Original Article

Association Between Protein Intake and Mortality in

Hypertensive Patients Without Chronic Kidney Disease in
the OLD-HTA Cohort
Pierre-Yves Courand,* Chloé Lesiuk,* Hugues Milon, Alice Defforges, Denis Fouque,
Brahim Harbaoui, Pierre Lantelme

Abstract—Protein intake may have some benefits on reducing blood pressure and cardiovascular events, but their effects
are still debated. The objective of this study was to test the prognostic value of protein intake assessed by 24-hour
urinary urea in a cohort of hypertensive patients with preserved renal function. A total of 1128 hypertensive patients
were followed according to tertile of protein intake adjusted for ideal body weight: <0.70, 0.70 to 0.93, and >0.93
g/kg. Baseline characteristics (mean±standard deviation) were age 45.1±13.2 years, systolic/diastolic blood pressure
185±32/107±20 mm Hg, and estimated glomerular filtration rate 82±32 mL/min. After 10 years of follow-up, 289 deaths
occurred, 202 of which were of cardiovascular cause. After adjustment for major cardiovascular risk factors, patients
in the second and third tertiles of protein intake had a decreased risk of all-cause death (hazard ratio [95% confidence
interval], 0.71 [0.56–0.91]) and cardiovascular death (0.72 [0.54–0.96]), but not of stroke death (0.72 [0.41–1.28])
in comparison to patients in the low protein intake tertile. Normal–high protein intake was associated with a better
outcome in a subset of the population: younger patients, low salt intake, without aortic atherosclerosis, or previous
cardiovascular events (Pinteraction<0.10 for all). Hypertensive patients having a protein intake >0.7 g/kg ideal body weight,
particularly those at low risk, had lower all-cause and cardiovascular mortality rates. Physicians may encourage hyper­
tensive patients to have normal or high protein diet in addition to low salt consumption, moderate alcohol consumption,
and regular physical activity.  (Hypertension. 2016;67:00-00. DOI: 10.1161/HYPERTENSIONAHA.116.07409.)
• Online Data Supplement
Key Words: blood pressure ■ hypertension ■ lifestyle changes ■ mortality ■ protein intake ■ stroke

A ppropriate lifestyle changes are recommended in current

practice guidelines as the cornerstone of prevention for
hypertension.1 Salt restriction, moderation of alcohol con-
sumption, high consumption of fruits and vegetables, weight
reduction, and regular physical exercise have demonstrated
their capacity to reduce blood pressure (BP).2 In patients with
chronic kidney disease, a low protein diet (0.6–0.7 g/kg per
day) reduces renal death.3,4 Much less is known about the effect
of protein intake in hypertensive patients without chronic kid-
ney disease; although it may be associated with changes in BP,
the results are controversial. In cross-sectional studies and in
short-term randomized controlled trials, high protein intake has
been associated with BP reduction,5 but results testing the link
between protein intake and incidence of hypertension are also
controversial.6,7 Protein intake may also be associated with car-
diovascular events, with a high consumption associated with a
protective effect against stroke in the general female popula-
tion.8 A frequent limitation of these studies is the various and
often unreliable methods in which protein intake is quantified,
with the use of food frequency questionnaires, 24-hour dietary
recall, and urinary urea concentration on a spot urine,9 whereas
the current gold standard to assess protein intake is 24-hour
urinary urea excretion.
The recommended amount of protein to be consumed by
healthy adults is currently 0.8 to 1.0 g/kg, but protein intake
in western countries currently far exceeds normal require-
ments (1.3–1.4 g/kg).10 To our knowledge, the prognostic
significance of protein intake in patients with hypertension
has never been properly addressed. Thus, the objective of the
present study was to test the prognostic value (in terms of
all-cause, cardiovascular, and stroke death) of protein intake
assessed by 24-hour urinary urea in a cohort of hypertensive

Received February 23, 2016; first decision March 2, 2016; revision accepted March 12, 2016.
From the Cardiology Department, European Society of Hypertension Excellence center, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, F-69004,
Lyon, France (P.-Y.C., C.L., H.M., A.D., B.H., P.L.); Université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Claude
Bernard Lyon 1, Hospices Civils de Lyon, France (P.-Y.C., B.H., P.L.); and Department of Nephrology and Nutrition, Hôpital Lyon Sud, Hospices Civils
de Lyon, CARMEN, CENS, Université Claude Bernard Lyon 1, F-69310, Pierre-Bénite, France (D.F.).
*These authors contributed equally to this work and are joint first authors.
The online-only Data Supplement is available with this article at http://hyper.ahajournals.org/lookup/suppl/doi:10.1161/HYPERTENSIONAHA.
116.07409/-/DC1.
Correspondence to Pierre-Yves Courand, Cardiology Department, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, F-69004, Lyon,
France. E-mail pycourand@hotmail.com
© 2016 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.116.07409

