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23
A formula to detect elevated sodium excretion levels
The difference between measured and excreted Figure 2. ROC curve showing sensitivity and specificity of measured
vs. estimated sodium excretion at a cutoff point of 3.6 g/day.
sodium was -0.01 g/day (Figure 1). The correlation
between measured and estimated sodium excretion
was moderate (r = 0.57; p < 0.001), but the P30 test
revealed that the accuracy of the formula was low
(61%). Therefore, sensitivity, specificity, PPV, and
NPV were calculated for the chosen cutoff points
(2.4, 3.6 and 4 g/day) in order to assess the ability of
the formula to identify individuals with sodium intake
above recommended levels, as shown in Table 2.
collected differed (first vs. second urine of the day) salt daily.28 Unlike wealthy nations, most of the sodium
and a number of other factors may have influenced available in Brazilian households comes from cooking
the formulas poor performance with our patient salt and salt-based condiments (74.4%).28
population. To name a few, the Brazilian study The differences related to the time of urine
included patients diagnosed with CKD of other specimen collection were tested in a cross-sectional
stages and, more importantly, sodium intake was study enrolling patients with pre-dialysis stage
significantly higher than that of the British study CKD, in which three urine samples were collected at
population (4.2 1.6 vs. 2.8 1.4 g/day). different times (morning, afternoon, and evening);
The formula published in the RRID study was the best correlation with 24-hour urinary sodium was
developed to estimate the sodium intake levels of obtained when the mean sodium level as calculated
more than 1,700 patients who were not offered for the samples taken at different times (r = 0.48;
24-hour urine specimen collection. Similarly to our p < 0.001) versus when the isolated samples were
study, the accuracy of their formula was low (P30 = analyzed separately.22
60%), but the sensitivity to detect individuals with The limitations of this study include the relatively
sodium intake above the recommended level of 2.4 g/ small population enrolled in the study, the use of
day was equally high (85%). one single urine specimen collected the day after the
Thus, in the subsequent analyses, sodium intake collection of the 24-hour urine specimen, and the lack
was granted the status of categorical variable, which of validation of the formula for other populations.
meant patients were divided into groups of individuals Additionally, we were unable to assess the adequacy
with adequate (up to 2.4 g/day) or excessive (> 2.4 g/ of the 24-hour urine specimen collection based on the
day) sodium intake levels.23 The determining factors urine creatinine/weight ratio, as we ran into technical
connected to excessive sodium intake were identified,17 problems when trying to measure this variable. However,
as well as the relationships with risk factors for renal the verification performed, the urine volumes and sodium
disease progression and cardiovascular disease26 and excretion levels consistent with those of the Brazilian
the effects of decreasing sodium intake to adequate population support the idea that specimen collection was
levels after one year of follow-up.27 performed adequately by the participants.
The observed results (and the relationships with
blood pressure and urinary protein) were similar Conclusion
to the ones of better controlled studies,7,12 in which In conclusion, a simple formula was developed to
24-hour urinary sodium was also used as part of identify individuals with sodium intake levels above
the method, thus reinforcing the reliability of this 3.6 g/day (9g of cooking salt). More studies are
assessment method. required to assess the performance of this method in
In our study, only 12% of the patients presented other populations.
sodium intake below recommended levels (2.4 g/
day), while in the RRID study 42% of the individuals Acknowledgements
complied with the recommendations. This fact may
have precluded the use of the same cutoff point, since This study received funding from CNPq and CAPES
specificity was 0%, i.e., the formula was unable to detect in the form of research scholarships offered to FBN,
patients with sodium intake levels below 2.4 g/day. AECH and RPF; the study was received funds from
Therefore, as most participants had sodium intake the PPSUS Program - Fundao Araucria.
levels well above the recommendation, using a higher
cutoff point for sodium intake may be more useful
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