Moderation of dietary sodium potentiates the renal and cardiovascular protective effects of angiotensin receptor blockers

Abstract

Dietary sodium restriction has been shown to enhance the short-term response of blood pressure and albuminuria to angiotensin receptor blockers (ARBs). Whether this also enhances the long-term renal and cardiovascular protective effects of ARBs is unknown. Here we conducted a post-hoc analysis of the RENAAL and IDNT trials to test this in patients with type 2 diabetic nephropathy randomized to ARB or non-renin-angiotensin-aldosterone system (non-RAASi)-based antihypertensive therapy. Treatment effects on renal and cardiovascular outcomes were compared in subgroups based on dietary sodium intake during treatment, measured as the 24-h urinary sodium/creatinine ratio of 1177 patients with available 24-h urinary sodium measurements. ARB compared to non-RAASi-based therapy produced the greatest long-term effects on renal and cardiovascular events in the lowest tertile of sodium intake. Compared to non-RAASi, the trend in risk for renal events was significantly reduced by 43%, not changed, or increased by 37% for each tertile of increased sodium intake, respectively. The trend for cardiovascular events was significantly reduced by 37%, increased by 2% and 25%, respectively. Thus, treatment effects of ARB compared with non-RAASi-based therapy on renal and cardiovascular outcomes were greater in patients with type 2 diabetic nephropathy with lower than higher dietary sodium intake. This underscores the avoidance of excessive sodium intake, particularly in type 2 diabetic patients receiving ARB therapy.

Effects of Intensive Low-Salt Diet Education on Albuminuria among Nondiabetic Patients with Hypertension Treated with Olmesartan

“…According to the sodium DFQ55 in this study, participants exhibited relatively lower levels of sodium consumption (105.1 mEq at week 0 and 78.6 mEq at week 16, which are equivalent to sodium intakes of 2.4 and 1.8 g/d, respectively) than typically consumed by Korean populations or reported in previous studies (24)(25)(26). These underestimated DFQ55 values may reflect the inexactitude of sodium intake estimation only by dietary recall.…”

The effect of sodium glucose cotransporter 2 inhibition with empagliflozin on microalbuminuria and macroalbuminuria in patients with type 2 diabetes

“…Therapeutic options for patients with persistent albuminuria in the setting of satisfactory HbA 1c and BP control are limited to changes in lifestyle, such as sodium restriction and weight loss, which are supported by limited evidence and are often difficult to achieve [5,6].…”

N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) predicts the cardio‐renal response to aliskiren in patients with type 2 diabetes at high renal and cardiovascular risk

“…Extracellular volume restriction, by means of moderating dietary sodium intake or concomitant diuretic treatment has been shown to improve the albuminuria‐reducing and blood pressure‐lowering response to RAAS blockade as well as the efficacy of RAAS blockade to decrease cardio‐renal risk 5, 14, 15. The present study shows that NT‐proBNP can help to identify individuals who may not respond to dual RAAS inhibition with aliskiren and who may benefit from diuretic treatment or dietary sodium‐lowering.…”

“…People with type 2 diabetes are susceptible to retaining sodium and fluid as a result of disturbed insulin homeostasis 3. Previous studies have shown that sodium retention and subsequent volume overload are the main determinants of poor response to RAAS therapy 4, 5. Accordingly, volume restriction by means of co‐diuretic treatment or a low sodium diet enhances the blood pressure‐lowering and albuminuria‐reducing effects of RAAS inhibition 6.…”