1 at Tulane University on April 20, 2016

Downloaded from http://hyper.ahajournals.org/
2  Hypertension  June 2016
patients. As some conditions, such as renal function and car-
diovascular remodeling, may exert a modifying effect, the
interaction with several metabolic or organ damage variables
was also tested.
Methods
Patients
The OLD-HTA Lyon cohort has been described.11 Briefly, 1152
patients were hospitalized between 1969 and December 1976 in the
Cardiology Department at Louis Pradel Hospital (Lyon, France) for
a work-up of their hypertension. Twenty-four patients were lost to
follow-up and were excluded, leaving a study population of 1128
hypertensive inpatients with a 24-hour urinary collection form. Of
these patients, 1092 also had a spot urine collection and 539 com-
pleted a food frequency questionnaire.
All patients provided oral consent to participate in the study, in
accordance with the French regulation prevailing in the 1970s. The
study was approved by the Commission Nationale Informatique et
Liberté. Under French law, as mentioned in several published techni-
cal notes in line with European directives, only the approval of the
Commission is required for single-center observational usual-care
studies, such as this one. The vital status query was approved by na-
tional authorities before data extraction by the Institut National de la
Statistique et des Etudes Economiques.
Baseline Work-Up
A standardized form was completed for all patients, which collected
data on various morphometric characteristics, risk factors for cardio-
vascular events (smoking status, alcohol intake, salt consumption,
etc), history of cardiovascular disease, current medication, and known
symptoms. A food frequency questionnaire was also completed for
half of the cohort.
Smoking status was based on current tobacco consumption or
consumption stopped <5 years previously. BP was measured with
a manual sphygmomanometer with the patient in the supine posi-
tion. Systolic BP, diastolic BP, and pulse pressure were the aver-
age of 6 measurements. A 12-lead ECG was performed with the
patient in the supine position. An ophthalmoscopic fundus exami-
nation of the right eye was performed after pharmacological pupil
dilation to detect signs of hypertensive retinopathy. A consensual
classification of hypertensive retinopathy was made by 2 trained
cardiologists according to the 4-grade classification of Keith,
Wagener, and Barker.12
An overnight fasting blood sample was drawn for hemogram and
plasma measurements (electrolytes, creatinine, glucose, and total
cholesterol). Diabetes mellitus was retrospectively defined as either a
fasting glucose measuring ≥1.26 g/L (≥7.9 mmol/L) on 2 separate oc-
casions or current use of antidiabetic medication. Renal function was
estimated using the Modification in Diet in Renal Disease formula.
Between the second and the third day of hospitalization, 24-hour
urine (n=1128) and a spot urine (n=1092) were collected and urinary
sodium, potassium, urea, and albumin measured.
Previous cardiovascular diseases included history of heart failure
(clinical or chest X-ray findings, such as dyspnea, edema, cardio-
megaly, or pulmonary congestion), coronary artery disease (clini-
cal findings, such as angina pectoris or myocardial infarction, or
Q wave on ECG), peripheral artery disease (walking impairment
or pain at rest), and stroke (clinical findings). Target organ damage
was defined as electric left ventricular hypertrophy in the case of
a Sokolow index >3.5 mV, a simplified 3-grade classification for
hypertensive retinopathy (none for grade 0, mild for grades 1 and
2, and severe for grades 3 and 4)12 and albuminuria >300 mg/d as-
sessed on 24-hour analysis.
Detailed data on aortography have been described.13,14 In brief,
patients were classified according to a simplified 2-modality score:
absence of atherosclerosis (aortic atherosclerosis) when aortography
showed absent or mild atherosclerosis and presence of atherosclerosis
for patients with moderate or severe lesions.
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Assessment of Protein Intake
Total protein intake (PInt) was estimated from 24-hour urinary urea
excretion by the method of Maroni et al.15 We used the following
equation to determine PInt in g/24 hour:
P int = ( urinary urea × 0.1750125) + proteinuria
+ ( body weight × 0.193755)
Urinary urea is expressed in mmol/24 hour, proteinuria in g/24
hour, and body weight in kg. PInt was finally adjusted for ideal body
weight (IBW) to standardize this protein intake and is expressed
in g/kg per day. The IBW was derived from the real height us-
ing a body mass index (BMI) value of 22 kg/m2 as the reference.
Multivariable Cox regression model was also performed with real
body weight. In a subset of patients with spot urine available, pro-
tein intake was estimated based on crude urinary urea concentra-
tion in mmol/L.
The food frequency questionnaire used to assess diet at base-
line encompassed 5 items. In this questionnaire, participants
detailed how often they consumed bread, cheese, ham, or other
delicatessen, meat, and milk each week. Protein intake was calcu-
lated according to the protein content and the frequency of con-
sumption of these foodstuffs using composition values from the
ANSES (Agence Nationale de Sécurité Sanitaire alimentation,
environnement, travail) database (https://www.anses.fr/fr/content/
les-proteines).
Assessment of Outcomes
Deaths at 10 years of follow-up were obtained from the Répertoire
National d’Identification des Personnes Physiques (a directory
maintained by the Institut National de la Statistique et des Etudes
Economiques). A follow-up of 10 years was selected to balance the
need to have enough events to provide the statistical power to assess
a meaningful association, while avoiding a weakening of the deter-
minant effect with time. Causes of death were then coded from the
death certificates, as provided by INSERM SC8, according to the
International Classification of Diseases, Ninth Revision. All subjects
not officially declared dead were considered to be alive at the end of
follow-up.
The end points used in this study were all-cause death (cardiovas-
cular and noncardiovascular, including sudden death), cardiovascu-
lar death (from cerebrovascular disease, myocardial infarction, heart
failure, or renal death), and stroke death as classified by the French
national CépiDC (Center d’Epidémiologie sur les Causes Médicales
de Décès).16
Statistical Analysis
Continuous variables with close to normal distributions are sum-
marized as mean±standard deviation. Continuous variables with
skewed distributions are summarized as median (interquartile range).
Categorical variables are expressed as percentages.
Appropriate tests (analysis of variance or χ2) were used to compare
the characteristics of subgroups. Correlations were assessed with a
linear regression analysis (Pearson’s coefficient of correlation r) af-
ter logarithmic transformation, if appropriate. Multiple regression
analysis (forward stepwise) included variables with a P value <0.10
in univariate analysis.
The prognostic value of PInt/IBW was first examined in the whole
cohort using tertiles (<0.70, 0.70–0.93, and >0.93 g/kg). The times to
all-cause, cardiovascular, and stroke death were analyzed by Kaplan–
Meier curves, and these curves were compared using the log-rank
test. In a second step, adjusted hazard ratios for PInt/IBW were calcu-
lated as categorical variables (tertiles and the recommended threshold
of protein intake at 0.8 g/kg by public health17) and as a continuous
variable in univariate analysis and in a multivariable Cox regression
model. The proportional hazard hypothesis was tested by introducing
a variable-by-time interaction into the Cox regression model. Two
multivariable Cox regression models were used: model 1 was built
with potential confounding dietary variables such as plasma total
 Courand et al   Protein Intake and Hypertension   3

