The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes

Urinary Sodium Excretion and Kidney Disease Progression in IgA Nephropathy: A Cohort Study

INTRODUCTION

The role of dietary sodium intake in the risk of chronic kidney disease progression remains controversial. This study aimed to evaluate the association of urinary sodium excretion and progression of IgA nephropathy.

METHODS

We assessed 596 patients with IgA nephropathy, and urinary sodium excretion was measured at the time of kidney biopsy. Cox proportional hazards models and restricted cubic splines were used to assess the association between urinary sodium excretion and kidney disease progression events, defined as 50% eGFR decline or development of kidney failure.

RESULTS

After a mean follow-up of 58.9 months, a total of 75 (12.6%) participants of IgA nephropathy reached composite kidney disease progression events. The risk of kidney disease progression events was higher in patients with higher urinary sodium excretion. After adjustment for traditional risk factors, higher levels of ln-transformed urinary sodium excretion was associated with the kidney disease progression events in patients with IgA nephropathy (HR: 2.1; 95% CI: 1.4-3.2). In reference to the first tertile of urinary sodium excretion, hazard ratios were 1.9 (95% CI: 1.0-3.4) for the second tertile and 2.1 (95% CI: 1.1-3.9) for the third tertile.

CONCLUSION

Higher levels of urinary sodium excretion were associated with kidney disease progression events in IgA nephropathy independent of clinical and biopsy characteristics.

Sodium Intake and Incident Atrial Fibrillation in Individuals With Vascular Disease

Importance

Numerous prospective cohort studies have reported a J-shaped association of urinary sodium excretion with cardiovascular events and mortality.

Objective

To study the association between sodium intake and incident atrial fibrillation (AF).

Design, Setting, and Participants

This cohort study included participants in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomised Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND) multicenter, randomized clinical trials comparing the effect of ramipril 10 mg daily with telmisartan 80 mg daily, or their combination (ONTARGET) or 80 mg telmisartan daily with placebo (TRANSCEND) for the outcome of death from cardiovascular causes, myocardial infarction, stroke, or hospitalization for heart failure. ONTARGET and TRANSCEND included 31 546 participants with vascular disease or high-risk diabetes, and this study excluded participants without a urine sample for sodium measurement, missing data for key covariates, a history of AF, or AF detected in the first year after enrollment. Analyses were performed in July 2023 to May 2024.

Exposure

Estimated sodium intake from a morning fasting urine sample (Kawasaki formula).

Main Outcomes and Measures

The main outcome was incident AF. The association between estimated sodium intake and incident AF was modeled using multivariable adjusted Cox regression and cubic splines.

Results

A total of 27 391 participants (mean [SD] age, 66.3 [7.2] years; 19 310 [70.5%] male) were included. Mean (SD) estimated sodium intake was 4.8 (1.6) g/d. During a mean (SD) follow-up of 4.6 (1.0) years, 1562 participants (5.7%) had incident AF. After multivariable adjustment, a J-shaped association between sodium intake and AF risk was observed (P for nonlinearity = .03). Sodium intake of 8 g/d or greater (3% of participants) was associated with incident AF (hazard ratio, 1.32; 95% CI, 1.01-1.74) compared with sodium intake of 4 to 5.99 g/d. Cubic splines showed that sodium intake greater than 6 g/d (19% of participants) was associated with a 10% increased AF risk per additional 1-g/d sodium intake (hazard ratio, 1.10; 95% CI, 1.03-1.18), but with no further lowering of AF risk at lower levels of sodium intake.

Conclusions and Relevance

In this cohort study of sodium intake and AF risk, there was a J-shaped association between sodium intakes and AF risk in patients with cardiovascular disease or diabetes. Lowering sodium intake for AF prevention is best targeted at individuals who consume high sodium diets.

High sodium intake and fluid overhydration predict cardiac structural and functional impairments in chronic kidney disease

Background

High sodium intake and fluid overhydration are common factors of and strongly associated with adverse outcomes in chronic kidney disease (CKD) patients. Yet, their effects on cardiac dysfunction remain unclear.

Aims

The study aimed to explore the impact of salt and volume overload on cardiac alterations in non-dialysis CKD.

Methods

In all, 409 patients with CKD stages 1-4 (G1-G4) were enrolled. Daily salt intake (DSI) was estimated by 24-h urinary sodium excretion. Volume status was evaluated by the ratio of extracellular water (ECW) to total body water (TBW) measured by body composition monitor. Recruited patients were categorized into four groups according to DSI (6 g/day) and median ECW/TBW (0.439). Echocardiographic and body composition parameters and clinical indicators were compared. Associations between echocardiographic findings and basic characteristics were performed by Spearman's correlations. Univariate and multivariate binary logistic regression analysis were used to determine the associations between DSI and ECW/TBW in the study groups and the incidence of left ventricular hypertrophy (LVH) and elevated left ventricular filling pressure (ELVFP). In addition, the subgroup effects of DSI and ECW/TBW on cardiac abnormalities were estimated using Cox regression.

Results

Of the enrolled patients with CKD, the median urinary protein was 0.94 (0.28-3.14) g/d and estimated glomerular filtration rate (eGFR) was 92.05 (IQR: 64.52-110.99) mL/min/1.73 m2. The distributions of CKD stages G1-G4 in the four groups was significantly different (p = 0.020). Furthermore, compared to group 1 (low DSI and low ECW/TBW), group 4 (high DSI and high ECW/TBW) showed a 2.396-fold (95%CI: 1.171-4.902; p = 0.017) excess risk of LVH and/or ELVFP incidence after adjusting for important CKD and cardiovascular disease risk factors. Moreover, combined with eGFR, DSI and ECW/TBW could identify patients with higher cardiac dysfunction risk estimates with an AUC of 0.704 (sensitivity: 75.2%, specificity: 61.0%). The specificity increased to 85.7% in those with nephrotic proteinuria (AUC = 0.713). The magnitude of these associations was consistent across subgroups analyses.

Conclusion

The combination of high DSI (>6 g/d) and high ECW/TBW (>0.439) independently predicted a greater risk of LVH or ELVFP incidence in non-dialysis CKD patients. Moreover, the inclusion of eGFR and proteinuria improved the risk stratification ability of DSI and ECW/TBW in cardiac impairments in CKD.

Cardiovascular Disease Burden Attributable to High Sodium Intake in China: A Longitudinal Study from 1990 to 2019

BACKGROUND

Overconsumption of sodium has been identified as a key driving factor for diet-related cardiovascular diseases (CVDs). China, being a country bearing a hefty burden of CVD, has a large population with diverse cultural traditions and ethnic beliefs, which complicates the patterns of dietary sodium intake, necessitating a systematic investigation into the profile of the high sodium intake (HSI)-related burden of CVD within its subregions. This study aims to estimate the evolving patterns of HSI-induced CVD burden across China from 1990 to 2019.

METHODS

The methodology used in the Global Burden of Disease Study was followed to assess deaths and disability-adjusted life years (DALYs) by age, sex, region, and socio-demographic index (SDI). The estimated annual percentage change (EAPC) was calculated to quantify the secular changes in the age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR).

RESULTS

In 2019, 0.79 million deaths and 1.93 million DALYs of CVD were attributed to HSI, an increase of 53.91% and 39.39% since 1990, respectively. Nevertheless, a downward trend in ASMR (EAPC: -1.45, 95% CI: -1.55, -1.35) and ASDR (EAPC: -1.61, 95% CI: -1.68, -1.53) was detected over time. ASMR and ASDR were higher for males, individuals aged ≥60 years, and regions with low-middle SDI. A markedly negative association between the EAPC in both ASMR and ASDR and the SDI was found in 2019 (ρ = -0.659, p < 0.001 and ρ = -0.558, p < 0.001, respectively).

CONCLUSIONS

The HSI-induced CVD burden is gender-, age-, and socioeconomic-dependent. Integrated and targeted strategies for CVD prevention are anticipated in the future throughout China.

