Mechanisms of sodium balance: total body sodium, surrogate variables, and renal sodium excretion

Eight months of marathon school training reduced blood pressure, systemic vascular resistance and extracellular water volume

The effects of an eight-month marathon school training program on blood pressure (BP) and underlying hemodynamics were examined in 45 participants and 43 controls. Hemodynamics were recorded using whole-body impedance cardiography, radial tonometric pulse wave analysis, and third-finger BP measurements during passive head-up tilt. The mean ages were 40.9 and 42.2 years, and body mass indexes (BMI) 25.1 and 25.8 kg/m2, respectively. Marathon training decreased mean weight (-1.6 kg), fat percentage (-2.7%), and BMI (-0.5 kg/m2) and increased maximal oxygen uptake (+3.2 ml/kg/min) and insulin sensitivity (+0.013 units) (p < 0.03 for all). During head-up tilt, systolic BP and cardiac output decreased, while diastolic BP, heart rate, and systemic vascular resistance (SVR) increased, but training did not affect these posture-induced changes. Initial aortic and third finger systolic/diastolic BP were numerically but not significantly lower in the marathon vs. control group (by 3.4/2.3 and 5.5/4.5 mmHg, respectively, p > 0.075). Final BP values were significantly lower in the marathon group (by 7.2/4.5 and 10.9/10.2 mmHg, respectively, p < 0.01). Marathon training reduced SVR by 167 dyn×s/cm5×m2(p = 0.041), and extracellular water volume by 0.34 L (p = 0.045). To conclude, aerobic exercise training appears to lower BP, a significant cardiovascular risk factor, by reducing SVR and decreasing extracellular water volume.

Diuretics in patients with chronic kidney disease

Diuretic drugs act on electrolyte transporters in the kidney to induce diuresis and are often used in chronic kidney disease (CKD), given that nephron loss creates a deficit in the ability to excrete dietary sodium, which promotes an increase in plasma volume. This rise in plasma volume is exacerbated by CKD-induced systemic and intra-renal activation of the renin-angiotensin-aldosterone-system, which further limits urinary sodium excretion. In the absence of a compensatory decrease in systemic vascular resistance, increases in plasma volume induced by sodium retention can manifest as a rise in systemic arterial blood pressure. Management of sodium and volume overload in patients with CKD is therefore typically based on restriction of dietary sodium intake and the use of diuretic agents to enhance urinary sodium excretion. Thiazide and thiazide-type diuretics are foundational therapies for the management of hypertension, whereas loop diuretics are often needed for volume overload, which might also require combination therapies. Mineralocorticoid receptor antagonists have an important role in the management of diuretic-resistant volume overload or treatment-resistant hypertension. Additionally, diuretics can be used for the diagnosis of kidney diseases and in the management of hyperkalaemia or hypokalaemia, hyponatraemia, hypercalcaemia and hypomagnesaemia.

Hyponatremia in Critically Ill Patients Due to Continuous Venovenous Hemofiltration With Diluted Sodium Citrate

Continuous venovenous hemofiltration (CVVH) is frequently performed in critically ill patients using diluted citrate for regional anticoagulation. The impact of this renal replacement strategy on plasma sodium has not been evaluated yet. Our aim was therefore to assess the period prevalence of hyponatremia (sodium <135 mmol/L) during CVVH and discuss possible underlying mechanisms. After 48 hours of treatment, 70% of the 27 oligo-anuric critically ill patients were hyponatremic, despite the use of dialysis fluid bags (Regiocit 18/0, Phoxilium by Baxter, Deerfield, IL, and Multibic K2 by Fresenius Medical Care AG & Co. KGaA, Bad Homburg, Germany) with sodium content of 140 mmol/L. Indeed, sodium decreased from 142 ± 7 to 135 ± 3 mmol/L, p < 0.001. Sodium concentrations of employed dialysis bags were confirmed using ion chromatography. However, ionized sodium of Regiocit measured with a direct-ion selective electrode (ISE) resulted lower (~118 mmol/L), suggesting the presence of sodium-to-citrate complexes. Possible mechanisms explaining the hyponatremia development could therefore include: i) plasma water dilution; ii) a reduced Gibbs-Donnan effect, given the low albumin concentration (2.6 ± 0.8 g/dl) of our critically ill patients; iii) a negative sodium balance due to the loss of sodium-to-citrate complexes across the filter. The clinical implications of the described hyponatremia and the different contributions of the hypothesized mechanisms need to be addressed in future studies.

Toxic metal contamination in edible salts and its attributed human health risks: a systematic review and meta-analysis

Sodium chloride, commonly referred to as table salt, is the most widely utilized seasoning in culinary applications. Nevertheless, the most of oral salts used contain impurities. Arsenic (As), mercury (Hg), cadmium (Cd), and lead (Pb) are the most common impurities found in salt. In this meta-analysis, we examined the status of Pb, Hg, Cd, and As in the salt sample consumed in Iran. For this purpose, a complete search was carried out in English (Scopus, PubMed, and Web of Science) and Persian (Scientific Information Database, IranMedex, and Magiran) electronic databases to identify related articles published by July 2024. In the present meta-analysis, twelve studies with a total number of 610 salt samples were included in the analyses. According to the findings, the pooled mean levels of Hg, Pb, As, and Cd were 0.06 µg/g (95% CI: 0.04-0.08), 2.98 µg/g (95% CI: 2.35-3.61), 0.42 µg/g (95% CI: 0.19-0.66), and 0.71 µg/g (95% CI: 0.76-1.04), respectively. The levels of Cd and Pb in rock salt are higher than those found in the sea and refined salt. The hazard index (HI) values were recorded as 0.41 (95% CI: 0.235 to 0.588) for men, 0.428 (95% CI: 0.246 to 0.614) for women, and 0.594 (95% CI: 0.341 to 0.853) for children. The results of the present study show higher levels of Pb and Cd in unrefined salt compared to refined salt. Additionally, the health risk associated with exposure to Cd, Pb, As, and Hg through salt consumption is negligible in Iranian adults.

Immunomodulatory Effects of Selected Non-Nutritive Bioactive Compounds and Their Role in Optimal Nutrition

The contemporary approach to nutrition increasingly considers the role of non-nutritive bioactive compounds in modulating the immune system and maintaining health. This article provides up-to-date insight into the immunomodulatory effects of selected bioactive compounds, including micro- and macronutrients, vitamins, as well as other health-promoting substances, such as omega-3 fatty acids, probiotics, prebiotics, postbiotics (including butyric acid and sodium butyrate), coenzyme Q10, lipoic acid, and plant-derived components such as phenolic acids, flavonoids, coumarins, alkaloids, polyacetylenes, saponins, carotenoids, and terpenoids. Micro- and macronutrients, such as zinc, selenium, magnesium, and iron, play a pivotal role in regulating the immune response and protecting against oxidative stress. Vitamins, especially vitamins C, D, E, and B, are vital for the optimal functioning of the immune system as they facilitate the production of cytokines, the differentiation of immunological cells, and the neutralization of free radicals, among other functions. Omega-3 fatty acids exhibit strong anti-inflammatory effects and enhance immune cell function. Probiotics, prebiotics, and postbiotics modulate the intestinal microbiota, thereby promoting the integrity of the intestinal barrier and communication between the microbiota and the immune system. Coenzyme Q10, renowned for its antioxidant attributes, participates in the protection of cells from oxidative stress and promotes energy processes essential for immune function. Sodium butyrate and lipoic acid exhibit anti-inflammatory effects and facilitate the regeneration of the intestinal epithelium, which is crucial for the maintenance of immune homeostasis. This article emphasizes the necessity of an integrative approach to optimal nutrition that considers not only nutritional but also non-nutritional bioactive compounds to provide adequate support for immune function. Without them, the immune system will never function properly, because it has been adapted to this in the course of evolution. The data presented in this article may serve as a foundation for further research into the potential applications of bioactive components in the prevention and treatment of diseases associated with immune dysfunction.

Associations of heavy metals and urinary sodium excretion with obesity in adults: A cross-sectional study from Korean Health Examination and Nutritional Survey

BACKGROUNDS

Sodium and heavy metals are among the key elements to which humans are exposed due to environmental pollution and food consumption. Investigating the association between heavy metals, urinary sodium excretion, and obesity is of significant importance, given potential implications for public health. Therefore, this study aims to explore the relationship between heavy metals, urinary sodium excretion, and overweight and obesity in the Korean population.

METHODS

Data from 6,609 participants in the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2012 were analyzed. Associations between heavy metals (cadmium, mercury), urinary arsenic, sodium excretion levels, and overweight/obesity were assessed using polytomous logistic regression models, adjusting for confounders.

