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Estimating 24-H Urinary Sodium Excretion from Casual Spot Urine Specimen Among Hypertensive Patients in Northwest China: the Salt Substitute and Stroke Study

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Estimating 24-H Urinary Sodium Excretion from Casual Spot Urine Specimen Among Hypertensive Patients in Northwest China: the Salt Substitute and Stroke Study Public Health Nutrition: 24(4), 604–610 doi:10.1017/S1368980019005019 Estimating 24-h urinary sodium excretion from casual spot urine specimen among hypertensive patients in Northwest China: the Salt Substitute and Stroke Study Yi Zhao1,†, Wanlu Liu1,†, Sha Liu1, Xiaoxia Li1, Ting Yin1, Xiuying Liu1, Faxuan Wang1, Xiaoyu Chang1, Tianjing Zhang2, Maoyi Tian3,4 and Yuhong Zhang1,* 1Public Health and Management School of Ningxia Medical University, Yinchuan City, Ningxia, China: 2The People’s Hospital of Anyang City, Anyang City, Henan Province, China: 3The George Institute for Global Health at Peking University Health Science Center, Haidian District, Beijing 100088, China: 4The George Institute for Global Health, University of New South Wales, Newtown, NSW 2042, Australia Submitted 25 February 2019: Final revision received 12 November 2019: Accepted 3 December 2019: First published online 29 April 2020 Abstract Objective: To develop an equation that can estimate the 24-h urinary Na excretion by using casual spot urine specimen for older hypertensive participants in rural Ningxia and further to compare with the INTERSALT method, Kawasaki method and Tanaka method. Design: Older hypertensive participants in rural Ningxia provided their casual spot urine samples and 24-h urine samples between January 2015 and February 2017. Sex-specific equation was developed using linear forward stepwise regression analysis. Model fit was assessed using adjusted R2. Approximately half of all participants were randomly selected to validate the equation. Mean differences, intraclass correlation coefficients and Bland–Altman plots were used to evaluate the performance of all methods. Setting: Pingluo County and Qingtongxia County in Ningxia Hui Autonomous Region, China. Participants: Older hypertensive participants in rural Ningxia. Results: Totally, 807 of 1120 invited participants provided qualified 24-h urine sam- ples and spot urine samples. There was no statistical difference comparing the laboratory-based method against the new method and the INTERSALT method, while Kawasaki method had the largest bias with a mean difference of 40·81 g/d (95 % CI – 39·27, 42·35 g/d). Bland Altman plots showed similar pattern of the results. Keywords Conclusion: The INTERSALT method and the new equation have the potential to 24-h urine estimate the 24-h urinary Na excretion in this study population. However, the Casual spot urine extrapolation of the results to other population needs to be careful. Future research Sodium is required to establish a more reliable method to estimate 24-h urinary Na Hypertensive patients excretion. Equation High Na intake is a modifiable risk factor for hypertension. recall and 24-h urine collection remain as the two widely Studies showed every 100 mmol/d of Na intake resulted in used methods to estimate population Na intake. 24-h dietary 5·8 and 3·8 mmHg increases in systolic and diastolic blood recall usually underestimated Na intake due to under- pressure, respectively(1,2). Excessive Na intake is also associ- reporting and intangible Na content in food(6).24-hurine ated with cerebrovascular diseases and gastric cancer(3,4). collection is considered as the gold standard to assess dietary World Health Organization recommended the daily Na Na intake(7), but it is expensive in large-scale population intake within 2 g (equivalent to 5 g of salt per d) for adults(5). survey and burdensome to participants. Previous studies There is an urgent need to establish a feasible solution to used casual spot urine specimen to replace 24-h urine to monitor the Na intake on a population level. 24-h dietary assess dietary Na intake(8–10). INTERSALT method, Kawasaki method and Tanaka method have been established to (11–13) †These authors contributed equally to this work. estimate 24-h urinary Na excretion from spot urine . *Corresponding author: Email [email protected] © The Authors 2020. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://www.cambridge.org/core. 27 Sep 2021 at 14:32:48, subject to the Cambridge Core terms of use. Estimate 24-h urine sodium excretion 605 However, whether these three methods are valid to Chinese urine. The spot urine was collected into a disposable urine rural hypertensive patients remains unknown. cup, and two 1·5 ml aliquots were removed. 24-h urine col- Therefore, the objectives of this study are to develop a lection started immediately after the spot urine collection method to estimate 24-h urinary Na excretion by using completed. The participants were provided with six 1-litre casual spot urine specimen in rural hypertensive patients plastic containers and instructed to collect all urine voided in Ningxia Hui Autonomous Region (thereafter ‘Ningxia’) during a 24-h period according to standard procedures. and further to compare this method with the other three Participants were asked to return all containers at the com- established methods. pletion of the 24-h urine collection. Interviewers recorded the start and end time of 24-h urine collection, the total urine volume and participant’s self-reported missed vol- Methods ume on a worksheet. 