Sodium, potassium intake, and all-cause mortality: confusion and new findings

BACKGROUND

The World Health Organization (WHO) has established recommended daily intakes for sodium and potassium. However, there is currently some controversy regarding the association between sodium intake, potassium intake, the sodium-to-potassium ratio, and overall mortality. To assess the correlations between sodium intake, potassium intake, the sodium-to-potassium ratio, and overall mortality, as well as the potential differences in sodium and potassium intake thresholds among different population groups, we analyzed data from NHANES 2003-2018.

METHODS

NHANES is an observational cohort study that estimates sodium and potassium intake through one or two 24-h dietary recalls. Hazard ratios (HR) for overall mortality were calculated using multivariable adjusted Cox models accounting for sampling design. A total of 13855 out of 26288 participants were included in the final analysis. Restricted cubic spline analyses were used to examine the relationship between sodium intake, potassium intake, and overall mortality. If non-linearity was detected, we employed a recursive algorithm to calculate inflection points.

RESULTS

Based on one or two 24-h dietary recalls, the sample consisted of 13,855 participants, representing a non-institutionalized population aged 40-80 years, totaling 11,348,771 person-months of mean follow-up 99.395 months. Daily sodium intake and daily potassium intake were inversely associated with all-cause mortality. Restrictive cubic spline analysis showed non-linear relationships between daily sodium intake, potassium intake, sodium-potassium ratio, and total mortality. The inflection point for daily sodium intake was 3133 mg/d, and the inflection point for daily potassium intake was 3501 mg/d, and the inflection point for daily sodium-potassium ratio intake was 1.203 mg/mg/d. In subgroup analyses, a significant interaction was found between age and high sodium intake, which was further confirmed by the smooth curves that showed a U-shaped relationship between sodium intake and all-cause mortality in the elderly population, with a inflection point of 3634 mg/d.

CONCLUSION

Nonlinear associations of daily sodium intake, daily potassium intake and daily sodium-potassium ratio intake with all-cause mortality were observed in American individuals. The inflection point for daily sodium intake was 3133 mg/d. And the inflection point for daily sodium intake was 3634 mg/d in elderly population. The inflection point for daily potassium intake was 3501 mg/d. The inflection point for daily sodium-potassium ratio intake was 1.203 mg/mg/d, respectively, A healthy diet should be based on reasonable sodium intake and include an appropriate sodium-to-potassium ratio.

Effect of low sodium and high potassium diet on lowering blood pressure and cardiovascular events

Incorporating aggressive lifestyle modifications along with antihypertensive medication therapy is a crucial treatment strategy to enhance the control rate of hypertension. Dietary modification is one of the important lifestyle interventions for hypertension, and it has been proven to have a clear effect. Among food ingredients, sodium and potassium have been found to have the strongest association with blood pressure. The blood pressure-lowering effect of a low sodium diet and a high potassium diet has been well established, especially in hypertensive population. A high intake of potassium, a key component of the Dietary Approaches to Stop Hypertension (DASH) diet, has also shown a favorable impact on the risk of cardiovascular events. Additionally, research conducted with robust measurement methods has shown cardiovascular benefits of low-sodium intake. In this review, we aim to discuss the evidence regarding the relationship between the low sodium and high potassium diet and blood pressure and cardiovascular events.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Nutritional Strategies for the Management of Type 2 Diabetes Mellitus: A Narrative Review

BACKGROUND

Thinking about greater adherence to dietary planning, it is extremely important to be aware of all nutritional strategies and dietary prescriptions available in the literature, and of which of them is the most efficient for the management of T2DM.

METHODS

A search was carried out in 2023 for randomized clinical trials, systematic reviews, meta-analyses, and guidelines in the following databases: Pubmed, Scielo, Web of Science, CrossRef and Google Scholar. In total, 202 articles were collected and analyzed. The period of publications was 1983-2023.

RESULTS

There is still no consensus on what the best nutritional strategy or ideal dietary prescription is, and individuality is necessary. In any case, these references suggest that Mediterranean Diet may of greater interest for the management of T2DM, with the following recommended dietary prescription: 40-50% carbohydrates; 15-25% proteins; 25-35% fats (<7% saturated, 10% polyunsaturated, and 10% monounsaturated); at least 14 g of fiber for every 1000 kcal consumed; and <2300 mg sodium.

CONCLUSIONS

Individuality is the gold standard for dietary prescriptions, however, the Mediterranean diet with low levels of carbohydrates and fats seems to be the most promising strategy for the management of T2DM.

Urine sodium excretion is related to extracellular water volume but not to blood pressure in 510 normotensive and never-treated hypertensive subjects

PURPOSE

High sodium intake is an accepted risk factor for hypertension, while low Na⁺ intake has also been associated with increased risk of cardiovascular events. In this cross-sectional study, we examined the association of 24-h urinary Na⁺ excretion with haemodynamics and volume status.

MATERIALS AND METHODS

Haemodynamics were recorded in 510 normotensive and never-treated hypertensive subjects using whole-body impedance cardiography and tonometric radial artery pulse wave analysis. The results were examined in sex-specific tertiles of 24-h Na⁺ excretion, and comparisons between normotensive and hypertensive participants were also performed. Regression analysis was used to investigate factors associated with volume status. The findings were additionally compared to 28 patients with primary aldosteronism.

RESULTS

The mean values of 24-h urinary Na⁺ excretion in tertiles of the 510 participants were 94, 148 and 218 mmol, respectively. Average tertile age (43.4-44.7 years), office blood pressure and pulse wave velocity were corresponding in the tertiles. Plasma electrolytes, lipids, vitamin D metabolites, parathyroid hormone, renin activity, aldosterone, creatinine and insulin sensitivity did not differ in the tertiles. In supine laboratory recordings, there were no differences in aortic systolic and diastolic blood pressure, heart rate, cardiac output and systemic vascular resistance. Extracellular water volume was higher in the highest versus lowest tertile of Na⁺ excretion. In regression analysis, body surface area and 24-h Na⁺ excretion were independent explanatory variables for extracellular water volume. No differences in urine Na⁺ excretion and extracellular water volume were found between normotensive and hypertensive participants. When compared with the 510 participants, patients with primary aldosteronism had 6.0% excess in extracellular water (p = .003), and 24-h Na⁺ excretion was not related with extracellular water volume.

CONCLUSION

In the absence of mineralocorticoid excess, Na⁺ intake, as evaluated from 24-h Na⁺ excretion, predominantly influences extracellular water volume without a clear effect on blood pressure.

Self-Reported Frequency of Adding Salt to Food and Risk of Incident Chronic Kidney Disease

Importance

The self-reported frequency of adding salt to foods could reflect a person's long-term salt taste preference, and salt intake has been associated with increased risk of cardiovascular diseases (CVD). Whether self-reported adding of salt to foods is associated with increased risk of chronic kidney disease (CKD) remains unknown.

Objective

To prospectively examine the association of self-reported frequency of adding salt to foods with incident CKD risk in a general population of adults.

Design, Setting, and Participants

This population-based cohort study evaluated UK Biobank participants aged 37 to 73 years who were free of CKD at baseline. Participants were enrolled from 2006 to 2010 and prospectively followed up for disease diagnosis. Data were analyzed from October 2022 to April 2023.

Exposure

Self-reported frequency of adding salt to foods, categorized into never or rarely, sometimes, usually, and always.

Main Outcome and Measure

Incident CKD cases were defined by diagnostic codes. Hazard ratios (HRs) and 95% CIs were calculated by using Cox proportional hazards models. Models were adjusted for several potential confounders including age, sex, race and ethnicity, Townsend Deprivation Index, estimated glomerular filtration rate (eGFR), body mass index, (BMI), smoking status, alcohol drinking status, regular physical activity, high cholesterol, diabetes, CVD, hypertension, infectious disease, immune disease, and nephrotoxic drugs use at baseline.