RESULTS

Higher mercury (OR = 1.57, 95% CI = 1.31-1.88) and urinary sodium (OR = 2.21, 95% CI = 1.84-2.66) levels are associated with an increased risk of overweight and obesity. Notably, participants with elevated levels of both mercury and urinary sodium had the highest odds of being overweight and obesity (OR = 3.61, 95% CI = 2.61-5.00). In contrast, other heavy metals, such as serum cadmium and urinary arsenic, were not statistically significantly associated with the risk of overweight and obesity.

CONCLUSIONS

This finding highlights the intricate multiplicative effect between mercury and sodium on obesity, necessitating further research to validate and understand the connections. Heavy metals, particularly mercury, exert an influence on obesity, and the possibility of an enhanced impact on obesity, especially when acting in conjunction with salt, is indicated.

A Meta-Analysis on Quantitative Sodium, Potassium and Chloride Metabolism in Horses and Ponies

The goal of this meta-analysis was to (i) identify any potential differences in the apparent and true digestibility, renal excretion, and retention between ponies and horses and (ii) examine the impact of work on these parameters. Additionally, the study aimed to (iii) evaluate the effects of water deficiency. This meta-analysis used data from 33 studies and plotted them in diagrams similar to the Lucas test against mineral intake. Three studies involved ponies that were later diagnosed with pituitary pars intermedia dysfunction (PPID). These were compared with other data to identify quantitative differences, as they may have clinical significance. If any significant difference was observed, the data were not used for the evaluation of the aforementioned goals. Data were compared within certain intake ranges using t-tests and ANOVA, followed by Holm-Sidak post hoc tests. Working equines showed significantly higher apparent and true Na digestibility and lower endogenous faecal Na losses compared to non-working ponies and horses, suggesting a rather important role of the gastrointestinal tract in the regulation of Na metabolism in equines. The true K digestibility was also significantly higher in working animals than in non-working ones, but the differences were quantitatively smaller than for Na. Retention plus sweat losses for Na, K and Cl were higher in working animals compared to equines in maintenance. Horses showed higher Na and K retention plus sweat losses compared to ponies. These effects are likely attributable to greater sweat losses in working equines, particularly horses. The apparent and true Cl digestibility was significantly higher in ponies than in horses. A clinical relevance of this observation is rather unlikely, as the digestibility remained very high in both. Water deprivation influenced serum Cl levels and increased renal K excretion, which subsequently led to reduced K retention. Compared to other animal species, no effects on blood K levels or Na metabolism were observed. The ponies diagnosed with PPID exhibited a significantly lower apparent K digestibility compared to healthy animals, which could be an important factor to consider when feeding soaked hay, due to potential electrolyte losses during soaking.

Clinical characteristics and management of adipsic arginine vasopressin deficiency in children and adolescents with sellar germ cell tumors

Adipsic arginine vasopressin deficiency(aAVP-D) is a rare, high-risk syndrome, particularly difficult to recognize and manage in children and adolescents. This investigation examined the clinical features and management of aAVP-D in children and adolescents with sellar germ cell tumors (GCTs). A retrospective survey was performed on 260 patients with sellar GCTs, categorized into aAVP-D and non-aAVP-D groups based on thirst presence. General characteristics, hypothalamic syndrome, pituitary function, metabolic indicators, and complications were compared. Biochemical indicator changes in the aAVP-D group were analyzed after systematic management, and receiver operating characteristic (ROC) curve analysis established the optimum serum sodium cut-off for predicting the aAVP-D. 25 patients (9.6%) developed aAVP-D. The aAVP-D group had larger tumors with hypothalamic involvement and more surgical resections. They also demonstrated more hypothalamic syndrome, central adrenal insufficiency, central hypogonadism, and insulin-like growth factor-1 levels below norms. Furthermore, aAVP-D patients exhibited significantly higher rates of hypernatremia (100% vs 20.9%, p < 0.001), hyperuricemia (60.0% vs 23.4%, p < 0.001), renal impairment (32.0% vs 1.7%, p < 0.001), and venous thrombosis (4.0% vs 0%, p = 0.002). Following systematic management, aAVP-D patients experienced significant reductions in serum sodium, uric acid, and creatinine levels, although these remained higher than in the non-aAVP-D group. ROC analysis indicated that a serum sodium level above 149.5 mmol/L predicted aAVP-D. Conclusion Patients with aAVP-D had more tumor involvement in the hypothalamic region, surgical resections, hypothalamic syndrome, hypopituitarism, and complications. Serum sodium levels above 149.5 mmol/L necessitated heightened vigilance for aAVP-D. Early identification and systematic management reduced complications, though clinical management remained challenging. What is Known • Adipsic arginine vasopressin deficiency (aAVP-D) is a rare and high-risk syndrome that is difficult to recognize and manage. • There are few reports on aAVP-D, most of which focus on adult patients. • The characteristics and management of aAVP-D in children and adolescents remain unclear. What is New • Children and adolescents with aAVP-D experienced higher rates of hypothalamic region tumor involvement, surgical resections, hypothalamic syndrome, hypopituitarism, and associated complications. • Serum sodium levels above 149.5 mmol/L necessitated heightened vigilance for aAVP-D. • Early recognition and structured management of ADI lowered the risk of complications.

Targeting Sodium in Heart Failure

A dominant event determining the course of heart failure (HF) includes the disruption of the delicate sodium (Na+) and water balance leading to (Na+) and water retention and edema formation. Although incomplete decongestion adversely affects outcomes, it is unknown whether interventions directly targeting (Na+), such as strict dietary (Na+) restriction, intravenous hypertonic saline, and diuretics, reverse this effect. As a result, it is imperative to implement (Na+)-targeting interventions in selected HF patients with established congestion on top of quadruple therapy with angiotensin receptor neprilysin inhibitor, β-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor, which dramatically improves outcomes. The limited effectiveness of (Na+)-targeting treatments may be partly due to the fact that the current metrics of HF severity have a limited capacity of foreseeing and averting episodes of congestion and guiding (Na+)-targeting treatments, which often leads to dysnatremias, adversely affecting outcomes. Recent evidence suggests that spot urinary sodium measurements may be used as a guide to monitor (Na+)-targeting interventions both in chronic and acute HF. Further, the classical (2)-compartment model of (Na+) storage has been displaced by the (3)-compartment model emphasizing the non-osmotic accumulation of (Na+), chiefly in the skin. 23(Na+) magnetic resonance imaging (MRI) enables the accurate and reliable quantification of tissue (Na+). Another promising approach enabling tissue (Na+) monitoring is based on wearable devices employing ion-selective electrodes for electrolyte detection, including (Na+) and (Cl-). Undoubtably, further studies using 23(Na+)-MRI technology and wearable sensors are required to learn more about the clinical significance of tissue (Na+) storage and (Na+)-related mechanisms of morbidity and mortality in HF.

Volume overload is a major characteristic in primary aldosteronism: a 3-year follow-up study

OBJECTIVES

We examined haemodynamics, focusing on volume balance and forward and backward wave amplitudes, before and after 2.8 years of targeted treatment of primary aldosteronism. Patients with essential hypertension and normotensive individuals were examined for comparison ( n  = 40 in each group).

METHODS

Recordings were performed using radial artery pulse wave analysis and whole-body impedance cardiography. Unilateral aldosteronism was treated with adrenalectomy ( n  = 20), bilateral aldosteronism with spironolactone-based medication ( n  = 20), and essential hypertension with standard antihypertensive agents.

RESULTS

Aortic SBP and DBP, forward and backward wave amplitudes, and systemic vascular resistance were equally elevated in primary aldosteronism and essential hypertension. All these haemodynamic variables were similarly reduced by the treatments. Primary aldosteronism presented with 1 litre (∼10%) extracellular water excess ( P  < 0.001) versus the other groups, and this excess was normalized by treatment. Initial pulse wave velocity (PWV) was similarly increased in primary aldosteronism and essential hypertension, but final values remained higher in primary aldosteronism ( P  < 0.001). In regression analyses, significant explanatory factors for treatment-induced forward wave amplitude reduction were decreased systemic vascular resistance ( β  = 0.380) and reduced extracellular water volume ( β  = 0.183). Explanatory factors for backward wave amplitude reduction were changes in forward wave amplitude ( β  = 0.599), heart rate ( β  = -0.427), and PWV ( β  = 0.252).

CONCLUSION

Compared with essential hypertension, the principal haemodynamic difference in primary aldosteronism was higher volume load. Volume excess elevated forward wave amplitude, which was subsequently reduced by targeted treatment of primary aldosteronism, along with normalization of volume load. We propose that incorporating extracellular water evaluation alongside routine diagnostics could enhance the identification and diagnosis of primary aldosteronism.

