Dietary salt reduction in the general population lowers blood pressure and cardiovascular risk. Despite being widely recommended, there is limited evidence as to whether this is applicable to individuals with end-stage renal disease (ESRD) receiving dialysis. Therefore, we carried out a systematic review and meta-analysis of randomised controlled trials (RCTs) investigating dietary salt reduction in individuals receiving dialysis. Studies were identified through search strategies for CENTRAL, MEDLINE, and EMBASE. Two authors independently assessed studies for eligibility with the inclusion criteria as follows: participants aged 18 years and over; a reduction in salt intake of at least 1 g/day over one week; no concomitant interventions during the study. The primary outcome was change in systolic and diastolic blood pressure. 848 reports were screened, from which 12 studies were selected for the systematic review. Four were RCTs (91 participants) that met the study inclusion criteria: three were conducted in haemodialysis patients and one in peritoneal dialysis patients; three were crossover trials and one was a parallel study. Dietary salt reduction was associated with an 8.4 mmHg reduction in systolic blood pressure (95% CI 4.8–12.0, Ι2 = 0%), and a 4.4 mmHg reduction in diastolic blood pressure (95% CI 2.2–6.6, Ι2 = 0%). In conclusion, few studies have investigated the role of dietary salt reduction in individuals with ESRD receiving dialysis, but these results suggest the importance of this intervention for lowering blood pressure in this group.
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Rao A, Pitcher D, Farrington K. UK Renal Registry 16th Annual Report: blood pressure profile of prevalent patients receiving renal replacement therapy in 2012: national and centre-specific analysis. Nephron Clin Pract. 2013;125:209–218.
Agarwal R, Flynn J, Pogue V, Rahman M, Reisin E, Weir MR. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol. 2014;25:1630–1646.
Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010;55:762–768.
Byrne C, Caskey F, Castledine C, Dawnay A, Ford D, Fraser S et al. UK Renal Registry: 19th report of the Renal Association. Nephron. 2017; 137 (Suppl 1).
Saran R, Robinson B, Abbott KC, Agadoa LY, Albertus P, Ayanian J, et al. US Renal Data System 2017 Annual Data Report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2017;69(Suppl. 1):S1–S688.
Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int. 1996;49:1379–1385.
Comty C, Rottka H, Shaldon S. Blood pressure control in patients with end-stage renal failure treated by intermittent haemodialysis. Proc EDTA. 1964;1:209–220.
Levin NW, Kotanko P, Eckardt KU, Kasiske BL, Chazot C, Cheung AK, et al. Blood pressure in chronic kidney disease stage 5D-report from a kidney disease: Improving Global Outcomes controversies conference. Kidney Int. 2010;77:273–284.
Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens. 2017;35:657–676.
He FJ, Li J, Macgregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev. 2013;4:CD004937.
McMahon EJ, Campbell KL, Bauer JD, Mudge DW. Altered dietary salt intake for people with chronic kidney disease. Cochrane Database Syst Rev. 2015;2:CD010070.
Farmer C, Donohoe P, Dallyn P, Cox J, Kingswood J, Goldsmith D. Low-sodium haemodialysis without fluid removal improves blood pressure control in chronic haemodialysis patients. Nephrology. 2000;5:237–241.
Chazot C, Charra B, Laurent G, Didier C, Vo Van C, Terrat JC, et al. Interdialysis blood pressure control by long haemodialysis sessions. Nephrol Dial Transplant. 1995;10:831–837.
Krautzig S, Janssen U, Koch KM, Granolleras C, Shaldon S. Dietary salt restriction and reduction of dialysate sodium to control hypertension in maintenance haemodialysis patients. Nephrol Dial Transplant. 1998;13:552–553.
Özkahya M, Ok E, Cirit M, Aydin Ş, Akçiçek F, Başçi A, et al. Regression of left ventricular hypertrophy in haemodialysis patients by ultrafiltration and reduced salt intake without antihypertensive drugs. Nephrol Dial Transplant. 1998;13:1489–1493.
Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions, version 5.1.0 (London: The Cochrane Collaboration; 2011).
