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Meta-Analysis
. 2021 Jun 24;6(6):CD010070.
doi: 10.1002/14651858.CD010070.pub3.

Altered dietary salt intake for people with chronic kidney disease

Emma J McMahon  1 , Katrina L Campbell  2   3 , Judith D Bauer  4 , David W Mudge  5 , Jaimon T Kelly  2
Affiliations
Meta-Analysis

Altered dietary salt intake for people with chronic kidney disease

Emma J McMahon et al. Cochrane Database Syst Rev. .

Abstract

Background: Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015.

Objectives: To evaluate the benefits and harms of altering dietary salt for adults with CKD.

Search methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

Selection criteria: Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD.

Data collection and analysis: Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

Main results: We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events.

Authors' conclusions: We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.

Trial registration: ClinicalTrials.gov NCT01125202 NCT00447317 NCT00702312 NCT00141609 NCT01552954 NCT01458808 NCT00974636 NCT02875886 NCT02276742 NCT01259700 NCT01015313 NCT03373500 NCT01552317 NCT02458248 NCT02132013 NCT02945969.

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Conflict of interest statement

  1. Emma J McMahon: none known

  2. Katrina L Campbell: none known

  3. Judith D Bauer: none known

  4. David W Mudge: none known

  5. Jaimon T Kelly: JK reports consultancy fees from Amgen for travel and professional presentation unrelated to the submitted work.

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Studies were frequently assessed as having unclear or high risk of bias for the risk of bias study domains with selection bias, performance bias, detection bias, and confounding bias domains having the largest proportion of unclear/high risk of bias.
4
4
Funnel plot of comparison: 1 CKD stage, outcome: 1.1 Sodium intake/excretion [mmol/d].
5
5
Funnel plot of comparison: 1 CKD stage, outcome: 1.2 Systolic blood pressure [mm Hg].
6
6
Funnel plot of comparison: 1 CKD stage, outcome: 1.3 Diastolic blood pressure [mm Hg].
1.1
1.1. Analysis
Comparison 1: CKD stage, Outcome 1: Sodium intake/excretion
1.2
1.2. Analysis
Comparison 1: CKD stage, Outcome 2: Systolic blood pressure
1.3
1.3. Analysis
Comparison 1: CKD stage, Outcome 3: Diastolic blood pressure
1.4
1.4. Analysis
Comparison 1: CKD stage, Outcome 4: Proteinuria [ln mg/d]
1.5
1.5. Analysis
Comparison 1: CKD stage, Outcome 5: Albuminuria [ln mg/d]
1.6
1.6. Analysis
Comparison 1: CKD stage, Outcome 6: eGFR [mL/min/1.73 m2]
1.7
1.7. Analysis
Comparison 1: CKD stage, Outcome 7: Creatinine clearance
1.8
1.8. Analysis
Comparison 1: CKD stage, Outcome 8: Serum creatinine
1.9
1.9. Analysis
Comparison 1: CKD stage, Outcome 9: Filtration fraction
1.10
1.10. Analysis
Comparison 1: CKD stage, Outcome 10: Weight
1.11
1.11. Analysis
Comparison 1: CKD stage, Outcome 11: Inter‐dialytic weight gain
1.12
1.12. Analysis
Comparison 1: CKD stage, Outcome 12: Extracellular fluid volume
1.13
1.13. Analysis
Comparison 1: CKD stage, Outcome 13: Presence of oedema
1.14
1.14. Analysis
Comparison 1: CKD stage, Outcome 14: Plasma renin activity
1.15
1.15. Analysis
Comparison 1: CKD stage, Outcome 15: Aldosterone (plasma or serum)
1.16
1.16. Analysis
Comparison 1: CKD stage, Outcome 16: Reduction in antihypertensive dose
1.17
1.17. Analysis
Comparison 1: CKD stage, Outcome 17: Symptomatic hypotension
1.18
1.18. Analysis
Comparison 1: CKD stage, Outcome 18: Total cholesterol
2.1
2.1. Analysis
Comparison 2: Duration, Outcome 1: Sodium intake/excretion
2.2
2.2. Analysis
Comparison 2: Duration, Outcome 2: Systolic blood pressure
2.3
2.3. Analysis
Comparison 2: Duration, Outcome 3: Diastolic blood pressure
2.4
2.4. Analysis
Comparison 2: Duration, Outcome 4: Creatinine clearance
2.5
2.5. Analysis
Comparison 2: Duration, Outcome 5: Serum creatinine
2.6
2.6. Analysis
Comparison 2: Duration, Outcome 6: Weight
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Suckling 2016 {published data only}
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References to ongoing studies

NCT03373500 {published data only}
    1. Swift P. Effect of dietary salt reduction on blood pressure in kidney transplant recipients. clinicaltrials.gov/show/nct03373500 (first received 14 December 2017).
OxCKD1 2012 {published data only}
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References to other published versions of this review

McMahon 2012b
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