Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2026 Jan 1;7(1):94-106.
doi: 10.34067/KID.0000000943. Epub 2025 Aug 8.

Urinary Sodium and Potassium Excretion and the Risk of Cardiovascular Events in CKD

Cass G G Sunga  1 , Leila R Zelnick  2   3 , Nisha Bansal  2   3
Affiliations

Urinary Sodium and Potassium Excretion and the Risk of Cardiovascular Events in CKD

Cass G G Sunga et al. Kidney360. .

Abstract

Key Points:

  1. A high urinary sodium-to-potassium ratio is associated with incident cardiovascular disease in individuals with CKD.

  2. Dietary sodium and potassium intake represent potential modifiable risk factors for cardiovascular disease prevention in kidney disease.

  3. Further research is needed to determine whether this relationship is causal in nature.

Background: Kidney disease is a known, independent driver of cardiovascular disease (CVD). While dietary sodium and potassium intake, approximated through urinary excretion, are known cardiac risk factors in the general population, their role for prevention in persons with kidney disease is unclear. Thus, we studied the relationship between the ratio of urinary sodium-to-potassium (Na:K) excretion and incident CVD in individuals with CKD.

Methods: We included 2342 adults with CKD enrolled in the Chronic Renal Insufficiency Cohort free of CVD on study entry. Urinary sodium and potassium were measured through 24-hour urine collection at the baseline visit. Primary study outcomes included atrial fibrillation (AF), heart failure (HF; overall, HF reduced ejection fraction [HFrEF] and HF preserved ejection fraction), and myocardial infarction (MI). Incidence rates (with 95% confidence intervals [CIs]) were calculated per 1000 person-years. Nested models were created using Cox regression and adjusted for sociodemographic data (age, sex and race/ethnicity), lifestyle habits (body mass index and cigarette smoking), medication use, medical comorbidities, and renal characteristics.

Results: Among the study population, mean (SD) age was 56 (11) years, and mean eGFR was 51 (20) ml/min per 1.73 m2. The highest quartile (versus lowest quartile) of urinary Na:K ratio was associated with a 1.4-fold increased risk of overall HF (hazard ratio [HR], 1.44; 95% CI, 1.05 to 1.98), 1.9-fold increased risk of HFrEF (HR, 1.90; 95% CI, 1.08 to 3.36), and 1.5-fold increased risk of AF (HR, 1.48; 95% CI, 1.03 to 2.13) after adjustment for the covariates above. We did not find an association with incident MI (HR, 1.14; 95% CI, 0.78 to 1.68) and HF preserved ejection fraction (HR, 1.18; 95% CI, 0.75 to 1.87).

Conclusions: A higher ratio of urinary Na:K excretion was associated with incident AF and HF (particularly HFrEF), but not MI, in persons with CKD. Dietary sodium and potassium represent possible modifiable risk factors for CVD prevention in individuals with kidney disease.

Trial registration: ClinicalTrials.gov NCT03253172.

Keywords: cardiovascular.

PubMed Disclaimer

Conflict of interest statement

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/B210.

Figures

None
Graphical abstract
Figure 1
Figure 1
Unadjusted incidence rates of cardiovascular events by quartile of urinary Na:K excretion. HFpEF, heart failure preserved ejection fraction; HFrEF, heart failure reduced ejection fraction; Na:K, sodium-to-potassium.
Figure 2
Figure 2
Functional form of unadjusted associations of urinary Na:K excretion with incident cardiovascular outcomes. CI, confidence interval; HR, hazard ratio.
See this image and copyright information in PMC

References

    1. Tonelli M Wiebe N Culleton B, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006;17(7):2034–2047. doi: 10.1681/ASN.2005101085 - DOI - PubMed
    1. Gansevoort RT Correa-Rotter R Hemmelgarn BR, et al. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. Lancet. 2013;382(9889):339–352. doi: 10.1016/S0140-6736(13)60595-4 - DOI - PubMed
    1. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu C-y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296–1305. doi: 10.1056/NEJMoa041031 - DOI - PubMed
    1. Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol. 1998;9(12 suppl):S16–S23. PMID: 11443763 - PubMed
    1. Kazi DS Elkind MSV Deutsch A, et al. Forecasting the economic burden of cardiovascular disease and stroke in the United States through 2050: a presidential advisory from the American Heart Association. Circulation. 2024;150(4):e89–e101. doi: 10.1161/CIR.0000000000001258 - DOI - PubMed

Associated data