Catto G, Smith F, MacLeod M. Treatment of muscle cramps during maintenance haemodialysis. Br Med J. 1973;3:389–390.
Doulton TWR, Cassidy A, Wood M, Markandu ND, MacGregor GA. Reducing daily salt intake by ~6 grams leads to decreased thirst, less inter-dialytic weight gain and lower blood pressure in HD patients [Abstract]. The Renal Association Annual Conference 2007, Brighton, United Kingdom. http://www.renalarchive.org/. Accessed 01 Jul 2018.
Fine A, Fontaine B, Ma M. Commonly prescribed salt intake in continuous ambulatory peritoneal dialysis patients is too restrictive: results of a double-blind crossover study. J Am Soc Nephrol. 1997;8:1311–1314.
Rodrigues Telini LS, de Carvalho Beduschi G, Caramori JC, Castro JH, Martin LC, Barretti P. Effect of dietary sodium restriction on body water, blood pressure, and inflammation in hemodialysis patients: a prospective randomized controlled study. Int Urol Nephrol. 2014;46:91–97.
Maduell F, Navarro V. Dietary salt intake and blood pressure control in haemodialysis patients. Nephrol Dial Transplant. 2000;15:2063.
Craswell PW, Hird VM, Judd PA, Baillod RA, Varghese Z, Moorhead JF. Plasma renin activity and blood pressure in 89 patients receiving maintenance haemodialysis therapy. Br Med J. 1972;4:749–753.
Nerbass FB, Morais JG, dos Santos RG, Kruger TS, Sczip AC, da Luz, et al. Factors associated to salt intake in chronic hemodialysis patients. J Bras Nefrol. 2013;35:87–92.
Wu PY, Yang SH, Wong TC, Chen TW, Chen HH, Chen TH, et al. Association of processed meat intake with hypertension risk in hemodialysis patients: a cross-sectional study. PLoS One. 2015;10:e0141917.
Chen W, Cheng LT, Wang T. Salt and fluid intake in the development of hypertension in peritoneal dialysis patients. Ren Fail. 2007;29:427–432.
Cheng LT, Wang T. Changes in total sodium intake do not lead to proportionate changes in total sodium removal in CAPD patients. Perit Dial Int. 2006;26:218–223.
Kurasawa N, Mori T, Naganuma E, Sato E, Koizumi K, Sato S, et al. Association between home blood pressure and body composition by bioimpedance monitoring in patients undergoing peritoneal dialysis. Adv Perit Dial. 2015;31:38–44.
Mc Causland FR, Waikar SS, Brunelli SM. Increased dietary sodium is independently associated with greater mortality among prevalent hemodialysis patients. Kidney Int. 2012;82:204–211.
Kalantar-Zadeh K, Tortorici AR, Chen JL, Kamgar M, Lau WL, Moradi H, et al. Dietary restrictions in dialysis patients: is there anything left to eat? Semin Dial. 2015;28:159–168.
Sevick MA, Piraino BM, St-Jules DE, Hough LJ, Hanlon JT, Marcum ZA, et al. No difference in average interdialytic weight gain observed in a randomized trial with a techonology-supported behavioral intervention to reduce dietary sodium intake in adults undergoing maintenance hemodialysis in the United States: primary outcomes of the BalanceWise Study. J Ren Nutr. 2016;26:149–158.
We thank Professor Norman Campbell for his critical review of the analysis.
Conflict of interest
FJH is a member of Consensus Action on Salt & Health (CASH) and World Action on Salt & Health (WASH). Both CASH and WASH are non-profit charitable organisations and FJH does not receive any financial support from CASH or WASH. GAM is Chairman of Blood Pressure UK (BPUK), Chairman of CASH, WASH and Action on Sugar (AoS). BPUK, CASH, WASH and AoS are non-profit charitable organisations. GAM does not receive any financial support from any of these organisations. The remaining authors declare that they have no conflict of interest.
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Cole, N.I., Swift, P.A., He, F.J. et al. The effect of dietary salt on blood pressure in individuals receiving chronic dialysis: a systematic review and meta-analysis of randomised controlled trials. J Hum Hypertens 33, 319–326 (2019). https://doi.org/10.1038/s41371-018-0131-5