cholesterol, plasma triglycerides, salt consumption, 24-hour urinary
potassium excretion, and fasting glucose; model 2 was adjusted for
the usual cardiovascular risk factors, including age, sex, systolic BP,
smoking status, diabetes mellitus, total cholesterol, estimated glo-
merular filtration rate, BMI, antihypertensive treatment, and previous
cardiovascular disease.
Sensitivity analyses were performed with the 2 same multivariable
Cox regression models, after the exclusion of patients with secondary
hypertension (n=856 remaining), and after exclusion of patients who
died in the first 2 years (n=1034 remaining).
The modifying effect of the following variables on the prog-
nostic value of PInt/IBW in model 2 was assessed with (1) demo-
graphic variables such as sex and age (median value at 46 years);
(2) cardiovascular variables, that is, systolic BP (median value at
180 mm Hg), diastolic BP (median value at 107 mm Hg), aortic
atherosclerosis condition, hypertensive retinopathy, previous car-
diovascular disease; and (3) metabolic variables, that is, diabetes
mellitus condition, BMI (normal or overweight patients with a
threshold value at 25 kg/m2), salt intake (median value at 6 g/d),
and total cholesterol (median value at 2.2 g/L). Interactions were
tested for all these conditions.
The analyses were performed with the SPSS 20.0.0 program
(SPSS, Chicago). A P value of <0.05 was considered as statistically
significant, except for the test of interaction in which case a P value
of <0.10 was retained for statistical significance.
Results
Patient Baseline Characteristics and Outcomes
As indicated in Table 1, BP was markedly elevated (180/107
mm Hg) and a history of cardiovascular disease was present
in 27.6% of patients. Half of the patients were receiving at
least one antihypertensive drug at baseline: thiazide diuret-
ics (34.5%), centrally acting drugs (30.3%), antialdosterone
(13.2%), and β-blockers (3.7%). With respect to underlying
cause, 76.8% of patients had essential hypertension, 5% had

Table 1.  Baseline Characteristics of the Whole Cohort According to Tertile of Protein Intake
1st Tertile, <0.70 g/kg 2nd Tertile, 0.70–0.93 3rd Tertile, >0.93 g/kg
Characteristics All (n=1128) (n=376) g/kg (n=376) (n=376) P Value
General variables
 Mean age, y 45.1±13.2 45.7±13.3 45.3±13.6 44.3±12.6 0.30
 Ratio women/men 42.1/57.9 42.3/57.7 45.2/54.8 39.4/60.6 0.27
 Current smoking 49.0 47.9 49.1 49.3 0.91
 Body mass index, kg/m 2
25.0 (22.3–28.0) 24.4 (21.7–27.2) 25.0 (22.4–28.0) 25.8 (22.7–29.0) 0.46
Cardiac variables
 Systolic blood pressure, mm Hg 185±32 186±32 184±32 184±32 0.61
 Diastolic blood pressure, mm Hg 107±20 109±22 107±19 107±20 0.46
 Pulse pressure, mm Hg 75 (60–90) 75 (60–90) 74 (62–90) 73 (60–92) 0.86
Medical variables
 Left ventricular hypertrophy 23.8 29.2 21.2 24.9 0.048
 Retinopathy grades III–IV 18.6 20.2 16.5 19.1 0.40
 Diabetes mellitus 15.4 15.4 17.0 14.4 0.60
 History of heart failure 12.8 12.5 13.3 12.5 0.93
 Coronary artery disease 7.6 8.8 7.4 6.9 0.62
 Peripheral artery disease 3.2 2.9 4.3 2.7 0.42
 Stroke 9.8 10.6 8.0 10.9 0.33
 Antihypertensive treatment 44.5 44.7 46.3 43.6 0.44
Biochemical variables
 24-h protein intake, g/kg 0.85±0.15 0.51±0.15 0.82±0.07 1.24±0.37
 eGFR, mL/min 81 (64–98) 77 (62–97) 82 (64–97) 83 (67–100) 0.06
 Kalemia, mmol/L 3.7±0.5 3.6±0.5 3.7±0.6 3.7±0.5 0.09
 Natremia, mmol/L 141±4 141±4 141±4 141±3 0.12
 24-h albuminuria, mg 8±34 11±43 7±36 5±18 0.033
 24-h urinary sodium excretion, mmol 109±68 85±59 110±54 132±80 <0.001
 24-h urinary potassium excretion, mmol 38±20 36±20 39±20 40±19 0.020
 Triglycerides, g/L 1.1 (0.8–1.6) 1.1 (0.8–1.6) 1.1 (0.8–1.6) 1.1 (0.8–1.5) 0.79
 Total cholesterol, g/L 2.2 (2.0–2.5) 2.2 (1.9–2.5) 2.1 (1.9–2.4) 2.3 (2.0–2.5) 0.28
Unless otherwise stated, data are presented as percent, mean±SD, or median (interquartile range). P values indicate significance levels between the 3 subgroups.
eGFR indicates estimated glomerular filtration rate.