Results

Within a cohort of 465 288 individuals (mean [SD] age 56.32 [8.08] years; 255 102 female participants [54.83%]; 210 186 male participants [45.17%]), participants with higher self-reported frequency of adding salt to foods were more likely to have a higher BMI, higher Townsend Deprivation Index score, and diminished baseline eGFR compared with those who reported a lower frequency of adding salt to foods. Participants who added salt to their foods were also more likely than those who did not add salt to their foods to be current smokers and have diabetes or CVD at baseline. During a median (IQR) follow-up of 11.8 (1.4) years, 22 031 incident events of CKD were documented. Higher self-reported frequency of adding salt to foods was significantly associated with a higher CKD risk after adjustment for covariates. Compared with those who reported never or rarely adding salt to foods, those who reported sometimes adding salt to food (adjusted HR [aHR], 1.04; 95% CI, 1.00-1.07), those who reported usually adding salt to food (aHR, 1.07; 95% CI, 1.02-1.11), and those who reported always adding salt to food (aHR, 1.11; 95% CI, 1.05-1.18) had an increased risk of CKD (P for trend < .001). In addition, eGFR, BMI, and physical activity significantly modified the associations, which were more pronounced among participants with a higher eGFR, lower BMI, or lower level of physical activity.

Conclusions and Relevance

In this cohort study of 465 288 individuals, a higher self-reported frequency of adding salt to foods was associated with a higher risk of CKD in the general population. These findings suggest that reducing the frequency of adding salt to foods at the table might be a valuable strategy to lower CKD risk in the general population.

Intrarenal Mechanisms of Sodium-Glucose Cotransporter-2 Inhibitors on Tubuloglomerular Feedback and Natriuresis

When sodium-glucose cotransporter-2 (SGLT2) inhibitors were first introduced a decade ago, no one expected them to have substantial effects beyond their known glucose-lowering effects, until the emergence of evidence of their robust renal and cardiovascular benefits showing that they could attenuate progression of kidney disease, irrespective of diabetes, as well as prevent the development of acute kidney injury. Still, the precise and elaborate mechanisms underlying the major organ protection of SGLT2 inhibitors remain unclear. SGLT2 inhibitors inhibit the reabsorption of sodium and glucose in the proximal tubule of the kidney and then recovers tubuloglomerular feedback, whereby SGLT2 inhibitors reduce glomerular hyperfiltration. This simple demonstration of their beneficial effects has perplexed experts in seeking more plausible and as yet undisclosed explanations for the whole effects of SGLT2 inhibitors, including metabolism reprogramming and the modulation of hypoxia, inflammation, and oxidative stress. Given that the renal benefits of SGLT2 inhibitors in patients with kidney disease but without diabetes were comparable to those seen in patients with diabetes, it may be reasonable to keep the emphasis on their hemodynamic actions. In this context, the aim of the present review is to provide a comprehensive overview of renal hemodynamics in individuals with diabetes who are treated with SGLT2 inhibitors, with a focus on natriuresis associated with the regulation of tubuloglomerular feedback and potential aquaresis. Throughout the discussion of alterations in renal sodium and water transports, particular attention will be given to the potential enhancement of adenosine and its receptors following SGLT2 inhibition.

Serum sodium levels associate with recovery of kidney function in immune checkpoint inhibitor nephrotoxicity

Background

Immune checkpoint inhibitors (ICIs) are novel drugs targeting programmed cell death protein 1-ligand 1 (PD-L1) or its receptor (PD-1). Enhancing the immune system has also been associated with a wide range of immune-related adverse events (irAE). Among them, acute interstitial nephritis (AIN) is a rare but deleterious irAE in the kidney. However, determinants of recovery and long-term kidney function after ICI withdrawal and steroid therapy thereafter remain elusive. Therefore, we here aimed to identify parameters associated with recovery of kidney function in this previous established cohort of AIN in the context of ICI therapy.

Methods

We here monitored kidney function over a mean follow-up time of 812 days in comparison with clinical, histopathological and laboratory parameters associated with recovery of kidney function after AIN related to ICI nephrotoxicity.

Results

Abundance of intrarenal PD-L1/PD-1 did not correlate with recovery of kidney function. Furthermore, cumulative steroid dose that was initiated for treatment of AIN related to ICI nephrotoxicity was also not associated with improvement of kidney function. Finally, chronic lesions in the kidney including glomerular sclerosis and interstitial fibrosis/tubular atrophy (IF/TA) did not correlate with eGFR change during the follow-up time. However, we here identified that lower levels of serum sodium at time of kidney biopsy were the strongest independent predictor of renal recovery in ICI-related nephrotoxicity.

Conclusion

Because low serum sodium levels associated with better improvement of kidney function, these observations might contribute to novel approaches to enhance recovery after AIN related to ICI nephrotoxicity.

Estimated 24-h urinary sodium excretion and risk of end-stage kidney disease

The association between sodium intake and long-term kidney disease endpoints is debated and yet to be proven. We aimed to investigate the associations of estimated 24-h urinary sodium excretion, reflecting daily sodium intake, with the incidence of end-stage kidney disease (ESKD). In this prospective cohort study including 444,375 UK Biobank participant, 865 (0.2%) ESKD events occurred after median follow-up of 12.7 years. For every 1 g increment in estimated 24-h urinary sodium excretion, multivariable-adjusted hazard ratio for incident ESKD was 1.09 (95% confidence interval 0.94-1.26). Nonlinear associations were not detected with restricted cubic splines. The null findings were confirmed by a series of sensitivity analyses, which attenuated potential bias from measurement errors of the exposure, regression dilution, reverse causality, and competing risks. In conclusion, there is insufficient evidence that estimated 24-h urinary sodium excretion is associated with the incidence of ESKD.

The effect of a low versus high sodium diet on blood pressure in diabetic patients: A systematic review and meta-analysis of clinical trials

There have been numerous clinical trials that have investigated the effect of sodium intake on blood pressure in diabetic patients. The purpose of this systematic review and meta-analysis was to evaluate the clinical trial studies performed on the effect of low sodium diet (LSD) versus high sodium diet (HSD) on blood pressure in diabetic patients. PubMed, Scopus, and Web of Science were systematically searched from database inception to July 10, 2021. Both type 1 and 2 diabetes was considered. Overall, there were 15 studies included in this meta-analysis. The weighted (WMD) mean difference with 95% confidence interval (CI) was calculated using a random-effects model. Risk of bias in the studies was assessed based on the Cochrane collaboration tool and the quality of all the studies was considered as good. Overall, LSD significantly reduced SBP (systolic blood pressure) (WMD: -3.79 mmHg, 95% CI: -6.02, -1.56) and DBP (diastolic blood pressure) (WMD: -1.62 mmHg, 95% CI: -2.84, -0.40), in comparison with HSD, in diabetics. However, LSD had no significant effect on MAP (mean arterial pressure) in comparison with HSD (WMD: -1.81, 95%CI: -5.49, 1.87). Although subgroup analysis could not attenuate heterogeneity in SBP, subgroup analysis in DBP based on duration (≤1 week: WMD: -2.35, 95%CI: -3.69, -1.00, I 2  = 48.9%, p = 0.081, >1 week: WMD: -1.04, 95% CI: -2.83, 0.76, I 2  = 74.7%, p = 0.003) and study design (cross-over: WMD: -1.94, 95% CI: -2.71, -1.17, I 2  = 32.1%, p = 0.183, parallel: WMD: -2.17, 95% CI: -6.48, 2.13, I 2  = 82.4%, p = 0.001) successfully detected sources of heterogeneity. LSD significantly reduced SBP and DBP, however, had no effect on MAP, in comparison with HSD.