Serial direct sodium removal in patients with heart failure and diuretic resistance

AIMS

Loop diuretics may exacerbate cardiorenal syndrome (CRS) in heart failure (HF). Direct sodium removal (DSR) using the peritoneal membrane, in conjunction with complete diuretic withdrawal, may improve CRS and diuretic resistance.

METHODS AND RESULTS

Patients with HF requiring high-dose loop diuretics were enrolled in two prospective, single-arm studies: RED DESERT (n = 8 euvolaemic patients), and SAHARA (n = 10 hypervolaemic patients). Loop diuretics were withdrawn, and serial DSR was utilized to achieve and maintain euvolaemia. At baseline, participants required a median 240 mg (interquartile range [IQR] 200-400) oral furosemide equivalents/day, which was withdrawn in all participants during DSR (median time of DSR 4 weeks [IQR 4-6]). Diuretic response (queried by formal 40 mg intravenous furosemide challenge and 6 h urine sodium quantification) increased substantially from baseline (81 ± 37 mmol) to end of DSR (223 ± 71 mmol, p < 0.001). Median time to re-initiate diuretics was 87 days, and the median re-initiation dose was 8% (IQR 6-10%) of baseline. At 1 year, diuretic dose remained substantially below baseline (30 [IQR 7.5-40] mg furosemide equivalents/day). Multiple dimensions of kidney function such as filtration, uraemic toxin excretion, kidney injury, and electrolyte handling improved (p < 0.05 for all). HF-related biomarkers including N-terminal pro-B-type natriuretic peptide, carbohydrate antigen-125, soluble ST2, interleukin-6, and growth differentiation factor-15 (p < 0.003 for all) also improved.

CONCLUSIONS

In patients with HF and diuretic resistance, serial DSR therapy with loop diuretic withdrawal was feasible and associated with substantial and persistent improvement in diuretic resistance and several cardiorenal parameters. If replicated in randomized controlled studies, DSR may represent a novel therapy for diuretic resistance and CRS.

CLINICAL TRIAL REGISTRATION

RED DESERT (NCT04116034), SAHARA (NCT04882358).

The sodium-chloride difference: A marker of prognosis in patients with acute myocardial infarction

BACKGROUND

The difference between serum sodium and chloride ion concentrations (SCD) may be considered as a surrogate of a strong ion difference and may help to identify patients with a worse prognosis. We aimed to assess SCD as an early prognostic marker among patients with myocardial infarction.

METHODS

Data of 594 consecutive patients with acute myocardial infarction treated with PCI (44.9% STEMI patients; 70.7% males) was analysed for SCD in relation to their 30-day mortality. A restricted cubic spline regression model was used to study the relationship between mortality and SCD. Cox regression models were used to assess the association between SCD and the mortality risk.

RESULTS

Patients with Killip class ≥3 had lower SCD values in comparison to patients with Killip class ≤2: (32.0 [30.0-34.0] vs. 33.0 [31.0-36.0], p = .006). The overall 30-day mortality was 7.7% (n = 46). There was a significant difference in SCD values between survivors and non-survivors groups of patients (median (IQR): (33.0 [31.0-36.0] vs. 31.5 [28.0-34.0] (mmol/L), p = .002). The restricted cubic splines model confirmed a non-linear association between SCD and mortality. Patients with SCD <30 mmol/L (in comparison to SCD ≥30 mmol/L) had an increased mortality risk (unadjusted HR 2.92, 95% CI 1.59-5.36, p = .001; and an adjusted HR 2.30, 95% CI 1.02-5.19, p = .04).

CONCLUSIONS

Low SCD on admission is associated with an increased risk of 30-day mortality in patients with acute myocardial infarction treated with PCI and may serve as a useful prognostic marker for these patients.

Correlation of plasmatic sodium determined by the laboratory and that determined by the dialysis machine

INTRODUCTION

Changes in plasma sodium concentration (pNa, expressed in mEq/L) are common in hemodialysis (HD) patients. Hemodialysis monitors can estimate pNa by using an internal algorithm based on ion dialysance measurements. The present study studies the accuracy of the correlation between the pNa estimated by the dialysis monitor and that measured by the biochemistry laboratory at our center.

MATERIAL AND METHODS

A single-centre prospective observational study in patients on a chronic HD program with the 6008 CAREsystem monitor and standard sodium (138mmol/L) and bicarbonate (32mmol/L) prescriptions. Venous blood samples were drawn from each patient before and after each HD session to ensure inter- and intra-individual validity. The pNa was measured in the biochemistry laboratory using indirect potentiometry and simultaneously the estimated pNa by the HD monitor was recorded at the beginning and at the end of the HD session. For statistical analysis, a scatterplot was made, and Spearman's correlation quotient was calculated. In addition, the differences between both methods were represented as Bland-Altman diagrams.

RESULTS

The pre-dialysis pNa measured in the laboratory was 137.49±3.3, and that of the monitor, 137.96±2.91, with a correlation with R2 value of 0.683 (p<0.001). The post-dialysis pNa measured in the laboratory was 137.08±2.23, and that of the monitor was 138.87±1.88, with an R2 of 0.442 (p<0.001). On the Bland-Altman plots, the pre-dialysis pNa has a systematic error of 0.49, in favor of the monitor-estimated pNa, with a 95% confidence interval (CI) of (-3.24 to a 4.22). In the post-dialysis pNa, a systematic error of 1.79 with a 95% CI of (-1.64 to 5.22) was obtained.

CONCLUSION

The correlation between the pNa estimated by Fresnius 6008 CAREsystem HD monitor and that measured by the laboratory is good, especially pre-dialysis measurements. Further studies should verify the external validity of these results.

Positive association between sodium-to-chloride ratio and in-hospital mortality of acute heart failure

Previous studies have suggested that levels of sodium and chloride in the blood may be indicative of the prognosis of different medical conditions. Nevertheless, the assessment of the prognostic significance of the sodium-to-chloride (Na/Cl) ratio in relation to in-hospital mortality among individuals suffering from acute heart failure (AHF) remains unexplored. In this study, the participants were selected from the Medical Information Mart for Intensive Care IV database and divided into three groups based on the Na/Cl ratio level upon admission. The primary results were the mortality rate within the hospital. Cox regression, Kaplan-Meier curves, receiver operator characteristic (ROC) curve analysis and subgroup analyses were utilized to investigate the correlation between the admission Na/Cl ratio and outcomes in critically ill patients with AHF. A total of 7844 patients who met the selection criteria were included in this study. After adjusting for confounders, the multivariable Cox regression analysis revealed that the baseline Na/Cl ratio significantly elevated the risk of in-hospital mortality among critically ill patients with AHF (HR = 1.34, 95% CI 1.21-1.49). Furthermore, when the Na/Cl ratio was converted into a categorical factor and the initial tertile was taken as a point of comparison, the hazard ratios (HRs) and 95% confidence intervals (CIs) for the second and third tertiles were 1.27 (1.05-1.54) and 1.53 (1.27-1.84), respectively. Additionally, a P value indicating a significant trend of < 0.001 was observed. ROC curve analysis showed that Na/Cl ratio had a more sensitive prognostic value in predicting in-hospital mortality of AHF than the sodium or chloride level alone (0.564 vs. 0.505, 0.544). Subgroup examinations indicated that the association between the Na/Cl ratio upon admission and the mortality rate of critically ill patients with AHF remained consistent in the subgroups of hyponatremia and hypochlorhydria (P for interaction > 0.05). The linear relationship between the Na/Cl ratio and in-hospital mortality in AHF patients indicates a positive association.

Sodium, Interstitium, Lymphatics and Hypertension-A Tale of Hydraulics

Blood pressure is regulated by vascular resistance and intravascular volume. However, exchanges of electrolytes and water between intra and extracellular spaces and filtration of fluid and solutes in the capillary beds blur the separation between intravascular, interstitial and intracellular compartments. Contemporary paradigms of microvascular exchange posit filtration of fluids and solutes along the whole capillary bed and a prominent role of lymphatic vessels, rather than its venous end, for their reabsorption. In the last decade, these concepts have stimulated greater interest in and better understanding of the lymphatic system as one of the master regulators of interstitial volume homeostasis. Here, we describe the anatomy and function of the lymphatic system and focus on its plasticity in relation to the accumulation of interstitial sodium in hypertension. The pathophysiological relevance of the lymphatic system is exemplified in the kidneys, which are crucially involved in the control of blood pressure, but also hypertension-mediated cardiac damage. Preclinical modulation of the lymphatic reserve for tissue drainage has demonstrated promise, but has also generated conflicting results. A better understanding of the hydraulic element of hypertension and the role of lymphatics in maintaining fluid balance can open new approaches to prevent and treat hypertension and its consequences, such as heart failure.