24-h urine specimens were excluded in any of the following conditions: (1) the first void of urine Study sites and participants in the morning was missed; (2) the missed volume reported This study was a sub-study of the current ongoing large- by the participant was over 10 % of the total volume; (3) the scale cluster randomised controlled trial: the Salt Substitute urine was contaminated or (4) the participant reported and Stroke Study. The trial was registered in clinicaltrial. vomiting or diarrhoea during the collection. In addition, gov (NCT02092090). A total of 120 villages from Pingluo samples were excluded from the analysis if 24-h creatinine < > < County and Qingtongxia County in Ningxia participated in excretion was 4mmolor 25 mmol in women or 6mmol > the Salt Substitute and Stroke Study trial. In each village, or 30 mmol in men. thirty-five individuals with high risk of stroke were recruited. The fieldwork was carried out between January 2015 The selection criteria of the participants included: (1) with and February 2017. Both spot urine and 24-h urine speci- – a history of stroke; (2) or age ≥ 60 years with uncontrolled mens were frozen at 20°C within 4 h after collection. high blood pressure (systolic blood pressure ≥ 140 mmHg Specimens were then shipped to a central laboratory in at visit if on blood pressure lowering medication or systolic Beijing for analysis. The concentration of urinary Na and blood pressure ≥ 160 mmHg at visit if not on blood pressure K was analysed using ion selective electrode method, lowering medication). A series of process indicators were and urinary creatinine was analysed using sarcosine oxidase measured in a random subset of individuals. Key indicators method with the HITACHI 7600 automated biochemistry include blood pressure, medication use, urinary Na and uri- analyzer. Weight, height and blood pressure were measured ’ nary K measured from the 24-h urine and spot urine sam- according to a standardised protocol. Participants demo- ples. The process indicators were collected from a random graphic information was also collected. sample of twenty individuals drawn from a stratified random sample of at least six villages in each county (three from the intervention group and three from the control group). In Statistical analysis ± each village, a randomised list of participants was generated. Continuous variables were described as mean SD, while cat- Interviewers invited the first twenty participants from the list egorical variable were described as proportions (%). Spot to participate the survey. If anyone from the list was unable urine Na concentration (Naspot), spot urine K concentration to take part in, the interviewer will move to the next available (Kspot), spot urine creatinine concentration (Crspot), age, participant. Participants with the following conditions weight, height and BMI were used in the regression analysis were excluded from the urine collection: (1) urinary incon- to develop the new method. Age, weight, height and BMI are tinence; (2) unable to collect urine on its own and cannot influence factors on volume of urinary, and creatinine con- (16) find help from others; (3) acute or chronic urinary tract infec- centration is thought to be constant throughout the day . tion, vaginal infection and perianal infection; (4) acute or The factors mentioned above were included in published chronic urinary tract, vaginal and gastrointestinal bleeding; predictive equations: the INTERSALT equation, Kawasaki (11–13,17) ’ (5) females who were pregnant, breast-feeding or during equation and Tanaka equation . All participants data menstruation (only allowed to participate after 2 d when were defined as the test data set to develop the sex-specific their period was clear); (6) vomiting or diarrhoea. The proc- equations. Approximately 50 % of all participants were ess indicator survey was repeated every 12 months through- randomly selected as validation data set to verify the equa- out the follow-up. Details of the Salt Substitute and Stroke tions. All regression analyses were linear forward stepwise 2 Study trial were published elsewhere(14,15). regression analysis. Adjusted R was used to assess the model fitting. The performance of all methods was determined by Specimen collection and analysis comparing the laboratory-based method against the new At each process indicator survey, participants were invited method, INTERSALT method, Kawasaki method and to collect both casual spot urine and 24-h urine samples. Tanaka method. Mean difference, intraclass correlation Participants were asked to provide a casual spot urine coefficient and Bland–Altman plots were used to evaluate specimen (midstream urine) before the collection of 24-h the agreement(18). All statistical analyses were performed Downloaded from https://www.cambridge.org/core.
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