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4  Hypertension  June 2016
Figure 1. Kaplan–Meier survival curves for all-cause mortality (A), cardiovascular mortality (B), and stroke mortality (C), relative to 24-hour
protein intake assessment, adjusted to ideal body weight according to tertiles.
renal artery stenosis, and 5% had renal parenchymal disease,
whereas primary aldosteronism and aortic coarctation were
encountered in <3% of cases each.
Table 1 shows the classification into tertiles of patients
according to their PInt/IBW: first tertile <0.70 (0.51±0.15),
second tertile 0.70 to 0.93 (0.82±0.07), and third tertile >0.93
(1.24±0.37) g/kg/d. These subgroups illustrated, respectively,
baseline low, normal, and high protein diets. Baseline charac-
teristics in term of demographics, cardiac, and medical data
were similar among tertiles. An increased protein intake was
associated with higher salt and potassium intake consumption
and a lower albuminuria.
PInt/IBW was slightly correlated with spot urine protein
intake adjusted for IBW (r=0.218, P<0.001, n=1092) and
with food frequency questionnaire protein intake assessment
adjusted for IBW (r=0.105, P=0.015, n=539; Figure S1 in
the online-only Data Supplement). PInt/IBW was statistically
positively correlated with BMI, renal function, kalemia,
total cholesterol, plasma urea, and 24-hour urinary sodium
excretion and negatively correlated with plasma creatinine
(Table S1). In multivariable regression analysis, all of these
variables except kalemia remained correlated with PInt/IBW
(Table S2).
After a 10-year follow-up, there were 289 deaths, 202 of
which were from a cardiovascular cause (including 50 acute
stroke deaths and 25 renal deaths).
Survival Analysis in the Whole Cohort
As shown in the Kaplan–Meier curves, after 10 years of
follow-up, the survival rates decreased for patients in the
lowest tertile of PInt/IBW for all-cause mortality (P=0.008;
Figure 1A) and for cardiovascular mortality (P=0.029;
Figure 1B). No significant difference was observed for stroke
mortality (P=0.29; Figure 1C).
Table 2 shows the results from the univariate and mul-
tivariable Cox regression analyses for all-cause, cardiovas-
cular, and stroke death. Overall, patients in the second and
third tertiles had a decreased risk of all-cause and cardio-
vascular death in comparison with those in tertile 1. No
significant effect was observed for stroke deaths. After
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adjustment, the results were essentially the same, albeit
some limited statistical differences were observed for
stroke mortality (only in multivariable model 1). Similar
results were observed after adjustment for the real body
weight of patients (Table S3).
Sensitivity Analyses
After exclusion of patients with secondary hypertension, we
observed similar results for tertiles 3 and 2 versus 1: multi-
variable model 1, hazard ratio (95% confidence interval for
all-cause mortality 0.67 (0.50–0.91), P=0.009; cardiovascu-
lar mortality 0.60 (0.42–0.85), P=0.004; and stroke mortality
0.38 (0.19–0.74), P=0.004; multivariable model 2, all-cause
mortality 0.68 (0.52–0.90), P=0.007; cardiovascular mortality
0.64 (0.46–0.90), P=0.009; and stroke mortality 0.54 (0.29–
1.01), P=0.055. The exclusion of patients who died in the first
2 years of follow-up gave similar results: multivariable model
1, all-cause mortality 0.69 (0.52–0.92), P=0.012; cardiovascu-
lar mortality 0.68 (0.48–0.97), P=0.036; and stroke mortality
0.45 (0.23–0.89), P=0.021; multivariable model 2, all-cause
mortality 0.70 (0.53–0.92), P=0.010; cardiovascular mortality
0.73 (0.52–1.02), P=0.064; and stroke mortality 0.67 (0.35–
1.28), P=0.229.
Prognostic Value of Protein Intake According to
Various Conditions
To test the interaction of various clinical conditions, tertiles
3 and 2 were grouped because of their similar survival rates,
which led to a comparison between 2 groups: <0.7 versus
≥0.7 g/kg. Table 3 shows the prognostic value of tertiles
3 and 2 versus 1 according to various conditions. Overall,
the protective effect of a PInt/IBW >0.7 g/kg was observed,
particularly for all-cause death in young patients and in the
absence of previous cardiovascular disease or aortic athero-
sclerosis. For cardiovascular mortality, the protective effect
of a PInt/IBW >0.7 g/kg was more marked in absence of pre-
vious cardiovascular disease and to a lesser extent in young
patients and in absence of aortic atherosclerosis (albeit the
P value for interaction was >0.1). For stroke mortality, we
observed a better prognostic value for tertiles 2 and 3 in the
 Courand et al   Protein Intake and Hypertension   5