Effect of short-term changes in salt intake on plasma cytokines in women with healthy and hypertensive pregnancies

BACKGROUND

Salt (NaCl) promotes T-lymphocyte conversion to pro-inflammatory Th-17 cells in vitro. Interleukin (IL)-17A aggravates hypertension in preeclampsia (PE) models.

OBJECTIVES

It was hypothesized that 1) women with PE exhibit increased plasma IL-17A and related cytokines and 2) high dietary salt intake elevates circulating IL-17A in patients with PE compared to women with healthy pregnancy (HP) and non-pregnant (NonP) women.

MAIN OUTCOME MEASURES

Plasma concentration of cytokines IL-17A, IFN-γ, IL-10, TNF, IL-6, and IL-1β in samples from NonP women (n = 13), HP (n = 15), and women with PE (n = 7).

STUDY DESIGN

Biobanked samples from a randomized, double-blind, cross-over placebo-controlled dietary intervention study. Participants received a low sodium diet (50-60 mmol NaCl/24 h) for 10 days and were randomly assigned to ingest placebo tablets (low salt intake) or salt tablets (172 mmol NaCl/24 h, high salt intake) for 5 + 5 days. Plasma samples were drawn at baseline and after each diet.

RESULTS

While a high salt diet suppressed renin, angiotensin II, and aldosterone levels, it did not affect blood pressure or plasma cytokine concentrations in any group compared to low salt intake. Plasma TNF was significantly higher in PE than in HP and NonP at baseline and after a low salt diet. Plasma IL-6 was significantly higher in PE compared to HP at baseline and NonP at low salt.

CONCLUSION

Interleukin-17A and related T-cell and macrophage-cytokines are not sensitive to salt-intake in PE. Preeclampsia is associated with elevated levels of TNF and IL-6 macrophage-derived cytokines. Salt-sensitive changes in systemic IL-17A are less likely to explain hypertension in PE.

Tangram of Sodium and Fluid Balance

Homeostasis of fluid and electrolytes is a tightly controlled physiological process. Failure of this process is a hallmark of hypertension, chronic kidney disease, heart failure, and other acute and chronic diseases. While the kidney remains the major player in the control of whole-body fluid and electrolyte homeostasis, recent discoveries point toward more peripheral mechanisms leading to sodium storage in tissues, such as skin and muscle, and a link between this sodium and a range of diseases, including the conditions above. In this review, we describe multiple facets of sodium and fluid balance from traditional concepts to novel discoveries. We examine the differences between acute disruption of sodium balance and the longer term adaptation in chronic disease, highlighting areas that cannot be explained by a kidney-centric model alone. The theoretical and methodological challenges of more recently proposed models are discussed. We acknowledge the different roles of extracellular and intracellular spaces and propose an integrated model that maintains fluid and electrolyte homeostasis and can be distilled into a few elemental players: the microvasculature, the interstitium, and tissue cells. Understanding their interplay will guide a more precise treatment of conditions characterized by sodium excess, for which primary aldosteronism is presented as a prototype.

Sodium as an Important Regulator of Immunometabolism

Salt sensitivity concerns blood pressure alterations after a change in salt intake (sodium chloride). The heart is a pump, and vessels are tubes; sodium can affect both. A high salt intake increases cardiac output, promotes vascular dysfunction and capillary rarefaction, and chronically leads to increased systemic vascular resistance. More recent findings suggest that sodium also acts as an important second messenger regulating energy metabolism and cellular functions. Besides endothelial cells and fibroblasts, sodium also affects innate and adaptive immunometabolism, immune cell function, and influences certain microbes and microbiota-derived metabolites. We propose the idea that the definition of salt sensitivity should be expanded beyond high blood pressure to cellular and molecular salt sensitivity.

Sodium - a systematic review for Nordic Nutrition Recommendations 2023

Blood pressure (BP) rises along with increasing sodium intake from early childhood to late adulthood, and leads to hypertension among most men and women living in Nordic and Baltic countries. Elevated BP is the leading global risk factor for premature deaths and disability-adjusted life-years. A reduction in sodium intake is essential in the prevention of hypertension in individuals, in the lowering of BP levels, in the treatment of hypertensive individuals, and in decreasing risks associated with elevated BP. There is a progressive linear dose-response relationship between sodium intake and BP beginning from a sodium intake of less than 0.8 g/day. Sodium reduction decreases BP linearly by a dose-response manner down to a sodium intake level of less than 2 g/day. Randomised intervention studies with a duration of at least 4 weeks confirm the efficiency and safety of reducing blood sodium intake to a level of less than 2 g/day. Results from prospective cohort studies show that higher sodium intake is positively associated with an increased risk of stroke and cardiovascular events and mortality among the general adult population, and the associations are linear in studies using proper sodium assessment methods. Analyses assessing sodium intake using at least two 24-h urine samples have shown a linear positive relationship between sodium intake and the risk of a cardiovascular event or death. Based on an overall evaluation of the available data, a limitation of the sodium intake to 2.0 g/day is suggested for adults. The optimal sodium intake level would be probably about 1.5 g/day. Sodium intake recommended for children can be extrapolated from the recommended sodium intake for adults. According to national dietary surveys, the average sodium intakes in Nordic countries range in adult men from 3.6 to 4.4 g/day and in adult women from 2.6. to 3.2 g/day, and in Baltic countries in men from 2.6 to 5.1 g/day and in women from 1.8 to 3.6 g/day.

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.

Role of Female Sex Hormones and Immune Response in Salt-Sensitive Hypertension Development: Evidence from Experimental Models

PURPOSEOF REVIEW

Female sex hormones have systemic effects unrelated to their reproductive function. We describe experiences of different research groups and our own, on aspects related to the importance of female sex hormones on blood pressure (BP) regulation and salt-sensitivity-mediated BP response and salt sensitivity without alterations in BP, as well as renal sodium handling and interactions with the immune system.

RECENT FINDINGS

Changes in sodium intake in normotensive premenopausal women cause more BP variations than in men. After menopause, women often develop arterial hypertension (HT) with a profile of sodium sensitivity. Besides, experimental results have shown that in adult rat models resembling the postmenopausal hormonal state induced by ovariectomy, controlling BP is not enough to avoid renal and other tissue infiltration with immune cells, which does not occur when sodium intake is low or normal. Therefore, excess sodium promotes an inflammatory state with the involvement of immune cells. The evidence of activation of adaptive immunity, besides changes in T cell subpopulations, includes changes in sodium transporters and receptors. More studies are needed to evaluate the particular sodium sensitivity of women and its meaning. Changes in lifestyle and sodium intake reduction are the main therapeutic steps. However, to face the actual burden of salt-sensitive HT in postmenopausal women and its associated inflammatory/immune changes, it seems reasonable to work on immune cell activity by considering the peripheral blood mononuclear cell phenotypes of molecules and transport proteins related to sodium handle, both to screen for and treat cell activation.

Dietary salt in liver cirrhosis: With a pinch of salt!

Patients with liver cirrhosis are advised to limit their sodium consumption to control excessive fluid accumulation. Salt is the most common form in which sodium is consumed daily. Consequently, various recommendations urge patients to limit salt intake. However, there is a lack of consistency regarding salt restriction across the guidelines. Moreover, there is conflicting evidence regarding the efficacy of salt restriction in the treatment of ascites. Numerous studies have shown that there is no difference in ascites control between patients with restriction of salt intake and those without restriction. Moreover, patients with cirrhosis may have several negative effects from consuming too little salt, although there are no recommendations on the lower limit of salt intake. Sodium is necessary to maintain the extracellular fluid volume; hence, excessive salt restriction can result in volume contraction, which could negatively impact kidney function in a cirrhotic patient. Salt restriction in cirrhotic patients can also compromise nutrient intake, which can have a negative impact on the overall outcome. There is insufficient evidence to recommend restricted salt intake for all patients with cirrhosis, including those with severe hyponatremia. The existing guidelines on salt restriction do not consider the salt sensitivity of patients; their nutritional state, volume status and sodium storage sites; and the risk of hypochloremia. This opinion article aims to critically analyze the existing literature with regard to salt recommendations for patients with liver cirrhosis and identify potential knowledge gaps that call for further research.

Endothelin mediates sex-differences in acclimation to high salt diet in rats

INTRODUCTION

Current understanding of sodium (Na+) handling is based on studies done primarily in males. Contrary to the gradual increase in high salt (HS) induced natriuresis over 3-5 days in males, female Sprague Dawley (SD) rats have a robust natriuresis after 1 day of HS. Renal endothelin-1 (ET-1) signaling, through ET receptor A and B, is an important natriuretic pathway and was implicated in our previous dietary salt acclimation studies, however, the contribution of ET receptors to sex-differences in acclimation to dietary Na+ challenges has yet to be clarified. We hypothesized that ET receptors mediate the augmented natriuretic capacity of female rats in response to a HS diet.