Sodium Management in Kidney Disease: Old Stories, New Tricks

Excessive dietary sodium intake is associated with an increased risk of hypertension, especially in the setting of chronic kidney disease (CKD). Although implementation of a low-sodium diet in patients with CKD generally is recommended, data supporting the efficacy of this practice is mostly opinion-based. Few controlled studies have investigated the specific association of dietary sodium intake and cardiovascular events and mortality in CKD. Furthermore, in epidemiologic studies, the association of sodium intake with CKD progression, cardiovascular risk, and mortality is not homogeneous, and both low- and high-sodium intake has been associated with adverse health outcomes in different studies. In general, the adverse effects of high dietary sodium intake are more apparent in the setting of advanced CKD. However, there is no established definitive target level of dietary sodium intake in different CKD stages based on glomerular filtration rate and albuminuria/proteinuria. This review discusses the current challenges regarding the rationale of sodium restriction, target levels and assessment of sodium intake, and interventions for sodium restrictions in CKD in relation to clinical outcomes.

The association between sodium intake and coronary and carotid atherosclerosis in the general Swedish population

Aims

A high intake of salt raises blood pressure and the risk of cardiovascular disease. Previous studies have reported on the association between salt intake and carotid stenosis, but the association with coronary atherosclerosis has not been reported. Therefore, this project aimed at studying the association between salt intake and both carotid and coronary atherosclerosis in a contemporary community-based cohort.

Methods and results

Estimated 24-h sodium excretion (est24hNa) was calculated by the Kawasaki formula for participants of two sites (Uppsala and Malmö) of the Swedish Cardiopulmonary bioImage Study, who underwent a coronary computed tomography (n = 9623) and measurement of coronary artery calcium score (CACS, n = 10 289). Carotid ultrasound was used to detect carotid plaques (n = 10 700). Ordered logistic regression was used to calculate odds ratios (OR) per 1000 mg increase in est24hNa. We also investigated potential J-formed associations using quintiles of est24hNa. Increased est24hNa was associated with increased occurrence of carotid plaques [OR: 1.09, P < 0.001, confidence interval (CI): 1.06-1.12], higher CACS (OR: 1.16, P < 0.001, CI: 1.12-1.19), and coronary artery stenosis (OR: 1.17, P < 0.001, CI: 1.13-1.20) in minimal adjusted models. Associations were abolished when adjusting for blood pressure. When adjusting for established cardiovascular risk factors (not including blood pressure), associations remained for carotid plaques but not for coronary atherosclerosis. There was no evidence of J-formed associations.

Conclusion

Higher est24hNa was associated with both coronary and carotid atherosclerosis in minimal adjusted models. The association seemed mainly mediated by blood pressure but to some degree also influenced by other established cardiovascular risk factors.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

[Diabetic kidney disease (update 2023) : Position paper of the Austrian Diabetes Association and the Austrian Society for Nephrology]

Epidemiological investigations have shown that approximately 2-3% of all Austrians have diabetes mellitus with renal involvement, leaving 250,000 people in Austria affected. The risk of occurrence and progression of this disease can be attenuated by lifestyle interventions as well as optimization of blood pressure, blood glucose control and special drug classes. The present article represents the joint recommendations of the Austrian Diabetes Association and the Austrian Society of Nephrology for the diagnostic and treatment strategies of diabetic kidney disease.

Dietary Intake and Physical Activity of Thai Children and Adolescents with Type 1 Diabetes Mellitus

Appropriate dietary intake and physical activity (PA) are essential for glycemic control and optimal growth in youth with type 1 diabetes (T1D). Thus, this study aimed to compare dietary intake and PA between youth with T1D and healthy controls. One hundred Thai youth with T1D and 100 age-matched healthy participants were recruited. A 3-day food record was completed and converted into nutrient intake data. PA data were collected via interview. Participants with T1D had a significantly higher mean ± SD carbohydrate (50.8 ± 6.8% vs. 46.2 ± 7.5%, p < 0.01), lower fat (32.4 ± 5.9% vs. 35.9 ± 6.4%, p < 0.01), and lower protein (16.8 ± 2.6% vs. 17.9 ± 3.5%, p = 0.01) intake compared to controls. Fifty percent of T1D participants and 41% of control participants consumed saturated fat more than recommendations (p = 0.20). Participants with T1D had a higher median (IQR) calcium intake compared to controls (474 (297−700) vs. 328 (167−447) mg/day, p < 0.01). Both groups consumed less fiber and more sodium compared to recommendations. Both groups had inadequate PA. Participants with T1D had significantly less PA compared to controls (25 (13−48) vs. 34 (14−77) minutes/day, p = 0.04). In addition to the need for counseling that promotes consumption of more dietary fiber and calcium and less saturated fat and sodium, the benefits of performing regular exercise need to be emphasized among youth with T1D.

Low sodium intake and cardiovascular disease mortality among adults with hypertension

Background

Though high sodium intake is linked to an increased risk of hypertension and cardiovascular diseases, the relationship between sodium intake and mortality remains controversial. Given that medications used to treat hypertension can potentially lower blood sodium levels and alter electrolyte balance, it begs the question whether a further reduction in dietary sodium below the recommended daily intake of 2300 mg is beneficial among adults with hypertension.

Objective

To evaluate the effect of low sodium intake on cardiovascular disease (CVD) mortality and all-cause mortality among adults with hypertension.

Design

A retrospective cohort study was conducted using data from the Continuous NHANES (1999-2010) linked to mortality files from the National Death Index. Using sodium intake categorized as low <2300 mg/day and high ≥2300 mg/day, the baseline demographic and health characteristics of participants were determined. Hazard ratios (HR) for CVD and all-cause mortality were determined through cox proportional hazard regression analysis adjusted for age, sex, race, total dietary calories, body mass index, physical activity, smoking, diabetes, alcohol consumption, and total serum cholesterol while considering the complex survey design.

Results

Of the 8542 adults with hypertension, 71.01% consumed sodium higher than the recommended daily intake of 2300 mg. The mean age was 54 years, 52.3% were female and 73.1% were white. Over 12.7 years of follow-up, there were 971 deaths, with 232 deaths from CVD. The low sodium intake group had a nonsignificant 5% higher risk of CVD mortality, [Adjusted HR 1.05,95% CI (0.7-1.6), p-value 0.82]. Similarly, there was a nonsignificant 17% higher risk for all-cause mortality for the low sodium intake group, [Adjusted HR 1.17,95% CI (1.0-1.4), p-value 0.10]. There was no effect modification by age, race, or sex.

Conclusion

The findings of an inverse association between sodium intake and mortality among adults with hypertension seen here, though not statistically significant warrant further investigation.

Inverse Salt Sensitivity of Blood Pressure: Mechanisms and Potential Relevance for Prevention of Cardiovascular Disease

PURPOSE OF REVIEW

To review the etiology of inverse salt sensitivity of blood pressure (BP).

RECENT FINDINGS

Both high and low sodium (Na+) intake can be associated with increased BP and cardiovascular morbidity and mortality. However, little is known regarding the mechanisms involved in the increase in BP in response to low Na+ intake, a condition termed inverse salt sensitivity of BP, which affects approximately 15% of the adult population. The renal proximal tubule is important in regulating up to 70% of renal Na+ transport. The renin-angiotensin and renal dopaminergic systems play both synergistic and opposing roles in the regulation of Na+ transport in this nephron segment. Clinical studies have demonstrated that individuals express a "personal salt index" (PSI) that marks whether they are salt-resistant, salt-sensitive, or inverse salt-sensitive. Inverse salt sensitivity results in part from genetic polymorphisms in various Na+ regulatory genes leading to a decrease in natriuretic activity and an increase in renal tubular Na+ reabsorption leading to an increase in BP. This article reviews the potential mechanisms of a new pathophysiologic entity, inverse salt sensitivity of BP, which affects approximately 15% of the general adult population.

Association between urinary sodium excretion and hard outcomes in non-dialysis chronic kidney disease patients

Background

Restriction of sodium intake is routinely recommended for patients with chronic kidney disease (CKD). Whether or not sodium intake is associated with the progression of CKD and mortality remains uncertain. We evaluated the association between urinary sodium excretion (as a surrogate for sodium intake) with the occurrence of renal failure and mortality in patients with non-dialytic CKD.

Methods

We conducted a retrospective study of patients followed at a CKD clinic care hospital from October 2006 to March 2017. Adult patients with non-dialytic CKD were included. Using a time-to-event analysis, we examined the association of urinary sodium excretion as a categorical variable (categorized as quintiles: 1st quintile: 0.54–2.51 g; 2nd quintile: 2.52–3.11 g, 3rd quintile: 3.12–3.97 g, 4th quintile: 3.98–5.24 g and 5th quintile: 5.26–13.80 g) and the outcomes of interest. The primary outcome was defined as progression to end-stage renal disease requiring any type of renal replacement therapy. The secondary outcome was mortality.

Results

Two hundred five patients were included in the study (mean follow up of 2.6 years) with a mean eGFR of 26 (19–41) ml/min/1.73m2. 37 patients (18%) required renal replacement therapy and 52 (25,3%) died. There was association between urinary sodium excretion and need for renal replacement therapy (adjusted HR 0.245; 95%CI 0.660–0.912). There was no association between urinary sodium excretion and mortality in adjusted models.

Conclusion

Moderate sodium intake was associated with a lower risk of renal failure.

Intestinal Gastrin/CCKBR (Cholecystokinin B Receptor) Ameliorates Salt-Sensitive Hypertension by Inhibiting Intestinal Na+/H+ Exchanger 3 Activity Through a PKC (Protein Kinase C)-Mediated NHERF1 and NHERF2 Pathway

Background:

The present study directly tested the crucial role of intestinal gastrin/CCKBR (cholecystokinin B receptor) in the treatment of salt-sensitive hypertension.

Methods:

Adult intestine-specific Cckbr-knockout mice (Cckbr^fl/flvillin-Cre) and Dahl salt-sensitive rats were studied on the effect of high salt intake (8% NaCl, 6–7 weeks) on intestinal Na^+/H⁺ exchanger 3 expression, urine sodium concentration, and blood pressure. High-salt diet increased urine sodium concentration and systolic blood pressure to a greater extent in Cckbr^fl/flvillin-Cre mice and Dahl salt-sensitive rats than their respective controls, Cckbr^fl/flvillin mice and SS13^BN rats. We constructed gastrin-SiO₂ microspheres to enable gastrin to stimulate specifically and selectively intestinal CCKBR without its absorption into the circulation.

Results:

Gastrin-SiO₂ microspheres treatment prevented the high salt-induced hypertension and increase in urine Na concentration by inhibiting intestinal Na^+/H⁺ exchanger 3 trafficking and activity, increasing stool sodium without inducing diarrhea. Gastrin-mediated inhibition of intestinal Na^+/H⁺ exchanger 3 activity, related to a PKC (protein kinase C)-mediated activation of NHERF1 and NHERF2.

Conclusions:

These results support a crucial role of intestinal gastrin/CCKBR in decreasing intestinal sodium absorption and keeping the blood pressure in the normal range. The gastrointestinal administration of gastrin-SiO₂ microspheres is a promising and safe strategy to treat salt-sensitive hypertension without side effects.

Sodium and Health: Old Myths and a Controversy Based on Denial

PURPOSE OF REVIEW

The scientific consensus on which global health organizations base public health policies is that high sodium intake increases blood pressure (BP) in a linear fashion contributing to cardiovascular disease (CVD). A moderate reduction in sodium intake to 2000 mg per day helps ensure that BP remains at a healthy level to reduce the burden of CVD.

RECENT FINDINGS

Yet, since as long ago as 1988, and more recently in eight articles published in the European Heart Journal in 2020 and 2021, some researchers have propagated a myth that reducing sodium does not consistently reduce CVD but rather that lower sodium might increase the risk of CVD. These claims are not well-founded and support some food and beverage industry's vested interests in the use of excessive amounts of salt to preserve food, enhance taste, and increase thirst. Nevertheless, some researchers, often with funding from the food industry, continue to publish such claims without addressing the numerous objections. This article analyzes the eight articles as a case study, summarizes misleading claims, their objections, and it offers possible reasons for such claims. Our study calls upon journal editors to ensure that unfounded claims about sodium intake be rigorously challenged by independent reviewers before publication; to avoid editorial writers who have been co-authors with the subject paper's authors; to require statements of conflict of interest; and to ensure that their pages are used only by those who seek to advance knowledge by engaging in the scientific method and its collegial pursuit. The public interest in the prevention and treatment of disease requires no less.

Short-term effects of modest salt reduction combined with DASH diet on changing salt eating habits in hypertensive patients with type II diabetes

OBJECTIVE

Excessive salt intake is currently the foremost universal risk factor for controllable chronic disease. This study evaluated the short-term effects of a modest salt intake reduction combined with the Chinese Modified Dietary Approaches to Stop Hypertension (CM-DASH) diet on sodium and potassium intake, mean arterial pressure (MAP), and pulse pressure (PP) in hypertensive patients with type II diabetes.

METHODS

Sixty-one participants were randomized to the intervention group (52% low-sodium salt and DASH) and control group (normal salt and DASH). An 8-week dietary intervention was applied. Daily salt intake, blood pressure (BP), and drug use were recorded every week. Twenty-four-hour urine, casual urine, and blood samples were measured at baseline, the 4th week, and the end of the intervention.

RESULTS

Fifty-nine patients (25 men) completed the entire study. Sodium intake decreased by 1259.66 (792.76, 1726.56)/705.80 (149.21, 1262.39) mg/day after 4 weeks (intervention: P < .001; control: P = .015). Potassium intake increased by 641.14 (73.31, 1208.96)/43.43 (-259.66, 346.53) mg/day (intervention: P = .028); MAP decreased by 9.06 (6.69, 11.43)/7.16 (4.03, 10.28) mmHg (both: P < .001); PP decreased by 7.97 (3.05, 12.88)/5.74 (2.55,8.94) mmHg (intervention: P = .002; control: P = .001) after 8 weeks. However, the difference between the two groups was not statistically significant.

CONCLUSION

Modest salt reduction and the CM-DASH diet for hypertensive patients with type II diabetes can achieve short-term salt reduction effects. The effect on changing salt-eating habits needs to be investigated with an extended follow-up.

Excessive dietary salt promotes neuroinflammation to worsen retinopathy in mice with streptozotocin-induced diabetes

OBJECTIVE

Diabetic retinopathy (DR) includes vascular and neural tissue injury. Persistent low-grade inflammation may contribute to DR. Increased salt intake has been shown to promote autoimmunity in the brain. This study determined the role of salt intake in DR development.

METHODS

Eight-week-old C57BL/6 J male mice received streptozotocin to induce diabetes. Diabetic or non-diabetic mice were fed a diet containing normal, low and high amounts of salt. The retinal function, structure and inflammatory response were determined 8 weeks after the establishment of diabetes. Interleukin (IL)-1β or a NLR family pyrin domain containing 3 (NLRP3) inhibitor was injected intravitreally and the retinal changes were evaluated.

RESULTS

A high salt diet worsened the functional and structural damage of retinal cells and increased IL-1β in the retina of diabetic mice. IL-1β injection impaired the function of photoreceptors and retinal structure in the diabetic mice. Blocking NLRP3 inhibited IL-1β increase in the mouse bone marrow macrophages cultured in high sodium medium. NLRP3 inhibition attenuated retinal injury of diabetic mice on high salt diet. A low-salt diet also triggered inflammation and cell damage in the retina of diabetic mice but at a lower grade than those induced by high salt diet. A low or high salt diet for 8 weeks did not induce inflammation or cell injury in the retina of mice without diabetes.

CONCLUSION

These results indicate that high salt intake has deleterious effects in DR development through NLRP3 inflammasome activation and the subsequent production of IL-1β. Limiting salt intake may not attenuate DR development.

Associations of sodium and potassium intake with chronic kidney disease in a prospective cohort study: findings from the Hispanic Community Health Study/Study of Latinos, 2008-2017

BACKGROUND

According to dietary recommendations, reduction of sodium intake has potential to reduce Chronic Kidney Disease (CKD) risk; however the role of dietary potassium and the sodium -to- potassium ratio in the development of CKD is unclear.

METHODS

We studied 9778 participants of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) from four US urban communities. Participants were aged 18-74 yrs., free from CKD at baseline in 2008-2011 and re-examined between 2014 and - 2017. Dietary intake of sodium, potassium and the ratio of dietary sodium -to- potassium were measured from two baseline 24-h dietary recalls. Incident CKD was defined as: 1) estimated glomerular filtration rate (eGFR) decline of 1 unit per year and eGFR < 60 ml/min/1.73m2 or 2) albumin to creatinine ratio ≥ 30 mg/g at the follow-up visit. We used multivariable survey weighted Poisson regression to estimate adjusted incident rates of incident CKD.

RESULTS

At baseline, mean age was 41 years. Average follow up time was 6.2 years. From fully adjusted Poisson regression analyses, self-reported sodium intake was not associated with incident CKD. However, for each 500 mg decrement in potassium intake, there was an 11% increase risk of incident CKD (IRR = 1.11, 95% CI = 1.00, 1.24). Additionally, every 1 M ratio increment of sodium -to -potassium ratio was associated with a 21% increased risk of incident CKD (IRR = 1.21, 95% CI = 1.02, 1.45), p < 0.05).

CONCLUSIONS

We conclude that diets low in potassium and high in sodium are associated with increased risk of developing chronic kidney disease among healthy US Hispanic/Latino adults.

Relationship between modifiable lifestyle factors and chronic kidney disease: a bibliometric analysis of top-cited publications from 2011 to 2020

BACKGROUND

Chronic kidney disease (CKD) affects 8 to 16% of the world's population and is one of the top ten important drivers of increasing disease burden. Apart from genetic predisposition, lifestyle factors greatly contribute to the incidence and progression of CKD. The current bibliometric analysis aims to characterize the current focus and emerging trends of the research about the impact of modifiable lifestyle factors on CKD.

METHODS

We searched articles addressing the impact of modifiable lifestyle factors on the incidence and/or progression of CKD, published between 2011 and 2020, from the Science Citation Index Expanded (SCIE) database. An adjusted citation index, which considered both the original citation count and publication year, was derived for the selection of most-cited publications. Publishing trends, co-authorship network, keywords, and research hotspots were analyzed and visualized.

RESULTS

Among the top 100 most influential articles, 32 were narrative reviews, 16 systematic reviews and/or meta-analysis, 44 clinical research, and 8 basic research. The United States occupied a dominant position in the perspective of article numbers and international partnerships, followed by European countries. The modifiable factors that drew the most and constant attention over the decade were diet or nutrition management reported in 63 papers, followed by obesity or body mass index (n = 27), and physical activity or exercises (n = 8). Alcohol consumption, fish oil, chain fatty-acids, and water-soluble vitamins were emerging hotspots identified in the recent most cited publications.

CONCLUSIONS

Based on the bibliometric analysis of the most influential articles, our study provides a comprehensive description of publishing trends and research focus over a decade in the field of lifestyle factors' impact on CKD. Diet, obesity, and physical activity were factors receiving the most attention in this topic.

The relation between urinary sodium and potassium excretion and risk of cardiovascular events and mortality in patients with cardiovascular disease

Background

Most evidence on the relationship between sodium and potassium intake and cardiovascular disease originated from general population studies. This study aimed to evaluate the relation between estimated 24-hour sodium and potassium urinary excretion and the risk of recurrent vascular events and mortality in patients with vascular disease.

Methods

7561 patients with vascular disease enrolled in the UCC-SMART cohort (1996–2015) were included. Twenty-four hour sodium and potassium urinary excretion were estimated (Kawasaki formulae) from morning urine samples. Cox proportional hazard models with restricted cubic splines were used to evaluate the relation between estimated urinary salt excretion and major adverse cardiovascular events (MACE; including myocardial infarction, stroke, cardiovascular mortality) and all-cause mortality.

Results

After a median follow-up of 7.4 years (interquartile range: 4.1–11.0), the relations between estimated 24-hour sodium urinary excretion and outcomes were J-shaped with nadirs of 4.59 gram/day for recurrent MACE and 4.97 gram/day for all-cause mortality. The relation between sodium-to-potassium excretion ratio and outcomes were also J-shaped with nadirs of 2.71 for recurrent MACE and 2.60 for all-cause mortality. Higher potassium urinary excretion was related to an increased risk of both recurrent MACE (HR 1.25 per gram potassium excretion per day; 95%CI 1.13–1.39) and all cause-mortality (HR 1.13 per gram potassium excretion per day; 95%CI 1.03–1.25).

Conclusions

In patients with established vascular disease, lower and higher sodium intake were associated with higher risk of recurrent MACE and all-cause mortality. Higher estimated 24-hour potassium urinary excretion was associated with a higher risk of recurrent MACE and all-cause mortality.

Effect of a low-salt diet on chronic kidney disease outcomes: a systematic review and meta-analysis

OBJECTIVE

The benefits of a low-salt diet for patients with chronic kidney disease (CKD) are controversial. We conducted a systematic review and meta-analysis of the effect of a low-salt diet on major clinical outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE by Ovid, EMBASE and the Cochrane Library databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised controlled trials (RCTs) and cohort studies that assessed the effect of a low-salt diet on the renal composite outcomes (more than 50% decline in estimated glomerular filtration rate (eGFR) during follow-up, doubling of serum creatinine or end-stage renal disease), rate of eGFR decline, change in proteinuria, all-cause mortality events, cardiovascular (CV) events, and changes in systolic blood pressure and diastolic blood pressure.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted data and evaluated their quality. Relative risks (RRs) with 95% CIs were used for dichotomous data. Differences in means (MDs) or standardised mean differences (SMDs) with 95% CIs were used to pool continuous data. We used the Cochrane Collaboration risk-of-bias tool to evaluate the quality of RCTs, and Newcastle-Ottawa Scale to evaluate the quality of cohort studies.

RESULTS

We found 9948 potential research records. After removing duplicates, we reviewed the titles and abstracts, and screened the full text of 230 publications. Thirty-three studies with 101 077 participants were included. A low-salt diet produced a 28% reduction in renal composite outcome events (RR: 0.72; 95% CI: 0.58 to 0.89). No significant effects were found in terms of changes in proteinuria (SMD: -0.71; 95% CI: -1.66 to 0.24), rate of eGFR (decline MD: 1.16; 95% CI: -2.02 to 4.33), risk of all-cause mortality (RR: 0.92; 95% CI: 0.58 to 1.46) and CV events (RR: 1.01; 95% CI: 0.46 to 2.22).

CONCLUSION

A low-salt diet seems to reduce the risk for renal composite outcome events in patients with CKD. However, no compelling evidence indicated that such a diet would reduce the eGFR decline rate, proteinuria, incidence of all-cause mortality and CV events. Further, more definitive studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42017072395.

Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021

People with type 1 and type 2 diabetes are at risk of developing progressive chronic kidney disease (CKD) and end-stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Blood pressure control has been shown to be beneficial in people with diabetes in slowing progression of kidney disease and reducing cardiovascular events. However, randomised controlled trial evidence differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure. Activation of the renin-angiotensin-aldosterone system (RAAS) is an important mechanism for the development and progression of CKD and cardiovascular disease. Randomised trials demonstrate that RAAS blockade is effective in preventing/ slowing progression of CKD and reducing cardiovascular events in people with type 1 and type 2 diabetes, albeit differently according to the stage of CKD. Emerging therapy with sodium glucose cotransporter-2 (SGLT-2) inhibitors, non-steroidal selective mineralocorticoid antagonists and endothelin-A receptor antagonists have been shown in randomised trials to lower blood pressure and further reduce the risk of progression of CKD and cardiovascular disease in people with type 2 diabetes. This guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of CKD in people with both type 1 and type 2 diabetes.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Assessment of dietary intake by self-report in adult patients with type 1 diabetes treated with a personal insulin pump

Introduction

Appropriate nutrition is an element affecting the metabolic control of patients with diabetes. There are only a few studies assessing the implementation of dietary recommendations in adult patients with type 1 diabetes; none of them assessed the implementation of nutritional standards. Our study aimed to assess the implementation of dietary recommendations and their relation to metabolic control in adults with T1DM treated with personal insulin pumps.

Materials and Methods

The study included 48 adult patients who were divided into two subgroups and compared, based on HbA1c above and below 6.5%. Each patient's nutrient, vitamin, and mineral intake was assessed on self-reported 3-day 24-hour surveys of food consumption. Records were introduced into the dietetic software DietaPro, (source: http://www.dietapro.eu/) which revealed nutrient content. We evaluated the percentage of patients with nutrient consumption below recommended values based on current recommendations.

Results

The studied population was characterized by insufficient consumption of most nutrients and vitamins: sodium, potassium, calcium, magnesium, iron, zinc, copper, iodine, manganese, vitamin A, vitamin D, vitamin E, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, vitamin C. Patients’ diet did supply correct amounts of phosphorus, and too much fatty acid and cholesterol. There were no statistically significant differences in most of the nutrient intakes across the two groups. Nevertheless, we observed a significant difference in the polyunsaturated fatty acids, sodium, niacin, and calcium intakes.

Conclusions

The studied patients consumed too much saturated fatty acid and dietary cholesterol. The consumption amounts of most nutrients and vitamins were associated with the risk of deficiency. The obtained results indicate the need for further dietary education for patients with T1DM.

From salt to hypertension, what is missed?

Excess salt intake is viewed as a major contributor to hypertension and cardiovascular disease, and dietary salt restriction is broadly recommended by public health guidelines. However, individuals can have widely varying physiological responses to salt intake, and a tailored approach to evaluation and intervention may be needed. The traditional sodium related concepts are challenging to assess clinically for two reasons: (1) spot and 24-hour urine sodium are frequently used to evaluate salt intake, but are more suitable for population study, and (2) some adverse effects of salt may be blood pressure-independent. In recent years, previously unknown mechanisms of sodium absorption and storage have been discovered. This review will outline the limitations of current methods to assess sodium balance and discuss new potential evaluation methods and treatment targets.

Sodium Intake and Health: What Should We Recommend Based on the Current Evidence?

Several health organizations recommend low sodium intake (below 2.3 g/day, 5.8 g/day of salt) for entire populations, on the premise that lowering of sodium intake, irrespective of its level of intake, will lower blood pressure and, in turn, will result in a lower incidence of cardiovascular disease. These guidelines were developed without effective interventions to achieve long term sodium intakes at low levels in free-living individuals and without high-quality evidence that low sodium intake reduces cardiovascular events (compared with average levels of intake). In this review, we examine whether advice to consume low amounts of sodium is supported by robust evidence. We contend that current evidence indicates that most people around the world consume a moderate range of dietary sodium (3 to 5 g/day), that this level of intake is associated with the lowest risk of cardiovascular disease and mortality, and that the risk of adverse health outcomes increases when sodium intakes exceeds 5 g/day or is below 3 g/day. While the current evidence has limitations, it is reasonable, based upon prospective cohort studies, to suggest a mean target of below 5 g/day in populations, while awaiting the results of large randomized controlled trials of sodium reduction on cardiovascular disease and death.

Dietary sodium and cardiovascular morbidity/mortality: a brief commentary on the 'J-shape hypothesis'

The last decade, a growing number of evidence support J-shape or inverse - instead of positive linear -- associations between dietary sodium intake and cardiovascular morbidity/mortality. A careful evaluation of these studies leads to the following observations: less accurate methods for dietary sodium assessment are usually used; most studies included high-risk participants, enhancing the possibility of a 'reverse causality' phenomenon. However, these limitations do not explain all the findings. Few carefully designed randomized clinical trials comparing different levels of sodium intake that address the issue of the optimal and safe range exist; therefore, current guidelines recommend a higher cut-off instead of a safe range of intake. Given the demonstrated harmful effects of very low sodium diets leading to subclinical vascular damage in animal studies, the 'J-shape hypothesis' cannot yet be either neglected or verified. There is a great need of well-designed general population-based prospective randomized clinical trials to address the issue.

Sodium status is associated with type 2 diabetes mellitus: a systematic review and meta-analysis of observational studies

PURPOSE

The relationship between sodium intake and the risk of developing type 2 diabetes mellitus (T2DM) is inconsistent. We, therefore, aimed to summarize the current evidence by conducting a systematic review and meta-analysis of observational studies.

METHODS

We retrieved studies which compared any marker of sodium status between individuals with T2DM and those without diabetes published in any language by searching online databases from inception up to June 2019. Summary effects were derived using random-effects model.

RESULTS

A total of 44 studies with 503,830 participants from 25 countries were included in this study. Sodium status was significantly different between individuals with and without T2DM (Hedges' g = 0.21; 95% CI 0.02, 0.40; P = 0.029). Individuals with T2DM had higher sodium intake compared to non-diabetic controls (WMD = 621.79 mg/day; 95% CI 321.53, 922.06; P < 0.001) and 24-h urinary excretion was associated with likelihood of developing T2DM (OR = 1.27, 95% CI 1.15, 1.41; P < 0.001). Furthermore, salivary, hair, and platelet sodium were higher in patients with T2DM compared to controls (P < 0.05).

CONCLUSION

The findings of the current meta-analysis suggest that sodium levels are higher in patients with T2DM compared to non-diabetic controls; however, given that these studies are observational, it is not possible to infer causality.

Measured sodium excretion is associated with CKD progression: results from the KNOW-CKD study

BACKGROUND

Diet is a modifiable factor of chronic kidney disease (CKD) progression. However, the effect of dietary salt intake on CKD progression remains unclear. Therefore, we analyzed the effect of dietary salt intake on renal outcome in Korean patients with CKD.

METHODS

We measured 24-h urinary sodium (Na) excretion as a marker of dietary salt intake in the prospective, multi-center, longitudinal KoreaN cohort study for Outcome in patients With CKD (KNOW-CKD). Data were analyzed from CKD patients at Stages G3a to G5 (n = 1254). We investigated the association between dietary salt intake and CKD progression. Patients were divided into four quartiles of dietary salt intake, which was assessed using measured 24-h urinary Na excretion. The study endpoint was composite renal outcome, which was defined as either halving the estimated glomerular filtration rate or developing end-stage renal disease.

RESULTS

During a median (interquartile range) follow-up of 4.3 (2.8-5.8) years, 480 (38.7%) patients developed the composite renal event. Compared with the reference group (Q2, urinary Na excretion: 104.2 ≤ Na excretion < 145.1 mEq/day), the highest quartile of measured 24-h urinary Na excretion was associated with risk of composite renal outcome [Q4, urinary Na excretion ≥192.9 mEq/day, hazard ratio 1.8 (95% confidence interval 1.12-2.88); P = 0.015] in a multivariable hazards model. Subgroup analyses showed that high-salt intake was particularly associated with a higher risk of composite renal outcome in women, in patients <60 years of age, in those with uncontrolled hypertension and in those with obesity.

CONCLUSIONS

High salt intake was associated with increased risk of progression in CKD.

Effects of SGLT2 inhibitor and dietary NaCl on glomerular hemodynamics assessed by micropuncture in diabetic rats

Inhibitors of the main proximal tubular Na-glucose cotransporter (SGLT2) mitigate diabetic glomerular hyperfiltration and have been approved by the United States Food and Drug Administration for slowing the progression of diabetic kidney disease. It has been proposed that SGLT2 inhibitors improve hard renal outcomes by reducing glomerular capillary pressure (PGC) via a tubuloglomerular feedback (TGF) response to a decrease in proximal reabsorption (Jprox). However, the effect of SGLT2 inhibition on PGC has not been measured. Here, we studied the effects of acute SGLT2 blockade (ertugliflozin) on Jprox and glomerular hemodynamics in two-period micropuncture experiments using streptozotocin-induced diabetic rats fed high- or low-NaCl diets. PGC was measured by direct capillary puncture or computed from tubular stop-flow pressure (PSF). TGF is intact while measuring PGC directly but rendered inoperative when measuring PSF. Acute SGLT2 inhibitor reduced Jprox by ∼30%, reduced PGC by 5-8 mmHg, and reduced glomerular filtration rate (GFR) by ∼25% (all P < 0.0001) but had no effect on PSF. The decrease in PGC was larger with the low-NaCl diet (8 vs. 5 mmHg, P = 0.04) where PGC was higher to begin with (54 vs. 50 mmHg, P = 0.003). Greater decreases in PGC corresponded, unexpectedly, to lesser decreases in GFR (P = 0.04). In conclusion, these results confirm expectations that PGC would decline in response to acute SGLT2 inhibition and that a functioning TGF system is required for this. We infer a contribution of postglomerular vasorelaxation to the TGF responses where decreases in PGC were large and decreases in GFR were small.NEW & NOTEWORTHY It has been theorized that Na-glucose cotransporter (SGLT2) blockade slows progression of diabetic kidney disease by reducing physical strain on the glomerulus. This is the first direct measurement of intraglomerular pressure during SGLT2 blockade. Findings confirmed that SGLT2 blockade does reduce glomerular capillary pressure, that this is mediated through tubuloglomerular feedback, and that the tubuloglomerular feedback response to SGLT2 blockade involves preglomerular vasoconstriction and postglomerular vasorelaxation.

Sodium intake, health implications, and the role of population-level strategies

Evidence to date suggests that high sodium intake affects health adversely, yet the role of a population-level strategy to reduce sodium intake is often contested. This review focuses on current available evidence on regional sodium intake levels, health implications of sodium intake, and population-level strategies implemented worldwide. The limitations in evidence, the difficulties in implementing population-wide strategies to reduce sodium intake, and the need for such strategies are critically reviewed. Evidence clearly shows that sodium has an adverse effect on blood pressure, cardiovascular disease, and mortality. However, whether reduced sodium intake benefits all individuals or only hypertensive individuals is still unclear. Methodological issues and publication bias in current evidence are other matters of concern in sodium-related research. While it is essential to continue working toward the World Health Organization's target of 30% reduction in sodium intake, due consideration should be given to improving the quality of research, reducing bias in publications, and reviewing evidence more critically.

Sodium Intake and Incidence of Diabetes Complications in Elderly Patients with Type 2 Diabetes-Analysis of Data from the Japanese Elderly Diabetes Intervention Study (J-EDIT)

This study investigates the associations between sodium intake and diabetes complications in a nationwide cohort of elderly Japanese patients with type 2 diabetes aged 65–85. Data from 912 individuals regarding their dietary intake at baseline is analyzed and assessed by the Food Frequency Questionnaire based on food groups. Primary outcomes are times to diabetic retinopathy, overt nephropathy, cardiovascular disease (CVD), and all-cause mortality during six years. We find that mean sodium intake in quartiles ranges from 2.5 g to 5.9 g/day. After adjustment for confounders, no significant associations are observed between sodium intake quartiles and incidence of diabetes complications and mortality, except for a significant trend for an increased risk of diabetic retinopathy (p = 0.039). Among patients whose vegetable intake was less than the average of 268.7 g, hazard ratios (HRs) for diabetic retinopathy in patients in the second, third, and fourth quartiles of sodium intake compared with the first quartile were 0.87 (95% CI, 0.31–2.41), 2.61 (1.00–6.83), and 3.70 (1.37–10.02), respectively. Findings indicate that high sodium intake under conditions of low vegetable intake is associated with an elevated incidence of diabetic retinopathy in elderly patients with type 2 diabetes.

Association between Daily Urinary Sodium Excretion, Ratio of Extracellular Water-to-Total Body Water Ratio, and Kidney Outcome in Patients with Chronic Kidney Disease

Whether dietary salt intake affects chronic kidney disease (CKD) progression remains unclear. We conducted a retrospective cohort study to analyze the effects of both daily salt intake (DSI) and volume status on renal outcomes in 197 CKD patients. DSI was estimated by 24-h urinary sodium excretion and volume status was assessed by the ratio of extracellular water (ECW) to total body water (TBW) measured by bioelectrical impedance analysis (BIA). We divided patients into two groups according to DSI (6 g/day) or median ECW/TBW (0.475) and compared renal outcomes of each group. Furthermore, we classified and analyzed four groups according to both DSI and ECW/TBW. The higher DSI group showed a 1.69-fold (95% confidence interval (CI) 1.12–2.57, p = 0.01) excess risk of outcome occurrence compared to the lower group. Among the four groups, compared with Group 1 (low DSI and low ECW/TBW), Group 3 (high DSI and low ECW/TBW) showed a 1.84-fold (95% CI 1.03–3.30, p = 0.04) excess risk of outcome occurrence; however, Group 2 (low DSI and high ECW/TBW) showed no significant difference. High salt intake appears to be associated with poor renal outcome independent of blood pressure (BP), proteinuria, and volume status.

Association of Urinary Sodium Excretion and Diabetic Kidney Disease in Patients With Type 2 Diabetes Mellitus: A Cross-Sectional Study

BACKGROUND

Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease worldwide. Epidemiological evidence of the association between urinary sodium excretion and the presence of DKD in patients with type 2 diabetes mellitus (T2DM) has not yet been well established.

METHODS

We performed a cross-sectional study of 1545 patients with T2DM over aged 20 years old from January 2018 to December 2020. Urinary sodium excretion was measured by 24-hour urine samples in inpatients and morning fasting urine samples in outpatients. The associations between urinary sodium excretion and the risks of DKD were examined using stepwise regression analysis, logistic regression analysis and multivariable-adjusted restricted cubic splines (RCS).

RESULTS

Regression analysis showed that urinary sodium was independently associated with urinary albumin to creatinine ratio (UACR) level (P = 0.006) and the risks of DKD (P = 0.042). In multivariable-adjusted RCS analysis, urinary sodium excretion was significantly associated with UACR in all patients (P = 0.008), and exhibited a J-shaped relationship. Logistic regression analysis showed that increased urinary sodium excretion was significantly associated with increased risks of DKD [OR (95% CI); 1.56 (1.07-2.27); P = 0.020]. However, the relationships between urinary sodium excretion and the risks of DKD and albuminuria showed no significance, after further adjustment for HOMA-IR and ba-PWV (brachial-ankle pulse wave velocity) (Both P > 0.05).

CONCLUSIONS

Higher urinary sodium excretion level was associated with increased risks of DKD among patients with T2DM, dependent of vascular sclerosis and insulin resistance.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of the Dietary Approaches to Stop Hypertension Diet and Sodium Reduction on Blood Pressure in Persons With Diabetes

Elevated blood pressure and blood pressure-related morbidity are extraordinarily common in persons with diabetes. The Dietary Approaches to Stop Hypertension dietary pattern and dietary sodium reduction are recommended as lifestyle interventions in individuals with diabetes. However, these recommendations have largely been based on studies conducted in persons without diabetes. In this review, we summarize available evidence from trials that tested the effects of these 2 dietary interventions on blood pressure in people with diabetes. Overall, of the 3 trials (total n=151) that tested the effects of the Dietary Approaches to Stop Hypertension dietary pattern in persons with diabetes, 2 trials documented that the Dietary Approaches to Stop Hypertension dietary pattern lowered blood pressure. While 16 trials (total n=445) tested the effects of sodium reduction in persons with diabetes, results were inconsistent, likely because of design limitations, for example, brief duration, small sample size, and low baseline blood pressure levels, as well as differences in the mode of intervention delivery (behavioral interventions, feeding studies, and sodium supplements). In conclusion, there is a substantial need for additional research on the blood pressure lowering effects of the Dietary Approaches to Stop Hypertension diet and sodium reduction in people with diabetes and hypertension, given the high prevalence of hypertension and the dearth of high-quality trials in this population.