Table 2.  Univariate and Multivariable Cox Regression Survival Analysis at 10 Years of Follow-Up
All-Cause Mortality Cardiovascular Mortality Stroke Mortality
Variables HR (95% CI) P Value HR (95% CI) P Value HR (95% CI) P Value
Univariate analysis
 Per 1 g/kg increase 0.69 (0.48–0.97) 0.035 0.56 (0.35–0.90) 0.017 0.40 (0.15–1.04) 0.06
 Tertile 2 vs 1 0.69 (0.53–0.92) 0.010 0.69 (0.49–0.96) 0.026 0.73 (0.38–1.40) 0.35
 Tertile 3 vs 1 0.69 (0.52–0.91) 0.009 0.69 (0.49–0.96) 0.026 0.59 (0.29–1.17) 0.13
 Tertile 3 vs 2 0.99 (0.74–1.34) 0.97 1.00 (0.70–1.43) 0.997 0.80 (0.39–1.67) 0.55
 Tertiles 3 and 2 vs 1 0.69 (0.55–0.87) 0.002 0.069 (0.52–0.91) 0.008 0.66 (0.38–1.15) 0.14
 >0.8 vs <0.8 g/kg 0.74 (0.58–0.93) 0.009 0.68 (0.52–0.90) 0.006 0.64 (0.37–1.12) 0.12
Multivariable 1*
 Per 1 g/kg increase 0.65 (0.43–0.98) 0.037 0.58 (0.36–0.95) 0.032 0.28 (0.10–0.79) 0.016
 Tertile 2 vs 1 0.75 (0.56–1.01) 0.06 0.71 (0.50–1.00) 0.053 0.65 (0.33–1.28) 0.21
 Tertile 3 vs 1 0.70 (0.51–0.95) 0.020 0.62 (0.44–0.88) 0.007 0.43 (0.20–0.92) 0.029
 Tertile 3 vs 2 0.95 (0.68–1.31) 0.74 0.92 (0.62–1.34) 0.65 0.59 (0.25–1.37) 0.22
 Tertiles 3 and 2 vs 1 0.73 (0.57–0.95) 0.017 0.71 (0.53–0.97) 0.028 0.54 (0.30–0.97) 0.039
 >0.8 vs <0.8 g/kg 0.76 (0.60–0.98) 0.033 0.71 (0.52–0.95) 0.023 0.57 (0.31–1.04) 0.068
Multivariable 2†
 Per 1 g/kg increase 0.73 (0.53–1.01) 0.056 0.64 (0.40–1.04) 0.073 0.45 (0.17–1.20) 0.109
 Tertile 2 vs 1 0.67 (0.51–0.89) 0.006 0.69 (0.49–0.97) 0.030 0.79 (0.41–1.53) 0.49
 Tertile 3 vs 1 0.75 (0.56–0.99) 0.040 0.76 (0.54–1.06) 0.11 0.65 (0.32–1.32) 0.24
 Tertile 3 vs 2 1.11 (0.81–1.52) 0.53 1.10 (0.76–1.61) 0.61 0.82 (0.39–1.74) 0.61
 Tertiles 3 and 2 vs 1 0.71 (0.56–0.91) 0.005 0.72 (0.54–0.96) 0.025 0.72 (0.41–1.28) 0.26
 >0.8 vs <0.8 g/kg 0.73 (0.57–0.92) 0.008 0.70 (0.52–0.92) 0.012 0.68 (0.38–1.20) 0.18
CI indicates confidence interval; and HR, hazard ratio.
*Total cholesterol, triglycerides, salt consumption, 24-h urinary potassium excretion, and fasting glucose.
†Age, sex, systolic blood pressure, smoking status, diabetes mellitus, total cholesterol, estimated glomerular filtration rate, body mass index, antihypertensive
treatment, and previous cardiovascular disease.