METHODS

To test our hypothesis, male and female SD rats were implanted with telemeters and randomly assigned to treatment with A-182086, a dual ETA and ETB receptor antagonist, or control. 24-h urine samples were collected and assessed for electrolytes and ET-1. Studies were performed on a normal salt (NS, 0.3% NaCl) diet and after challenging rats with HS (4% NaCl) diet for 1 day.

RESULTS

We found that A-182086 increased blood pressure in male and female SD rats fed either diet. Importantly, A-182086 eliminated sex-differences in natriuresis on NS and HS. In particular, A-182086 promotes HS-induced natriuresis in male rats rather than attenuating the natriuretic capacity of females. Further, the sex-difference in urinary ET-1 excretion in NS-fed rats was eliminated by A-182086.

CONCLUSION

In conclusion, ET receptors are crucial for mediating sex-difference in the natriuretic capacity primarily through their actions in male rats.

Association between serum sodium levels within 24 h of admission and all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: a retrospective analysis of the MIMIC-IV database

Objective

The study aimed to evaluate the relationship between serum sodium and mortality in critically ill patients with non-traumatic subarachnoid hemorrhage.

Methods

This is a retrospective investigation of critically ill non-traumatic patients with subarachnoid hemorrhage (SAH) utilizing the MIMIC-IV database. We collected the serum sodium levels at admission and determined the all-cause death rates for the ICU and hospital. We employed a multivariate Cox proportional hazard regression model and Kaplan-Meier survival curve analysis to ascertain the relationship between serum sodium and all-cause mortality. In order to evaluate the consistency of correlations, interaction and subgroup analyses were also conducted.

Results

A total of 864 patients with non-traumatic SAH were included in this study. All-cause mortality in the ICU and hospital was 32.6% (282/864) and 19.2% (166/864), respectively. Sodium levels at ICU admission showed a statistically significant J-shaped non-linear relationship with ICU and hospital mortality (non-linear P-value < 0.05, total P-value < 0.001) with an inflection point of ~141 mmol/L, suggesting that mortality was higher than normal serum sodium levels in hypernatremic patients. Multivariate analysis after adjusting for potential confounders showed that high serum sodium levels (≥145 mmol/L) were associated with an increased risk of all-cause mortality in the ICU and hospital compared with normal serum sodium levels (135-145 mmol/L), [hazard ratio (HR) = 1.47, 95% CI: 1.07-2.01, P = 0.017] and (HR = 2.26, 95% CI:1.54-3.32, P < 0.001). Similarly, Kaplan-Meier (K-M) survival curves showed lower survival in patients with high serum sodium levels. Stratified analysis further showed that the association between higher serum sodium levels and hospital all-cause mortality was stronger in patients aged < 60 years with a hospital stay of <7 days.

Conclusion

High serum sodium levels upon ICU admission are related to higher ICU and hospital all-cause mortality in patients with non-traumatic SAH. A new reference is offered for control strategies to correct serum sodium levels.

Corin Deficiency Diminishes Intestinal Sodium Excretion in Mice

Sodium excretion, a critical process in sodium homeostasis, occurs in many tissues, including the kidney and intestine. Unlike in the kidney, the hormonal regulation of intestinal sodium excretion remains unclear. Atrial natriuretic peptide (ANP) is a crucial hormone in renal natriuresis. Corin is a protease critical for ANP activation. Corin and ANP are expressed mainly in the heart. In this study, we investigated corin, ANP, and natriuretic peptide receptor A (Npra) expression in mouse intestines. Corin and ANP expression was co-localized in enteroendocrine cells, whereas Npra expression was on the luminal epithelial cells. In Corin knockout (KO) mice, fecal Na⁺ and Cl^- excretion decreased compared with that in wild-type (WT) mice. Such a decrease was not found in conditional Corin KO mice lacking cardiac corin selectively. In kidney conditional Corin KO mice lacking renal corin, fecal Na⁺ and Cl^- excretion increased, compared to that in WT mice. When WT, Corin KO, and the kidney conditional KO mice were treated with aldosterone, the differences in fecal Na⁺ and Cl^- levels disappeared. These results suggest that intestinal corin may promote fecal sodium excretion in a paracrine mechanism independent of the cardiac corin function. The increased fecal sodium excretion in the kidney conditional Corin KO mice likely reflected an intestinal compensatory response to renal corin deficiency. Our results also suggest that intestinal corin activity may antagonize aldosterone action in the promotion of fecal sodium excretion. These findings help us understand the hormonal mechanism controlling sodium excretion the intestinal tract.

It is strongly recommended to not conduct, fund, or publish research studies that use spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes: a policy statement of the World Hypertension League, International Society of Hypertension and Resolve to Save Lives

Spot urine samples with estimating equations have been used to assess individuals' sodium (salt) intake in association with health outcomes. There is large random and systematic error in estimating sodium intake using this method and spurious health outcome associations. Substantial controversy has resulted from false claims the method is valid. Hence, the World Hypertension League, International Society of Hypertension and Resolve to Save Lives, supported by 21 other health organizations, have issued this policy statement that strongly recommends that research using spot urine samples with estimating equations to assess individuals' sodium (salt) intake in association with health outcomes should not be conducted, funded or published. Literature reviews on the health impacts of reducing dietary sodium that include studies that have used spot and short duration timed urine samples with estimating equations need to explicitly acknowledge that the method is not recommended to be used and is associated with spurious health outcome associations.

Sodium is a negative allosteric regulator of the ghrelin receptor

The functional properties of G protein-coupled receptors (GPCRs) are intimately associated with the different components in their cellular environment. Among them, sodium ions have been proposed to play a substantial role as endogenous allosteric modulators of GPCR-mediated signaling. However, this sodium effect and the underlying mechanisms are still unclear for most GPCRs. Here, we identified sodium as a negative allosteric modulator of the ghrelin receptor GHSR (growth hormone secretagogue receptor). Combining 23Na-nuclear magnetic resonance (NMR), molecular dynamics, and mutagenesis, we provide evidence that, in GHSR, sodium binds to the allosteric site conserved in class A GPCRs. We further leveraged spectroscopic and functional assays to show that sodium binding shifts the conformational equilibrium toward the GHSR-inactive ensemble, thereby decreasing basal and agonist-induced receptor-catalyzed G protein activation. All together, these data point to sodium as an allosteric modulator of GHSR, making this ion an integral component of the ghrelin signaling machinery.

Chai-Gui Decoction and its representative components ameliorate spontaneous hypertension rats by modulating lipid metabolism and gut microbiota

ETHNOPHARMACOLOGICAL RELEVANCE

Hypertension coincides with the category of "vertigo" and/or "headache" on the basis clinical manifestations and traditional Chinese medicine (TCM) theory. Chai-Gui Decoction (CGD), which is in usage for relieving "vertigo" and/or "headache", had been demonstrated to be useful in ameliorating hypertension.

AIM OF STUDY

This study was planned to investigate the mechanism of CGD and its components in hypertension by using spontaneous hypertension rat (SHR).

MATERIALS AND METHODS

CGD extract and its classification component samples (compounds in plasma, CP; compounds in gut, CG; compounds in plasma and gut, CPG) were prepared for animal experiment. SHR rats were induced with CGD extract (3 g/kg/d BW, 5 g/kg/d BW, 15 g/kg/d BW) and CGD-component classes (CP = 19.501 mg/kg/d, CG = 5.240 mg/kg/d, CPG = 24.741 mg/kg/d) for 4 weeks. Blood pressure (BP) and indexes of renin-angiotensin-aldosterone system (RAAS system) were measured. Histopathology was carried out to assess the efficacy of CGD and its components on aorta tissues. Untargeted metabolomics of lipid from rat serum samples were applied by Ultra-High performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UHPLC-Q-TOF-MS) and chemometric analysis to explore the relationship between metabolic pathways and hypertension. 16S rRNA gene sequencing of rat colon content and bioinformatics analysis were used to characterize the effects of CGD and its components on the gut microbiota composition of SHR rats.

RESULTS

CGD and its component mixtures showed antihypertensive effect on SHR rats, decreased the blood pressure and reduced the aortic wall thickness in SHR rats. CGD and its component mixtures could improve the RAAS in SHR rats, including increase the percentage of angiotensin 1-7 (Ang 1-7), decrease the percentage of angiotensin II (Ang II), and decrease the Ang Ⅱ/Ang 1-7 ratio. CGD and its component mixtures could regulate the metabolome in SHR rats, mainly as decreasing the higher serum levels of Lysophosphatidylcholine (LPC) 16: 0, LPC 20: 4, and LPC 22: 6. In addition, bacteria from family S24-7 were negatively correlated with levels of LPE 16:0, LPE 18:0, LPE 18:1, and LPE 18:2.

