.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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176
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Oh J, Lee J, Koo HS, Kim S, Chin HJ. Estimated 24-hour urine sodium excretion is correlated with blood pressure in Korean population: 2009-2011 Korean National Health and Nutritional Examination Survey. J Korean Med Sci 2014; 29 Suppl 2:S109-16. [PMID: 25317014 PMCID: PMC4194280 DOI: 10.3346/jkms.2014.29.s2.s109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/03/2014] [Indexed: 01/13/2023] Open
Abstract
No large-scale studies have investigated the association between salt intake and hypertension in Korean population. To investigate the relationship of blood pressure to salt consumption, we analyzed data from 19,476 participants in the 2009-2011 Korean National Health and Nutritional Examination Survey (KNHANES). Urinary sodium excretion over 24-hr (24HUNa) was estimated from spot urine tests using Tanaka's equation. The study subjects were stratified into hypertensive and normotensive groups. Hypertensive participants (n=6,552, 33.6%) had higher estimated 24HUNa, 150.4±38.8 mEq/day, than normotensive participants, 140.5±34.6 mEq/day (P<0.001). The association between 24HUNa and blood pressure outcomes was not affected by adjustment for other risk factors for hypertension (odds ratio 0.001; 95% confidence interval 0.001-0.003; P<0.001). Increases in 24HUNa of 100 mEq/day were associated with a 6.1±0.3/2.9±0.2 mmHg increase in systolic/diastolic blood pressure in all participants. This effect was stronger in hypertensive participants (increase of 8.1±0.5/3.4±0.3 mmHg per 100 mEq/day) and smaller in normotensive participants (2.9±0.3/1.3±0.2 mmHg). These results support recommendations for low salt intake in Korean population to prevent and control adverse blood pressure levels.
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Affiliation(s)
- Jieun Oh
- Department of Internal Medicine, Hallym University College of Medicine, Hallym Kidney Research Institute, Seoul, Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Hallym University College of Medicine, Hallym Kidney Research Institute, Seoul, Korea
| | - Ho Seok Koo
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Suhnggwon Kim
- Research Institute of Salt and Health, Seoul K-Clinic, Seoul, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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177
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Park SM, Jee J, Joung JY, Cho YY, Sohn SY, Jin SM, Hur KY, Kim JH, Kim SW, Chung JH, Lee MK, Min YK. High Dietary Sodium Intake Assessed by 24-hour Urine Specimen Increase Urinary Calcium Excretion and Bone Resorption Marker. J Bone Metab 2014; 21:189-94. [PMID: 25247156 PMCID: PMC4170081 DOI: 10.11005/jbm.2014.21.3.189] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/29/2014] [Accepted: 07/03/2014] [Indexed: 11/20/2022] Open
Abstract
Background The average dietary sodium intake of Koreans is 2.6 times higher than the World Health Organization's recommended amount. The effect of a diet high in sodium on the skeletal system, especially osteoporosis, has not previously been examined in Korean postmenopausal women with low bone mass. We assessed the daily sodium intake, and determined the impact of sodium intake on urinary calcium excretion and bone resorption marker. Methods A retrospective review of medical records was performed for 86 postmenopausal subjects who were initially diagnosed with osteopenia or osteoporosis at the health promotion center. They were subsequently referred to the Division of Endocrinology and Metabolism between 2010 and 2013. All subjects completed a modified food frequency questionnaire. Twenty-four hour urine collection for sodium, calcium and creatinine excretion, and serum C-terminal telopeptides of type I collagen (CTX-I) were also obtained. Results The average amount of daily sodium and calcium intake were 3,466 mg and 813 mg, respectively. Average dietary sodium intake and 24-hour urinary sodium excretion showed significant positive linear correlation (r=0.29, P=0.006). There was also a significant positive linear correlation between 24-hour urine sodium and calcium excretion (r=0.42, P<0.001); CTX-I and 24-hour urinary calcium excretion (r=0.29, P=0.007). Conclusions Excessive sodium intake assessed by 24-hour urine specimen is associated with high calcium excretion in urine. High calcium excretion is also related to increasing bone resorption marker.
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Affiliation(s)
- Sun Mi Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaehwan Jee
- Health Promotion Center, Samsung Medical Center, Seoul, Korea
| | - Ji Young Joung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seo Young Sohn
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Man Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Kyu Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Ki Min
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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178
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Stocker SD, Monahan KD, Browning KN. Neurogenic and sympathoexcitatory actions of NaCl in hypertension. Curr Hypertens Rep 2014; 15:538-46. [PMID: 24052211 DOI: 10.1007/s11906-013-0385-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Excess dietary salt intake is a major contributing factor to the pathogenesis of salt-sensitive hypertension. Strong evidence suggests that salt-sensitive hypertension is attributed to renal dysfunction, vascular abnormalities, and activation of the sympathetic nervous system. Indeed, sympathetic nerve transections or interruption of neurotransmission in various brain centers lowers arterial blood pressure (ABP) in many salt-sensitive models. The purpose of this article is to discuss recent evidence that supports a role of plasma or cerebrospinal fluid hypernatremia as a key mediator of sympathoexcitation and elevated ABP. Both experimental and clinical studies using time-controlled sampling have documented that a diet high in salt increases plasma and cerebrospinal fluid sodium concentration. To the extent it has been tested, acute and chronic elevations in sodium concentration activates the sympathetic nervous system in animals and humans. A further understanding of how the central nervous system detects changes in plasma or cerebrospinal fluid sodium concentration may lead to new therapeutic treatment strategies in salt-sensitive hypertension.
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Affiliation(s)
- Sean D Stocker
- Department of Cellular & Molecular Physiology, Pennsylvania State University College of Medicine, 500 University Drive H166, Hershey, PA, 17033, USA,
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179
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Abstract
PLEKHA7 (pleckstrin homology domain containing family A member 7) has been found in multiple studies as a candidate gene for human hypertension, yet functional data supporting this association are lacking. We investigated the contribution of this gene to the pathogenesis of salt-sensitive hypertension by mutating Plekha7 in the Dahl salt-sensitive (SS/JrHsdMcwi) rat using zinc-finger nuclease technology. After four weeks on an 8% NaCl diet, homozygous mutant rats had lower mean arterial (149 ± 9 mmHg vs. 178 ± 7 mmHg; P < 0.05) and systolic (180 ± 7 mmHg vs. 213 ± 8 mmHg; P < 0.05) blood pressure compared with WT littermates. Albumin and protein excretion rates were also significantly lower in mutant rats, demonstrating a renoprotective effect of the mutation. Total peripheral resistance and perivascular fibrosis in the heart and kidney were significantly reduced in Plekha7 mutant animals, suggesting a potential role of the vasculature in the attenuation of hypertension. Indeed, both flow-mediated dilation and endothelium-dependent vasodilation in response to acetylcholine were improved in isolated mesenteric resistance arteries of Plekha7 mutant rats compared with WT. These vascular improvements were correlated with changes in intracellular calcium handling, resulting in increased nitric oxide bioavailability in mutant vessels. Collectively, these data provide the first functional evidence that Plekha7 may contribute to blood pressure regulation and cardiovascular function through its effects on the vasculature.
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180
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O'Donnell M, Mente A, Rangarajan S, McQueen MJ, Wang X, Liu L, Yan H, Lee SF, 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 AH, Kruger L, Yusuf R, Chifamba J, Kabali C, Dagenais G, Lear SA, Teo K, Yusuf S. Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med 2014; 371:612-23. [PMID: 25119607 DOI: 10.1056/nejmoa1311889] [Citation(s) in RCA: 629] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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181
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Smell and salt: a delicate balance in health and disease. Nutrition 2014; 30:1094-6. [PMID: 25102823 DOI: 10.1016/j.nut.2013.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/26/2013] [Indexed: 11/22/2022]
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182
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Marckmann P, Osther P, Pedersen AN, Jespersen B. High-protein diets and renal health. J Ren Nutr 2014; 25:1-5. [PMID: 25091135 DOI: 10.1053/j.jrn.2014.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 05/21/2014] [Accepted: 06/06/2014] [Indexed: 12/16/2022] Open
Abstract
High-protein diets (i.e., protein content of more than 25% of energy or more than 2 g/kg body weight per day) based on meat and dairy products are repeatedly promoted for weight reduction and better health, but the evidence supporting these notions is quite dubious. As described in the present review, there is a reason to be concerned about adverse effects of such diets, including glomerular hyperfiltration, hypertensive effects of a concomitant increase in dietary sodium, and an increased risk of nephrolithiasis. These diet-induced physiological consequences might lead to an increase in the prevalence of chronic kidney disease in the general population without preexisting kidney disease. Accordingly, we find medical reasons to refrain from promoting high-protein diets, in particular those based on meat and dairy products, until clear-cut evidence for the safety and for the superiority of such diets on human health has been provided.
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Affiliation(s)
- Peter Marckmann
- Section of Nephrology, Department of Internal Medicine, Roskilde Hospital, Roskilde, Denmark.
| | - Palle Osther
- Department of Urology, Fredericia Hospital - a part of Hospital Littlebelt, University of Southern Denmark, Fredericia, Denmark
| | - Agnes N Pedersen
- Department of Nutrition, DTU Food, National Food Institute, Technical University of Denmark, Soeborg, Denmark
| | - Bente Jespersen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
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183
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Golledge J, Hankey GJ, Yeap BB, Almeida OP, Flicker L, Norman PE. Reported high salt intake is associated with increased prevalence of abdominal aortic aneurysm and larger aortic diameter in older men. PLoS One 2014; 9:e102578. [PMID: 25036037 PMCID: PMC4103816 DOI: 10.1371/journal.pone.0102578] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022] Open
Abstract
Background Salt intake has been implicated in the pathogenesis of abdominal aortic aneurysm (AAA) through studies in rodent models but not previously studied in humans. The aim of this study was to examine the association between reported addition of salt to food and the prevalence of AAA. Methods A risk factor questionnaire which contained a question about salt intake was included as part of a population screening study for AAA in 11742 older men. AAA presence was assessed by abdominal ultrasound imaging using a reproducible protocol. Results The prevalence of AAA was 6.9, 8.5 and 8.6% in men who reported adding salt to food never, sometimes and always, respectively, p = 0.005. Addition of salt to food sometimes (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.03–1.44) or always (OR: 1.23, 95% CI 1.04–1.47) was independently associated with AAA after adjustment for other risk factors including age, waist-hip ratio, blood pressure, history of hypertension, high cholesterol, angina, diabetes, myocardial infarction and stroke. Salt intake was also independently associated with aortic diameter (beta 0.023, p = 0.012). In men with no prior history of hypertension, high cholesterol, angina, myocardial infarction or stroke (n = 4185), the association between addition of salt to food sometimes (OR: 1.41, 95% CI 0.96–2.08) or always (OR: 1.52, 95% CI 1.04–2.22) and AAA remained evident. Conclusion Reported salt intake is associated with AAA in older men. Additional studies are needed to determine whether reducing salt intake would protect against AAA.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia
- * E-mail:
| | - Graeme J. Hankey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Department of Neurology, Royal Perth Hospital, Perth, Australia
| | - Bu B. Yeap
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Department of Endocrinology, Fremantle Hospital, Fremantle, Australia
| | - Osvaldo P. Almeida
- School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
- WA Centre for Health & Ageing, Centre for Medical Research, Perth, Australia
- Department of Psychiatry, Royal Perth Hospital, Perth, Australia
| | - Leon Flicker
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- WA Centre for Health & Ageing, Centre for Medical Research, Perth, Australia
- Department of Geriatric Medicine, Royal Perth Hospital, Perth, Australia
| | - Paul E. Norman
- School of Surgery, University of Western Australia, Perth, Australia
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184
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Ticinesi A, Nouvenne A, Maalouf NM, Borghi L, Meschi T. Salt and nephrolithiasis. Nephrol Dial Transplant 2014; 31:39-45. [PMID: 25031016 DOI: 10.1093/ndt/gfu243] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/18/2014] [Indexed: 12/17/2022] Open
Abstract
Dietary sodium chloride intake is nowadays globally known as one of the major threats for cardiovascular health. However, there is also important evidence that it may influence idiopathic calcium nephrolithiasis onset and recurrence. Higher salt intake has been associated with hypercalciuria and hypocitraturia, which are major risk factors for calcium stone formation. Dietary salt restriction can be an effective means for secondary prevention of nephrolithiasis as well. Thus in this paper, we review the complex relationship between salt and nephrolithiasis, pointing out the difference between dietary sodium and salt intake and the best methods to assess them, highlighting the main findings of epidemiologic, laboratory and intervention studies and focusing on open issues such as the role of dietary salt in secondary causes of nephrolithiasis.
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Affiliation(s)
- Andrea Ticinesi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
| | - Naim M Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Loris Borghi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
| | - Tiziana Meschi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy Internal Medicine and Critical Subacute Care Unit, Parma University Hospital, Parma, Italy
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185
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Mattson DL. Infiltrating immune cells in the kidney in salt-sensitive hypertension and renal injury. Am J Physiol Renal Physiol 2014; 307:F499-508. [PMID: 25007871 DOI: 10.1152/ajprenal.00258.2014] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The importance of the immune system in hypertension, vascular disease, and renal disease has been appreciated for over 50 years. Recent experimental advances have led to a greater appreciation of the mechanisms whereby inflammation and immunity participate in cardiovascular disease. In addition to the experimental data, multiple studies in patients have demonstrated a strong correlation between the observations made in animals and humans. Of great interest is the development of salt-sensitive hypertension in humans with the concurrent increase in albumin excretion rate. Experiments in our laboratory have demonstrated that feeding a high-NaCl diet to Dahl salt-sensitive (SS) rats results in a significant infiltration of T lymphocytes into the kidney that is accompanied by the development of hypertension and renal disease. The development of disease in the Dahl SS closely resembles observations made in patients; studies were therefore performed to investigate the pathological role of infiltrating immune cells in the kidney in hypertension and renal disease. Pharmacological and genetic studies indicate that immune cell infiltration into the kidney amplifies the disease process. Further experiments demonstrated that infiltrating T cells may accentuate the Dahl SS phenotype by increasing intrarenal ANG II and oxidative stress. From these and other data, we hypothesize that infiltrating immune cells, which surround the blood vessels and tubules, can serve as a local source of bioactive molecules which mediate vascular constriction, increase tubular sodium reabsorption, and mediate the retention of sodium and water to amplify sodium-sensitive hypertension. Multiple experiments remain to be performed to refine and clarify this hypothesis.
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Affiliation(s)
- David L Mattson
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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186
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Simmonds SS, Lay J, Stocker SD. Dietary salt intake exaggerates sympathetic reflexes and increases blood pressure variability in normotensive rats. Hypertension 2014; 64:583-9. [PMID: 24914195 DOI: 10.1161/hypertensionaha.114.03250] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Previous studies have reported that chronic increases in dietary salt intake enhance sympathetic nerve activity and arterial blood pressure (ABP) responses evoked from brain stem nuclei of normotensive, salt-resistant rats. The purpose of the present study was to determine whether this sensitization results in exaggerated sympathetic nerve activity and ABP responses during activation of various cardiovascular reflexes and also increases ABP variability. Male Sprague-Dawley rats were fed 0.1% NaCl chow (low), 0.5% NaCl chow (medium), 4.0% NaCl chow (high) for 14 to 17 days. Then, the animals were prepared for recordings of lumbar, renal, and splanchnic sympathetic nerve activity and ABP. The level of dietary salt intake directly correlated with the magnitude of sympathetic nerve activity and ABP responses to electrical stimulation of sciatic afferents or intracerebroventricular infusion of 0.6 mol/L or 1.0 mol/L NaCl. Similarly, there was a direct correlation between the level of dietary salt intake and the sympathoinhibitory responses produced by acute volume expansion and stimulation of the aortic depressor nerve or cervical vagal afferents. In contrast, dietary salt intake did not affect the sympathetic and ABP responses to chemoreflex activation produced by hypoxia or hypercapnia. Chronic lesion of the anteroventral third ventricle region eliminated the ability of dietary salt intake to modulate these cardiovascular reflexes. Finally, rats chronically instrumented with telemetry units indicate that increased dietary salt intake elevated blood pressure variability but not mean ABP. These findings indicate that dietary salt intake works through the forebrain hypothalamus to modulate various centrally mediated cardiovascular reflexes and increase blood pressure variability.
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Affiliation(s)
- Sarah S Simmonds
- From the Department of Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Hershey
| | - Jennifer Lay
- From the Department of Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Hershey
| | - Sean D Stocker
- From the Department of Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Hershey.
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187
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Henkin RI. Effects of smell loss (hyposmia) on salt usage. Nutrition 2014; 30:690-5. [DOI: 10.1016/j.nut.2013.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/07/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
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188
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Burnier M, Wuerzner G. Chronic kidney disease: Should sodium intake be restricted in patients with CKD? Nat Rev Nephrol 2014; 10:363-4. [PMID: 24846330 DOI: 10.1038/nrneph.2014.88] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Rue du Bugnon 17, Lausanne 1011, Switzerland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, Rue du Bugnon 17, Lausanne 1011, Switzerland
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189
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Kotliar C, Kempny P, Gonzalez S, Castellaro C, Forcada P, Obregon S, Cavanagh E, Chiabaut Svane J, Casarini MJ, Rojas M, Inserra F. Lack of RAAS inhibition by high-salt intake is associated with arterial stiffness in hypertensive patients. J Renin Angiotensin Aldosterone Syst 2014; 15:498-504. [DOI: 10.1177/1470320313503692] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Carol Kotliar
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Pablo Kempny
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Sergio Gonzalez
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Carlos Castellaro
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Pedro Forcada
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Sebastián Obregon
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Elena Cavanagh
- Biomedical School of Medicine, Universidad Austral, Argentina
| | - Jorge Chiabaut Svane
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Maria Jesus Casarini
- Centre of Hypertension, Cardiology Service, Hospital Universitario Austral, Argentina
| | - Mercedes Rojas
- Biochemical Central Laboratory, Hospital Universitario Austral, Argentina
| | - Felipe Inserra
- Biomedical School of Medicine, Universidad Austral, Argentina
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190
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Terker AS, Yang CL, McCormick JA, Meermeier NP, Rogers SL, Grossmann S, Trompf K, Delpire E, Loffing J, Ellison DH. Sympathetic stimulation of thiazide-sensitive sodium chloride cotransport in the generation of salt-sensitive hypertension. Hypertension 2014; 64:178-84. [PMID: 24799612 DOI: 10.1161/hypertensionaha.114.03335] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Excessive renal efferent sympathetic nerve activity contributes to hypertension in many circumstances. Although both hemodynamic and tubular effects likely participate, most evidence supports a major role for α-adrenergic receptors in mediating the direct epithelial stimulation of sodium retention. Recently, it was reported, however, that norepinephrine activates the thiazide-sensitive NaCl cotransporter (NCC) by stimulating β-adrenergic receptors. Here, we confirmed this effect and developed an acute adrenergic stimulation model to study the signaling cascade. The results show that norepinephrine increases the abundance of phosphorylated NCC rapidly (161% increase), an effect largely dependent on β-adrenergic receptors. This effect is not mediated by the activation of angiotensin II receptors. We used immunodissected mouse distal convoluted tubule to show that distal convoluted tubule cells are especially enriched for β₁-adrenergic receptors, and that the effects of adrenergic stimulation can occur ex vivo (79% increase), suggesting they are direct. Because the 2 protein kinases, STE20p-related proline- and alanine-rich kinase (encoded by STK39) and oxidative stress-response kinase 1, phosphorylate and activate NCC, we examined their roles in norepinephrine effects. Surprisingly, norepinephrine did not affect STE20p-related proline- and alanine-rich kinase abundance or its localization in the distal convoluted tubule; instead, we observed a striking activation of oxidative stress-response kinase 1. We confirmed that STE20p-related proline- and alanine-rich kinase is not required for NCC activation, using STK39 knockout mice. Together, the data provide strong support for a signaling system involving β₁-receptors in the distal convoluted tubule that activates NCC, at least in part via oxidative stress-response kinase 1. The results have implications about device- and drug-based treatment of hypertension.
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Affiliation(s)
- Andrew S Terker
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Chao-Ling Yang
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - James A McCormick
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Nicholas P Meermeier
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Shaunessy L Rogers
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Solveig Grossmann
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Katja Trompf
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Eric Delpire
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - Johannes Loffing
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.)
| | - David H Ellison
- From the Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland (A.S.T., C.-L.Y., J.A.M., N.P.M., S.L.R., D.H.E.); Renal Section, VA Medical Center, Portland, OR (C.-L.Y., N.P.M., D.H.E.); Institute of Anatomy, University of Zurich, Zurich, Switzerland (S.G., K.T., J.L.); and Department of Anesthesiology, Vanderbilt University Medical School, Nashville, TN (E.D.).