absence of aortic atherosclerosis and in patients with a low
salt intake, albeit the P value for interaction was not statisti-
cally significant. We noted a marked interaction for hyper-
tensive retinopathy and stroke.
Discussion
Based on a large cohort with a long follow-up, our results
demonstrate for the first time that hypertensive patients with
a normal–high protein intake had decreased all-cause and
cardiovascular mortality rates and, to a lesser extent, stroke
deaths. More specifically, a PInt/IBW >0.7 g/kg/d was associ-
ated with a good prognosis in the absence of overt cardiovas-
cular disease (heart failure, aortic atherosclerosis, or coronary
artery disease).
Effect of Protein Intake on BP and Outcomes
Our results clearly indicate a risk reduction for all-cause mor-
tality and cardiovascular mortality with a normal–high protein
intake because this was observed in 2 multivariable models
adjusting for a series of metabolic or risk factors. This prog-
nostic effect was consistent in several sensitivity analyses,
confirming the robustness of the finding.
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Evidence concerning the cardiovascular effect of protein
intake is scant and controversial, especially in hypertensive
patients without chronic kidney disease. Concerning the effect
on BP, the INTERSALT study showed a significant inverse
association between urinary urea nitrogen (estimated from
24-hour urinary urea) and BP.18 On the other hand, PREVEND
study,6 among others,19,20 did not report such an association.
A recent meta-analysis of 40 randomized controlled tri-
als demonstrated that dietary protein intake (median protein
supplementation of 40 g/d) was associated with a significant
decrease in mean systolic BP and diastolic BP of ≈2 mm Hg.5
There was no heterogeneity in BP reduction based on ani-
mal or vegetable protein sources. In our study, none of the
BP variables appeared correlated with 24-hour urinary urea,
emphasizing the fact that the BP effect of protein intake was
limited, if any.
With respect to the prognostic value of protein intake in
relation to cardiovascular events, particularly stroke, the results
also seem inconsistent. Data were obtained mainly in the gen-
eral population. Some studies indicated a reduction in risk of
stroke with high protein intake8,21–23 while others did not.24,25
The main limitation of these studies was the assessment of
protein intake based on food frequency questionnaire, 24-hour
6  Hypertension  June 2016

Table 3.  Cox Regression Analysis, Survival Analysis at 10 Years of Follow-Up, Comparison of Tertiles 3 and 2 Versus 1 in Various
Conditions
All-Cause Mortality Cardiovascular Mortality Stroke Mortality
P for P P for P P for
Variables HR (95% CI) P Value Interaction HR (95% CI) Value Interaction HR (95% CI) Value Interaction
Demographic variables
 Men (n=651) 0.70 (0.52–0.95) 0.020 0.78 0.63 (0.44–0.91) 0.012 0.19 0.88 (0.37–2.10) 0.78 0.49
 Women (n=477) 0.74 (0.49–1.12) 0.15 0.95 (0.59–1.55) 0.84 0.58 (0.27–1.26) 0.17
 Age >46 y (n=532) 0.81 (0.62–1.07) 0.14 0.069 0.77 (0.55–1.07) 0.12 0.12 0.67 (0.35–1.26) 0.21 0.58
 Age <46 y (n=596) 0.46 (0.29–0.74) 0.001 0.51 (0.28–0.94) 0.030 0.81 (0.18–3.70) 0.78
Cardiovascular variables
 SBP >180 mm Hg (n=550) 0.68 (0.51–0.91) 0.009 0.83 0.66 (0.46–0.93) 0.016 0.73 0.66 (0.35–1.27) 0.21 0.67
 SBP <180 mm Hg (n=576) 0.75 (0.49–1.14) 0.18 0.76 (0.46–1.27) 0.30 1.02 (0.30–3.50) 0.98
 DBP >107 mm Hg (n=535) 0.72 (0.53–0.99) 0.043 0.78 0.61 (0.43–0.89) 0.009 0.34 0.61 (0.29–1.26) 0.18 0.61
 DBP <107 mm Hg (n=591) 0.66 (0.49–0.95) 0.026 0.83 (0.52–1.33) 0.44 0.70 (0.26–1.87) 0.47
 ATS (n=261) 0.86 (0.54–1.34) 0.50 0.08 0.76 (0.45–1.28) 0.30 0.28 0.71 (0.23–2.16) 0.55 0.43
 No ATS (n=573) 0.50 (0.32–0.78) 0.002 0.49 (0.28–0.85) 0.010 0.42 (0.17–1.06) 0.07
 No retinopathy (n=382) 0.45 (0.25–0.80) 0.007 0.26 0.54 (0.25–1.20) 0.13 0.27 0.11 (0.01–1.33) 0.08 0.017
 Mild retinopathy (n=539) 0.71 (0.51–1.00) 0.053 0.56 (0.37–0.84) 0.005 0.55 (0.25–1.25) 0.15
 Severe retinopathy 0.85 (0.55–1.31) 0.46 0.90 (0.55–1.48) 0.69 1.46 (0.52–4.11) 0.48
(n=188)
 Previous CVD (n=311) 0.91 (0.65–1.29) 0.61 0.053 0.99 (0.63–1.58) 0.75 0.027 0.70 (0.30–1.62) 0.41 0.78
 No previous CVD (n=817) 0.55 (0.40–0.77) <0.001 0.50 (0.32–0.76) 0.001 0.66 (0.30–1.48) 0.31
Metabolic parameters
 BMI ≥25 kg/m2 (n=561) 0.79 (0.56–1.12) 0.19 0.59 0.71 (0.46–1.07) 0.10 0.92 0.55 (0.24–1.26) 0.16 0.58
 BMI <25 kg/m (n=561)
2
0.68 (0.49–0.95) 0.024 0.73 (0.49–1.09) 0.13 0.91 (0.40–2.08) 0.82
 Diabetes mellitus (n=179) 0.79 (0.48–1.30) 0.34 0.45 0.64 (0.36–1.15) 0.14 0.86 0.23 (0.04–1.18) 0.08 0.34
 No diabetes mellitus 0.68 (0.52–0.89) 0.006 0.69 (0.50–0.97) 0.030 0.81 (0.43–1.53) 0.51
(n=952)
 Salt ≥6 g/d (n=566) 0.82 (0.54–1.23) 0.33 0.23 0.95 (0.57–1.59) 0.84 0.18 1.16 (0.45–3.00) 0.76 0.11
 Salt <6 g/d (n=561) 0.64 (0.47–0.88) 0.005 0.61 (0.42–0.89) 0.010 0.37 (0.15–0.92) 0.031
Cox regression analysis adjusted for age, sex, systolic blood pressure, smoking status, diabetes mellitus, total cholesterol, estimated glomerular filtration rate, body
mass index, antihypertensive treatment, and previous cardiovascular disease. ATS indicates aortic atherosclerosis; BMI, body mass index; CI, confidence interval; CVD,
cardiovascular disease; DBP, diastolic blood pressure; HR, hazard ratio; and SBP, systolic blood pressure.

dietary recall, or urinary urea concentration on spot urine. This
aspect is a particular strength of our study because 24-hour uri-
nary urea excretion performed in a hospital ward was used to
quantify protein consumption and currently represents the gold
standard. Albeit statistically significant, the correlation with the
food frequency questionnaire and urinary urea concentration on
spot urine was extremely weak in our study, emphasizing the
limitations of these approaches, as already known.
Similarly, the prognostic value of protein intake for all-
cause mortality is also controversial.26 In addition to the ben-
efit on cardiovascular outcome, protein intake may also affect
cancer deaths, particularly in patients >65 years.27 Younger
age, no previous cardiovascular event (stroke, heart failure,
coronary artery disease, or peripheral artery disease), and
absence of hypertensive retinopathy or aortic remodeling
amplified the protective effect of protein intake. This is an
important point for the practical effect of our results because it
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confirms the current recommendations of a >0.8 g/kg protein
consumption in hypertensive patients, provided that they have
normal cardiac and vascular function.
Putative Mechanisms for the Protective Effect of
Protein Intake
Studies in healthy subjects demonstrate that an increase in
dietary protein from 15% to 30% of energy at a constant car-
bohydrate intake produces a sustained decrease in appetite and
spontaneous caloric intake by increasing central nervous sys-
tem leptin sensitivity and results in weight loss.28,29 Moreover,
fat mass decreased significantly in healthy subjects. On the con-
trary, data in renal failure patients suggest that a reduced protein
intake is associated with a decreased total caloric intake.30 Thus,
the implication of changes in the total caloric intake on out-
comes cannot be ruled out, albeit difficult to address because of
the fact that this parameter was not monitored in our study. Yet,
 Courand et al   Protein Intake and Hypertension   7
Figure 2. A, Mechanisms unbalancing myogenic tone and flow-mediated dilation in hypertension; B, hypothesis explaining the
cardiovascular protective effect of protein intake. NO indicates nitric oxide.
these metabolic effects probably do not account entirely for
the better outcome associated with high protein diet.
The profile of patients in whom a high protein intake had
the greatest favorable influence (ie, younger patients, without
detectable aortic atherosclerosis or previous cardiovascular
disease) is consistent with a rather preserved endothelial func-
tion. Mainly via nitric oxide production, a functional endo-
thelium has anti-inflammatory, antithrombotic, vasorelaxant,
and antihypertrophic properties. Arginine and tryptophan, 2
amino acids contained in most proteins, are involved in nitric
oxide production; in addition, tryptophan decreases plasma
concentration of epinephrine and norepinephrine.31,32 These
mechanisms, present when endothelial function is preserved
(Figure 2), may be in the case of endothelial dysfunction,
explaining why the protective effect of protein intake is no
longer observed with aging, hypertensive retinopathy, and
overt cardiovascular disease. High salt intake may also play
a role by reducing vascular nitric oxide bioavailability.33 In
clinical practice, one can suppose that high protein intake
coming from animal sources will be associated also with an
increased salt consumption, leading to less positive nutritional
consequence in hypertensive patients.
Other noncardiovascular benefits are less clear. Studies dem-
onstrating an increased risk of overall mortality and cancer death
in patients with a high protein intake made the hypothesis that
protein restriction decreases growth hormone receptor/insulin-
like growth factor-1 activity. This metabolic pathway displays a
major role in age-related diseases, such as cancer, and in over-
all mortality.27 But, once again, protein intake assessment was
based on reports of food and beverage intake and not indexed
on BMI.
Limitations
The main limitations of our study are its observational design,
the absence of data regarding the frequency of visits, changes
in antihypertensive medication, and achievement of BP control
during follow-up. Moreover, interaction between renal death and
protein intake could not specifically be explored in our cohort
because of a low number of outcomes after 10 years of follow-
up (n=25). Another limitation is the absence of urinary creatinine
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measurement to control for a complete 24-hour urinary collec-
tion. However, as mentioned, urinary collection was done during
the in-hospital stay using a standardized protocol. The patients’
characteristics differ from today’s hypertensive patients, with
a higher BP level, a high prevalence of severe retinopathy, and
different kinds of antihypertensive treatment. However, there
is no indication that the current disease differs from that in the
1970s in terms of its pathophysiology and that an interaction
exists between the kind of treatment and protein consumption.
Finally, we did not have information on the origin of protein
intake and whether it came from animal or vegetable sources.
Perspectives
In our historic cohort, we demonstrated that a PInt/IBW >0.7 g/kg
per day had a protective effect for all-cause, cardiovascular, and
stroke mortality in hypertensive patients. This may be because
some amino acids (arginine and tryptophan) may influence the
bioavailability of nitric oxide. This is supported by the fact that
the beneficial effect of protein intake apparently needs a pre-
served cardiovascular and probably endothelial function to be
observed (such as in young hypertensive patients without overt
cardiovascular disease). A major practical implication of these
data is to encourage hypertensive patients without chronic kid-
ney disease to have a normal (0.8–1.0 g/kg) or high (>1.0 g/kg)
protein diet in addition to low salt consumption, moderate alco-
hol consumption, and regular physical activity, particularly those
with low cardiovascular risk.
Acknowledgments
We thank Sophie Rushton-Smith, PhD, for thorough editing of this
article.
Disclosures
None.
References
1. ESH ESC Task Force for the Management of Arterial Hypertension. 2013
Practice guidelines for the management of arterial hypertension of the
European Society of Hypertension (ESH) and the European Society of
Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial
Hypertension. J Hypertens. 2013;31:1925–1938.
8  Hypertension  June 2016
2. Dickinson HO, Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV,
Williams B, Ford GA. Lifestyle interventions to reduce raised blood pres-
sure: a systematic review of randomized controlled trials. J Hypertens.
2006;24:215–233. doi: 10.1097/01.hjh.0000199800.72563.26.
3. Fouque D, Aparicio M. Eleven reasons to control the protein intake of
patients with chronic kidney disease. Nat Clin Pract Nephrol. 2007;3:383–
392. doi: 10.1038/ncpneph0524.
4. Fouque D, Laville M. Low protein diets for chronic kidney disease in non
diabetic adults. Cochrane Database Syst Rev. 2009:CD001892.
5. Rebholz CM, Friedman EE, Powers LJ, Arroyave WD, He J, Kelly TN.
Dietary protein intake and blood pressure: a meta-analysis of random-
ized controlled trials. Am J Epidemiol. 2012;176(suppl 7):S27–S43. doi:
10.1093/aje/kws245.
6. Tielemans SM, Geleijnse JM, van Baak MA, Engberink MF, Brink
EJ, de Jong PE, Gansevoort RT, Bakker SJ; PREVEND Study Group.
Twenty-four hour urinary urea excretion and 9-year risk of hypertension:
the PREVEND study. J Hypertens. 2013;31:1564–1569. doi: 10.1097/
HJH.0b013e328362213b.
7. Buendia JR, Bradlee ML, Singer MR, Moore LL. Diets higher in protein
predict lower high blood pressure risk in Framingham Offspring Study
adults. Am J Hypertens. 2015;28:372–379. doi: 10.1093/ajh/hpu157.
8. Larsson SC, Virtamo J, Wolk A. Dietary protein intake and risk of
stroke in women. Atherosclerosis. 2012;224:247–251. doi: 10.1016/j.
atherosclerosis.2012.07.009.
9. Zhang Z, Xu G, Yang F, Zhu W, Liu X. Quantitative analysis of dietary
protein intake and stroke risk. Neurology. 2014;83:19–25. doi: 10.1212/
WNL.0000000000000551.
10. Rand WM, Pellett PL, Young VR. Meta-analysis of nitrogen balance stud-
ies for estimating protein requirements in healthy adults. Am J Clin Nutr.
2003;77:109–127.
11. Courand PY, Milon H, Gustin MP, Froment A, Bricca G, Lantelme P.
Effect modification of aortic atheroma on the prognostic value of heart
rate in hypertension. J Hypertens. 2013;31:484–91; discussion 491. doi:
10.1097/HJH.0b013e32835c44bb.
12. Keith NM, Wagener HP, Barker NW. Some different types of essen-
tial hypertension: their course and prognosis. Am J Med. Sci.
1974;268:336–345.
13. Harbaoui B, Courand PY, Milon H, Fauvel JP, Khettab F, Mechtouff L,
Cassar E, Girerd N, Lantelme P. Association of various blood pressure
variables and vascular phenotypes with coronary, stroke and renal deaths:
Potential implications for prevention. Atherosclerosis. 2015;243:161–
168. doi: 10.1016/j.atherosclerosis.2015.09.011.
14. Courand PY, Milon H, Bricca G, Khettab F, Lantelme P. Diastolic blood
pressure, aortic atheroma, and prognosis in hypertension: new insights
into a complex association. Atherosclerosis. 2014;233:300–306. doi:
10.1016/j.atherosclerosis.2014.01.004.
15. Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen
intake of patients with chronic renal failure. Kidney Int. 1985;27:58–65.
16. Pavillon G, Laurent F. Certification et classification des causes de
décès. BEH. 2003;30–31:134–138 http://opac.invs.sante.fr/doc_num.
php?explnum_id=2065.
17. Rapport AFSSA Apports en protéines: consommation, qualité, besoins et
recommandations. 2007;2015:http://www.afssa.fr/Documents/NUT-Ra-
Proteines.pdf.
18. Stamler J, Elliott P, