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JAMA. 2016 May 24-31;315(20):2200-10. doi: 10.1001/jama.2016.4447.

Sodium Excretion and the Risk of Cardiovascular Disease in Patients With Chronic Kidney Disease.

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  • 1Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.
  • 2Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana2Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana.
  • 3Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia.
  • 4Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland.
  • 5Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland.
  • 6Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana.
  • 7Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania.
  • 8Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.
  • 9Department of Medicine, University of Michigan, Ann Arbor.
  • 10Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio10Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio.
  • 11Department of Medicine, University of Illinois at Chicago, Chicago.
  • 12Department of Internal Medicine-Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
  • 13Department of Medicine, St John's Health System, Detroit, Michigan.



Patients with chronic kidney disease (CKD) are at an increased risk of cardiovascular disease (CVD) compared with the general population. Prior studies have produced contradictory results on the association of dietary sodium intake with risk of CVD, and this relationship has not been investigated in patients with CKD.


To evaluate the association between urinary sodium excretion and clinical CVD events among patients with CKD.


A prospective cohort study of patients with CKD from 7 locations in the United States enrolled in the Chronic Renal Insufficiency Cohort Study and followed up from May 2003 to March 2013.


The cumulative mean of urinary sodium excretion from three 24-hour urinary measurements and calibrated to sex-specific mean 24-hour urinary creatinine excretion.


A composite of CVD events defined as congestive heart failure, stroke, or myocardial infarction. Events were reported every 6 months and confirmed by medical record adjudication.


Among 3757 participants (mean age, 58 years; 45% women), 804 composite CVD events (575 heart failure, 305 myocardial infarction, and 148 stroke) occurred during a median 6.8 years of follow-up. From lowest (<2894 mg/24 hours) to highest (≥4548 mg/24 hours) quartile of calibrated sodium excretion, 174, 159, 198, and 273 composite CVD events occurred, and the cumulative incidence was 18.4%, 16.5%, 20.6%, and 29.8% at median follow-up. In addition, the cumulative incidence of CVD events in the highest quartile of calibrated sodium excretion compared with the lowest was 23.2% vs 13.3% for heart failure, 10.9% vs 7.8% for myocardial infarction, and 6.4% vs 2.7% for stroke at median follow-up. Hazard ratios of the highest quartile compared with the lowest quartile were 1.36 (95% CI, 1.09-1.70; P = .007) for composite CVD events, 1.34 (95% CI, 1.03-1.74; P = .03) for heart failure, and 1.81 (95% CI, 1.08-3.02; P = .02) for stroke after multivariable adjustment. Restricted cubic spline analyses of the association between sodium excretion and composite CVD provided no evidence of a nonlinear association (P = .11) and indicated a significant linear association (P < .001).


Among patients with CKD, higher urinary sodium excretion was associated with increased risk of CVD.

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