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191
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Neal B. Dietary Salt Is a Public Health Hazard That Requires Vigorous Attack. Can J Cardiol 2014; 30:502-6. [DOI: 10.1016/j.cjca.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 11/25/2022] Open
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192
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Karimi P, Islami F, Anandasabapathy S, Freedman ND, Kamangar F. Gastric cancer: descriptive epidemiology, risk factors, screening, and prevention. Cancer Epidemiol Biomarkers Prev 2014; 23:700-13. [PMID: 24618998 PMCID: PMC4019373 DOI: 10.1158/1055-9965.epi-13-1057] [Citation(s) in RCA: 1195] [Impact Index Per Article: 119.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Less than a century ago, gastric cancer was the most common cancer in the United States and perhaps throughout the world. Despite its worldwide decline in incidence over the past century, gastric cancer remains a major killer across the globe. This article reviews the epidemiology, screening, and prevention of gastric cancer. We first discuss the descriptive epidemiology of gastric cancer, including its incidence, survival, mortality, and trends over time. Next, we characterize the risk factors for gastric cancer, both environmental and genetic. Serologic markers and histological precursor lesions of gastric cancer and early detection of gastric cancer using these markers are reviewed. Finally, we discuss prevention strategies and provide suggestions for further research.
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Affiliation(s)
- Parisa Karimi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Farhad Islami
- Institute for Transitional Epidemiology, Mount Sinai School of Medicine, New York, NY, United States
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sharmila Anandasabapathy
- Division of Gastroenterology, Department of Medicine, Mount Sinai Medical Center, New York, NY, United States
| | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Farin Kamangar
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, MD, United States
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193
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Susic D, Frohlich ED. Telmisartan improves survival and ventricular function in SHR rats with extensive cardiovascular damage induced by dietary salt excess. ACTA ACUST UNITED AC 2014; 8:297-302. [DOI: 10.1016/j.jash.2014.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/21/2014] [Accepted: 02/22/2014] [Indexed: 01/22/2023]
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194
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Girardet JP, Rieu D, Bocquet A, Bresson JL, Briend A, Chouraqui JP, Darmaun D, Dupont C, Frelut ML, Hankard R, Goulet O, Simeoni U, Turck D, Vidailhet M. Les enfants consomment-ils trop de sel ? Arch Pediatr 2014; 21:521-8. [DOI: 10.1016/j.arcped.2014.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/14/2014] [Indexed: 01/11/2023]
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195
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Abstract
Elevation of blood pressure (BP) and the risk for progression to hypertension (HTN) is of increasing concern in children and adolescents. Indeed, it is increasingly recognized that target organ injury may begin with even low levels of BP elevation. Sodium intake has long been recognized as a modifiable risk factor for HTN. While it seems clear that sodium impacts BP in children, its effects may be enhanced by other factors including obesity and increasing age. Evidence from animal and human studies indicates that sodium may have adverse consequences on the cardiovascular system independent of HTN. Thus, moderation of sodium intake over a lifetime may reduce risk for cardiovascular morbidity in adulthood. An appetite for salt is acquired, and intake beyond our need is almost universal. Considering that eating habits in childhood have been shown to track into adulthood, modest sodium intake should be advocated as part of a healthy lifestyle.
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Affiliation(s)
- Coral D Hanevold
- Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.820, Seattle, WA, 98105, USA,
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196
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Abstract
The pathogenic role of sodium surfeit in primary hypertension is widely recognized but that of potassium deficiency usually has been ignored or at best assigned subsidiary status. Weighing the available evidence, we recently proposed that the chief environmental factor in the pathogenesis of primary hypertension and the associated cardiovascular risk is the interaction of the sodium surfeit and potassium deficiency in the body. Here, we present the major evidence highlighting the relationship between high-sodium intake and hypertension. We then examine the blood pressure-lowering effects of potassium in conjunction with the pernicious impact of potassium deficiency on hypertension and cardiovascular risk. We conclude with summarizing recent human trials that have probed the joint effects of sodium and potassium intake on hypertension and its cardiovascular sequelae. The latter studies lend considerable fresh support to the thesis that the interaction of the sodium surfeit and potassium deficiency in the body, rather than either disturbance by itself, is the critical environmental factor in the pathogenesis of hypertension.
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Baylor College of Medicine, Houston, TX; Department of Medicine, Houston Methodist Hospital, Houston, TX; Renal Section, Veterans Affairs Medical Center, Houston, TX
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center, Boston, MA.