CONCLUSION

CGD and its component mixtures exhibited antihypertensive effect on SHR rats. The underlying mechanism could be related to modulation on RAAS, LPC metabolism and the bacterial abundance of family S24-7 in gut.

The association between dietary sodium intake and obesity in adults by sodium intake assessment methods: a review of systematic reviews and re-meta-analysis

BACKGROUND/OBJECTIVES

The scientific evidence of a sodium-obesity association is limited by sodium intake assessments. Our specific aim is to synthesize the association between dietary sodium intake and obesity across the sodium intake assessments as evidenced by systematic reviews in adults.

SUBJECTS/METHODS

A systematic search identified systematic reviews comparing the association of dietary sodium intakes with obesity-related outcomes such as body mass index (BMI), body weight, waist circumference, and risk of (abdominal) obesity. We searched PubMed on October 24, 2022. To assess the Risk of Bias in Systematic Reviews (ROBIS), we employed the ROBIS tool.

RESULTS

This review included 3 systematic reviews, consisting of 39 unique observational studies (35 cross-sectional studies and 4 longitudinal studies) and 15 randomized controlled trials (RCTs). We found consistently positive associations between dietary sodium intake and obesity-related outcomes in cross-sectional studies. Studies that used 24-h urine collection indicated a greater BMI for those with higher sodium intake (mean difference = 2.27 kg/m2; 95% confidence interval [CI], 1.59-2.51; P < 0.001; I2 = 77%) compared to studies that used spot urine (mean difference = 1.34 kg/m2; 95% CI, 1.13-1.55; P < 0.001; I2 = 95%) and dietary methods (mean difference = 0.85 kg/m2; 95% CI, 0.1-1.51; P < 0.05; I2 = 95%).

CONCLUSIONS

Quantitative synthesis of the systematic reviews has shown that cross-sectional associations between dietary sodium intake and obesity outcomes were substantially different across the sodium intake assessments. We need more high-quality prospective cohort studies and RCTs using 24-h urine collection to examine the causal effects of sodium intake on obesity.

An optimized method for neutron dose evaluation based on24Na activity distribution in the human body

The neutron dose resulting from external irradiation can be evaluated by measuring the counts of characteristicγrays produced by²⁴Na in the human body. The detection geometry with the highest detection efficiency for measuring the whole-body²⁴Na activity has not been studied. In this work, the MCNP code is used to calculate the spatial distribution of²⁴Na in the human body irradiated by neutrons with different energies in different irradiation geometries. The fluence distribution of²⁴Na characteristicγrays on the body surface is calculated. The counts of²⁴Na characteristicγrays induced by monochromatic neutron irradiation are simulated to fit the scenarios of neutron irradiation by a continuous energy spectrum neutron. When the spontaneous neutrons from²⁵²Cf with 1Gy dose irradiate the human body, (3.63-4.35) × 10^{10 24}Na atoms are produced. The lower detection limit for the neutron absorption dose is reduced from ∼100 to less than 1 mGy when the radiation detector is placed over the back of the human body close to the liver. The relative error between the measured counts of²⁴Na characteristic γ rays caused by²⁵²Cf neutron irradiation and the counts fitted by monochromatic neutron irradiation data is less than 5.7%. The neutron dose received from a continuous energy spectrum neutron can be acquired quickly and accurately by weighted summing of the data for monochromatic neutron irradiations calculated in this paper, which is more convenient and practical than the previous method.

Variability of 24-Hour Sodium Urinary Excretion in Young Healthy Males Based on Consecutive Urine Collections: Impact on Categorization of Salt Intake

OBJECTIVE

Several nonconsecutive 24-h urinary collections are considered the gold standard for estimating dietary salt intake. As those samples are logistically demanding, we aimed to describe the variability of 24-h sodium urinary excretion over consecutive days and report its adequacy with sodium intake.

METHODS

We enrolled 16 healthy male volunteers in a prospective controlled study. All participants randomly received a low salt diet (LSD) (3 g/day of NaCl), a normal salt diet (NSD) (6 g/day of NaCl), and a high salt diet (HSD) (15 g/day of NaCl) for 7 days in a crossover design without wash-out period.

RESULTS

On day 6, median sodium urinary excretion was 258 (216-338), 10 (8-18), and 87 (69-121) mmol/day for HSD, LSD, and NSD, respectively (P < .001). When considering days 4-6, sodium urinary excretion was in steady state as models with and without interaction term "diet type X sample day" were not significantly different (P = .163). On day 6, area under the curve (AUC) of receiver operating characteristic for urinary sodium excretion to detect HSD was 1.0 (1.0-1.0) and a cut-point of 175 mmol/day was 100% sensitive and specific to detect HSD. On day 6, receiver operating characteristic AUC to detect LSD was 0.993 (0.978-1.0) and a cut-point of 53 mmol/day was 96.4% sensitive and 100% specific to detect LSD.

CONCLUSION

A steady state of sodium balance, where sodium intake is proportional to its excretion, is reached within a few days under a constant diet in the real-life setting. Categorization of salt consumption into low (3 g/day), normal (6 g/day), or high (15 g/day) based on a single 24-h urine collection is nearly perfect. Based on these results, repeated nonconsecutive urine collection might prove unnecessary to estimate sodium intake in daily clinical practice provided that diet is rather constant over time.

Sodium Homeostasis, a Balance Necessary for Life

Body sodium (Na) levels must be maintained within a narrow range for the correct functioning of the organism (Na homeostasis). Na disorders include not only elevated levels of this solute (hypernatremia), as in diabetes insipidus, but also reduced levels (hyponatremia), as in cerebral salt wasting syndrome. The balance in body Na levels therefore requires a delicate equilibrium to be maintained between the ingestion and excretion of Na. Salt (NaCl) intake is processed by receptors in the tongue and digestive system, which transmit the information to the nucleus of the solitary tract via a neural pathway (chorda tympani/vagus nerves) and to circumventricular organs, including the subfornical organ and area postrema, via a humoral pathway (blood/cerebrospinal fluid). Circuits are formed that stimulate or inhibit homeostatic Na intake involving participation of the parabrachial nucleus, pre-locus coeruleus, medial tuberomammillary nuclei, median eminence, paraventricular and supraoptic nuclei, and other structures with reward properties such as the bed nucleus of the stria terminalis, central amygdala, and ventral tegmental area. Finally, the kidney uses neural signals (e.g., renal sympathetic nerves) and vascular (e.g., renal perfusion pressure) and humoral (e.g., renin-angiotensin-aldosterone system, cardiac natriuretic peptides, antidiuretic hormone, and oxytocin) factors to promote Na excretion or retention and thereby maintain extracellular fluid volume. All these intake and excretion processes are modulated by chemical messengers, many of which (e.g., aldosterone, angiotensin II, and oxytocin) have effects that are coordinated at peripheral and central level to ensure Na homeostasis.

Inverse salt sensitivity: an independent risk factor for cardiovascular damage in essential hypertension

OBJECTIVE

Salt sensitivity is a powerful risk factor for cardiovascular (CV) disease and mortality in both normotensive and hypertensive patients. We investigated the predictive value of the salt sensitivity phenotype in the development of CV events and hypertensive target organ damage (TOD) among essential hypertensive patients.

METHODS

Eight hundred forty-four naive hypertensive patients were recruited and underwent an acute saline test during which blood pressure (BP) displayed either no substantial variation (salt-resistant, SR individuals), an increase (salt-sensitive, SS), or a paradoxical decrease (inverse salt-sensitive, ISS). Sixty-one patients with the longest monitored follow-up (median 16 years) for blood pressure and organ damage were selected for the present study. A clinical score for TOD development based on the severity and the age of onset was set up by considering hypertensive heart disease, cerebrovascular damage, microalbuminuria, and vascular events.

RESULTS

CV events were significantly higher among SS and ISS than in SR patients. The relative risk of developing CV events was 12.67 times higher in SS than SR and 5.94 times higher in ISS than SR patients. The development of moderate to severe TOD was 10-fold higher in SS and over 15-fold higher in ISS than in SR patients. Among the three phenotypes, changes in plasma endogenous ouabain were linked with the blood pressure effects of saline.

CONCLUSIONS

Salt sensitivity and inverse salt sensitivity appear to be equivalent risk factors for CV events. The response to an acute saline test is predictive of CV damage for newly identified ISS individuals.

Development of semi-quantitative urinary sodium test strip

Excessive salt consumption has been associated with greater risk of hypertension. Therefore, monitoring of dietary sodium consumption should be prioritized. As sodium is mainly excreted through urine, 24-hours urine sample can be used to estimate individual sodium intake. Thus, a simple and inexpensive semi-quantitative urinary sodium detection test strip was developed based on the enzymatic reaction between β-galactosidase and chlorophenol red-β-D-galactopyranoside. When tested, colour formation was distinguished at 0 M (chartreuse yellow), 0.05 M (sunflower), 0.1-0.15 M (mango tango), and 0.2-0.25 M (persimmon) sodium. Analysis from ImageJ showed a linear result (r² >0.9), low SD, and significant increase in magenta difference (p<0.01) between 0 M and 0.05-0.25 M sodium. Test strip can detect 0.03 M sodium at minimum but did not last for >2 days in adverse storage conditions (laboratory conditions, ∼80% relative humidity, 40°C, and direct light exposure) when stored in test strip bottles, and even shorter when exposed to the environment. The presence of urinary potassium, urea, and glucose did not affect test strip performance. Test strip produced comparable results to flame photometry with <15% variation when tested on overnight, random spot, and 24-hours urine samples. Overall, the developed test strip can be used to enzymatically semi-quantify 0.05-0.25 M sodium. Test strip was developed by using β-galactosidase and chlorophenol red-β-D-galactopyranoside for the enzymatic detection of urinary sodium. Test strip could perform urinary sodium monitoring by providing colour indicator based on the concentration of sodium tested in the urine sample at a quicker timing in comparison to current quantification methods. The developed test strip could be used by hypertensive and normotensive users conveniently and repeatably wherever and whenever possible without additional equipment. This article is protected by copyright. All rights reserved.

Case Report: Severe Hypernatremia From Ingestion of One's Own Urine

An often unrecognized cause of hypernatremia is the ingestion of fluids or substances with high osmolality. We hereby report a case of severe hypernatremia with acute kidney injury in a severely debilitated patient with acute gouty arthritis who resorted to ingesting his own urine. Hypernatremia induced by drinking urine could be attributed to many underlying mechanisms, one of the important possible causes is the resultant high serum urea that leads to significant osmotic diuresis and a further increase in free water clearance. To the best of our knowledge this is the first case report that describes this unique cause of hypernatremia.

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

Background: Hypertension is the leading factor of cardiovascular mortality and morbidity. Although antihypertensive medical treatment is the cornerstone of blood pressure control, lifestyle modification, including optimal diet therapy, such as dietary approaches to stop hypertension (DASH), cannot be overemphasized.Current Concepts: Due to the mismatch between sodium intake and excretion process being the key mechanisms according to physiologic principles, low sodium and high potassium intakes are the critical components of DASH. If the patient has a sensitive elevation of blood pressure following increased sodium intake, a low sodium diet could be essential for optimal blood pressure control. Salt sensitivity is increased by the activated reninangiotensin system, sympathetic nervous activity, sodium channels disorder, and endothelial dysfunction and frequently observed in the elderly and patients with obesity and chronic kidney disease. Increased potassium intake could attenuate sodium absorption by affecting the intracellular chloride and WNK4 activity, especially in patients with salt sensitivity or high salt intake.Discussion and Conclusion: For low sodium and high potassium intakes, the Na/K diet ratio could be a good target for intervention, and this approach is a critical component of DASH.

Overview of salt restriction in the Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean diet for blood pressure reduction

Despite considerable advances in pharmacological treatments, hypertension remains a major cause of premature morbidity and mortality worldwide since elevated blood pressure (BP) adversely influences cardiovascular and renal outcomes. Accordingly, the current hypertension guidelines recommend the adoption of dietary modifications in all subjects with suboptimal BP levels. These modifications include salt intake reduction and a healthy diet, such as the Dietary Approaches to Stop Hypertension (DASH) diet or the Mediterranean diet (MedDiet), independently of the underlying antihypertensive drug treatment. However, dietary modifications for BP reduction in adults with prehypertension or hypertension are usually examined as stand-alone interventions and, to a lesser extent, in combination with other dietary changes. The purpose of the present review was to summarize the evidence regarding the BP effect of salt restriction in the context of the DASH diet and the MedDiet. We also summarize the literature regarding the effects of these dietary modifications when they are applied as the only intervention for BP reduction in adults with and without hypertension and the potent physiological mechanisms underlying their beneficial effects on BP levels. Available data of randomized controlled trials (RCTs) provided evidence about the significant BP-lowering effect of each one of these dietary strategies, especially among subjects with hypertension since they modulate various physiological mechanisms controlling BP. Salt reduction by 2.3 g per day in the DASH diet produces less than half of the effect on systolic blood pressure (SBP)/diastolic blood pressure (DBP) (-3.0/-1.6 mmHg) as it does without the DASH diet (-6.7/-3.5 mmHg). Although their combined effect is not fully additive, low sodium intake and the DASH diet produce higher SBP/DBP reduction (-8.9/-4.5 mmHg) than each of these dietary regimens alone. It is yet unsettled whether this finding is also true for salt reduction in the MedDiet.

High salt activates p97 to reduce host antiviral immunity by restricting Viperin induction

High-salt diets have recently been implicated in hypertension, cardiovascular disease, and autoimmune disease. However, whether and how dietary salt affects host antiviral response remain elusive. Here, we report that high salt induces an instant reduction in host antiviral immunity, although this effect is compromised during a long-term high-salt diet. Further studies reveal that high salt stimulates the acetylation at Lys663 of p97, which promotes the recruitment of ubiquitinated proteins for proteasome-dependent degradation. p97-mediated degradation of the deubiquitinase USP33 results in a deficiency of Viperin protein expression during viral infection, which substantially attenuates host antiviral ability. Importantly, switching to a low-salt diet during viral infection significantly enhances Viperin expression and improves host antiviral ability. These findings uncover dietary salt-induced regulation of ubiquitinated cellular proteins and host antiviral immunity, and could offer insight into the daily consumption of salt-containing diets during virus epidemics.

The roles of sodium and volume overload on hypertension in chronic kidney disease

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular (CV) events, and the disease burden is rising rapidly. An important contributor to CV events and CKD progression is high blood pressure (BP). The main mechanisms of hypertension in early and advanced CKD are renin-angiotensin system activation and volume overload, respectively. Sodium retention is well known as a factor for high BP in CKD. However, a BP increase in response to total body sodium or volume overload can be limited by neurohormonal modulation. Recent clinical trial data favoring intensive BP lowering in CKD imply that the balance between volume and neurohormonal control could be revisited with respect to the safety and efficacy of strict volume control when using antihypertensive medications. In hemodialysis patients, the role of more liberal use of antihypertensive medications with the concept of functional dry weight for intensive BP control must be studied.

Salt-Sensitive Hypertension, Renal Injury, and Renal Vasodysfunction Associated With Dahl Salt-Sensitive Rats Are Abolished in Consomic SS.BN1 Rats

Background

Abnormal renal hemodynamic responses to salt‐loading are thought to contribute to salt‐sensitive (SS) hypertension. However, this is based largely on studies in anesthetized animals, and little data are available in conscious SS and salt‐resistant rats.

Methods and Results

We assessed arterial blood pressure, renal function, and renal blood flow during administration of a 0.4% NaCl and a high‐salt (4.0% NaCl) diet in conscious, chronically instrumented 10‐ to 14‐week‐old Dahl SS and consomic SS rats in which chromosome 1 from the salt‐resistant Brown‐Norway strain was introgressed into the genome of the SS strain (SS.BN1). Three weeks of high salt intake significantly increased blood pressure (20%) and exacerbated renal injury in SS rats. In contrast, the increase in blood pressure (5%) was similarly attenuated in Brown‐Norway and SS.BN1 rats, and both strains were completely protected against renal injury. In SS.BN1 rats, 1 week of high salt intake was associated with a significant decrease in renal vascular resistance (−8%) and increase in renal blood flow (15%). In contrast, renal vascular resistance failed to decrease, and renal blood flow remained unchanged in SS rats during high salt intake. Finally, urinary sodium excretion and glomerular filtration rate were similar between SS and SS.BN1 rats during 0.4% NaCl and high salt intake.

Conclusions

Our data support the concept that renal vasodysfunction contributes to blood pressure salt sensitivity in Dahl SS rats, and that genes on rat chromosome 1 play a major role in modulating renal hemodynamic responses to salt loading and salt‐induced hypertension.

Quantitative assessment of sodium mass removal using ionic dialysance and sodium gradient as a proxy tool: Comparison of high-flux hemodialysis versus online hemodiafiltration

Restoration and maintenance of sodium are still a matter of concern and remains of critical importance to improve the outcomes in homeostasis of stage 5 chronic kidney disease patients on dialysis. Sodium mass balance and fluid volume control rely on the "dry weight" probing approach consisting mainly of adjusting the ultrafiltration volume and diet restrictions to patient needs. An additional component of sodium and fluid management relies on adjusting the dialysate-plasma sodium concentration gradient. Hypotonicity of ultrafiltrate in online hemodiafiltration (ol-HDF) might represent an additional risk factor in regard to sodium mass balance. A continuous blood-side approach for quantifying sodium mass balance in hemodialysis and ol-HDF using an online ionic dialysance sensor device ("Flux" method) embedded on hemodialysis machine was explored and compared to conventional cross-sectional "Inventory" methods using anthropometric measurement (Watson), multifrequency bioimpedance analysis (MF-BIA), or online clearance monitoring (OCM) to assess the total body water. An additional dialysate-side approach, consisting of the estimation of inlet/outlet sodium mass balance in the dialysate circuit was also performed. Ten stable hemodialysis patients were included in an "ABAB"-designed study comparing high-flux hemodialysis (hf-HD) and ol-HDF. Results are expressed using a patient-centered sign convention as follows: accumulation into the patient leads to a positive balance while recovery in the external environment (dialysate, machine) leads to a negative balance. In the blood-side approach, a slight difference in sodium mass transfer was observed between models with hf-HD (-222.6 [-585.1-61.3], -256.4 [-607.8-43.7], -258.9 [-609.8-41.3], and -258.5 [-607.8-43.5] mmol/session with Flux and Inventory models using V_Watson , V_MF-BIA , and V_OCM values for the volumes of total body water, respectively; global P value < .0001) and ol-HDF modalities (-235.3 [-707.4-128.3], -264.9 [-595.5-50.8], -267.4 [-598.1-44.1], and -266.0 [-595.6-55.6] mmol/session with Flux and Inventory models using V_Watson , V_MF-BIA , and V_OCM values for the volumes of total body water, respectively; global P value < .0001). Cumulative net ionic mass balance on a weekly basis remained virtually similar in hf-HD and ol-HDF using Flux method (P = n.s.). Finally, the comparative quantification of sodium mass balance using blood-side (Ionic Flux) and dialysate-side approaches reported clinically acceptable (a) agreement (with limits of agreement with 95% confidence intervals (CI): -166.2 to 207.2) and (b) correlation (Spearman's rho = 0.806; P < .0001). We validated a new method to quantify sodium mass balance based on ionic mass balance in dialysis patients using embedded ionic dialysance sensor combined with dialysate/plasma sodium concentrations. This method is accurate enough to support caregivers in managing sodium mass balance in dialysis patients. It offers a bridging solution to automated sodium proprietary balancing module of hemodialysis machine in the future.

Angiotensin-(3-4) normalizes blood pressure, decreases Na+ and energy intake, but preserves urinary Na+ excretion in overweight hypertensive rats

Hypertension, one of the most common and severe comorbidities of obesity and overweight, is a worldwide epidemic affecting over 30% of the population. We induced overweight in young male rats (aged 58 days) by exposure to a hypercaloric high lipid (HL) diet in which 70% of the calories originated from fat. The HL diet also contained 33 or 57% higher Na⁺ than the control (CTR) diet. Over the following weeks the HL rats gradually became overweight (490 ± 12 g vs 427 ± 7 g in the CTR group after 15 weeks) with high visceral fat. They developed elevated systolic blood pressure (SBP) (141 ± 1.9 mmHg), which was fully restored to CTR values (128 ± 1.1 mmHg) by oral administration of Ang-(3-4) (Val-Tyr), the shortest renin-angiotensin-derived peptide. The overweight rats had lower plasma Na⁺ concentration that augmented to CTR values by Ang-(3-4) treatment. Na⁺ ingestion was depressed by 40% as result of the Ang-(3-4) treatment, whereas the urinary excretion of Na⁺ (U_NaV) remained unmodified. The preservation of U_NaV after Ang-(3-4) treatment - despite the sharp decrease in the dietary Na⁺ intake - can be ascribed to the normalization of renal type 1 angiotensin II receptors and Na⁺-transporting ATPases, both up-regulated in overweight rats. These renal effects complete a counterregulatory action on elevated renin-angiotensin activity that allows the high SBP to be normalized and body Na⁺ homeostasis to be restored concomitantly in overweight rats.

Urinary sodium excretion and its association with blood pressure in Nigeria: A nationwide population survey

Assessment of level of salt intake in a population is the first step toward planning strategies aimed at salt reduction. As a surrogate of salt intake, we measured a single 24-hour urine sodium (uNa) of free-living 2503 adults in a nationally representative sample of Nigerians drawn from 12 rural and urban communities; and evaluated the community-level association of uNa with blood pressure (BP). Overall, the median (interquartile range (IQR)) of uNa was 99 (105) mmol, ranging from 23.8 (32.4) in rural north-central to 172.8 (131.0) mmol in urban northwestern region. Daily uNa was significantly higher (p < .001) in men compared to women (107.1 vs 93.9 mmol); and urban compared to rural dwellers (114.9 vs 86.0mmol). About one-half of participants excreted uNa in excess of recommended daily maximum value (86mmol). In a model adjusted for age, sex, body mass index (BMI), level of education, place of residence, and use of antihypertensive medication; being a man (odds ratio, OR 1.69, 95% confidence Interval CI, 1.21-2.37, p = .002) and being < 60 years of age (OR 1.74, 95% CI 1.23-2.45, p = .002), were associated with excreting higher than recommended uNa. In a fully adjusted model of the community-level analysis, urinary sodium, potassium, and sodium-to-potassium ratio each showed no significant independent association with both systolic and diastolic BPs. Among adult Nigerians, the median daily uNa excretion was 99 mmol and it had no significant association with blood pressure indices.

Dietary reference values for sodium

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) derived dietary reference values (DRVs) for sodium. Evidence from balance studies on sodium and on the relationship between sodium intake and health outcomes, in particular cardiovascular disease (CVD)-related endpoints and bone health, was reviewed. The data were not sufficient to enable an average requirement (AR) or population reference intake (PRI) to be derived. However, by integrating the available evidence and associated uncertainties, the Panel considers that a sodium intake of 2.0 g/day represents a level of sodium for which there is sufficient confidence in a reduced risk of CVD in the general adult population. In addition, a sodium intake of 2.0 g/day is likely to allow most of the general adult population to maintain sodium balance. Therefore, the Panel considers that 2.0 g sodium/day is a safe and adequate intake for the general EU population of adults. The same value applies to pregnant and lactating women. Sodium intakes that are considered safe and adequate for children are extrapolated from the value for adults, adjusting for their respective energy requirement and including a growth factor, and are as follows: 1.1 g/day for children aged 1-3 years, 1.3 g/day for children aged 4-6 years, 1.7 g/day for children aged 7-10 years and 2.0 g/day for children aged 11-17 years, respectively. For infants aged 7-11 months, an Adequate Intake (AI) of 0.2 g/day is proposed based on upwards extrapolation of the estimated sodium intake in exclusively breast-fed infants aged 0-6 months.

The exaggerated natriuresis of essential hypertension occurs independently of changes in renal medullary blood flow

AIMS

In patients with essential hypertension, abnormal renal sodium handling includes exaggerated natriuresis in response to extracellular volume expansion. We tested the hypothesis that exaggerated natriuresis is associated with increases in medullary and/or cortical renal blood flow.

METHODS

Patients with mild essential hypertension, but no signs of end organ damage, and control subjects were studied after 4 days of dietary standardization (<60 mmol Na⁺  day^-1 ) preceded in patients by a 14-day drug washout period. On the study day, subjects received a 4-hour intravenous volume expansion with saline (2.1% of body mass). Renal medullary and cortical blood flows were measured by PET scanning using H₂ ¹⁵ O as tracer; anatomical regions of interest were defined by contrast-enhanced CT scanning.

RESULTS

In patients, arterial blood pressure increased during volume expansion (107 ± 2-114 ± 3 mm Hg, P < 0.05) in contrast to the control group (92 ± 2-92 ± 2 mm Hg). Renal sodium excretion increased more in patients than in controls (+133 ± 31 µmol min^-1 vs +61 ± 14 µmol min^-1 , respectively, P < 0.05) confirming exaggerated natriuresis. During volume expansion, renal medullary blood flow did not change significantly in patients (2.8 ± 0.4-2.5 ± 0.5 mL (g tissue)^-1  min^-1 ) or in controls (3.2 ± 0.3-3.1 ± 0.2 mL (g tissue)^-1 min^-1 ). In control subjects, renal cortical blood flow fell during volume expansion (4.1 ± 0.3-3.7 ± 0.2 mL (g tissue)^-1  min^-1 , P < 0.05) in contrast to patients in which deviations remained insignificant.

CONCLUSION

Exaggerated natriuresis, a hallmark of essential hypertension, is not mediated by increases in regional, renal blood flow.