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197
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Cowley AW, Moreno C, Jacob HJ, Peterson CB, Stingo FC, Ahn KW, Liu P, Vannucci M, Laud PW, Reddy P, Lazar J, Evans L, Yang C, Kurth T, Liang M. Characterization of biological pathways associated with a 1.37 Mbp genomic region protective of hypertension in Dahl S rats. Physiol Genomics 2014; 46:398-410. [PMID: 24714719 DOI: 10.1152/physiolgenomics.00179.2013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The goal of the present study was to narrow a region of chromosome 13 to only several genes and then apply unbiased statistical approaches to identify molecular networks and biological pathways relevant to blood-pressure salt sensitivity in Dahl salt-sensitive (SS) rats. The analysis of 13 overlapping subcongenic strains identified a 1.37 Mbp region on chromosome 13 that influenced the mean arterial blood pressure by at least 25 mmHg in SS rats fed a high-salt diet. DNA sequencing and analysis filled genomic gaps and provided identification of five genes in this region, Rfwd2, Fam5b, Astn1, Pappa2, and Tnr. A cross-platform normalization of transcriptome data sets obtained from our previously published Affymetrix GeneChip dataset and newly acquired RNA-seq data from renal outer medullary tissue provided 90 observations for each gene. Two Bayesian methods were used to analyze the data: 1) a linear model analysis to assess 243 biological pathways for their likelihood to discriminate blood pressure levels across experimental groups and 2) a Bayesian graphical modeling of pathways to discover genes with potential relationships to the candidate genes in this region. As none of these five genes are known to be involved in hypertension, this unbiased approach has provided useful clues to be experimentally explored. Of these five genes, Rfwd2, the gene most strongly expressed in the renal outer medulla, was notably associated with pathways that can affect blood pressure via renal transcellular Na(+) and K(+) electrochemical gradients and tubular Na(+) transport, mitochondrial TCA cycle and cell energetics, and circadian rhythms.
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Affiliation(s)
- Allen W Cowley
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin;
| | - Carol Moreno
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Howard J Jacob
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Francesco C Stingo
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas; and
| | - Kwang Woo Ahn
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pengyuan Liu
- Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Purushottam W Laud
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Prajwal Reddy
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jozef Lazar
- Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Louise Evans
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Chun Yang
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theresa Kurth
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mingyu Liang
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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198
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Titze J, Dahlmann A, Lerchl K, Kopp C, Rakova N, Schröder A, Luft FC. Spooky sodium balance. Kidney Int 2014; 85:759-67. [DOI: 10.1038/ki.2013.367] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 04/29/2013] [Accepted: 05/02/2013] [Indexed: 11/09/2022]
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199
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Karimi P, Islami F, Anandasabapathy S, Freedman ND, Kamangar F. Gastric cancer: descriptive epidemiology, risk factors, screening, and prevention. Cancer Epidemiol Biomarkers Prev 2014. [PMID: 24618998 DOI: 10.1158/1055-9965].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Less than a century ago, gastric cancer was the most common cancer in the United States and perhaps throughout the world. Despite its worldwide decline in incidence over the past century, gastric cancer remains a major killer across the globe. This article reviews the epidemiology, screening, and prevention of gastric cancer. We first discuss the descriptive epidemiology of gastric cancer, including its incidence, survival, mortality, and trends over time. Next, we characterize the risk factors for gastric cancer, both environmental and genetic. Serologic markers and histological precursor lesions of gastric cancer and early detection of gastric cancer using these markers are reviewed. Finally, we discuss prevention strategies and provide suggestions for further research.
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Affiliation(s)
- Parisa Karimi
- Authors' Affiliations: Johns Hopkins Bloomberg School of Public Health; Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore; Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland; Institute for Transitional Epidemiology, Mount Sinai School of Medicine; Division of Gastroenterology, Department of Medicine, Mount Sinai Medical Center, New York, New York; and Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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200
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Sherman PM, Makarchuk MJ, Belanger P. Research agenda to support sodium reduction in Canada. Appl Physiol Nutr Metab 2014; 39:396-8. [PMID: 24552384 DOI: 10.1139/apnm-2013-0370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The Sodium Reduction Strategy for Canada includes an identification of priority areas for future research, based on a workshop convened by the Canadian Institutes of Health Research (CIHR) and partners. A strong portfolio of research is essential to addressing current developments and controversies raised in relation to the health outcomes associated with dietary sodium. CIHR aims to provide leadership in working together with other funders and partners to catalyze a broad range of sodium research.
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Affiliation(s)
- Philip M Sherman
- Canadian Institutes of Health Research, 160 Elgin Street, 9th Floor, 4809A, Ottawa, ON K1A 0W9, Canada
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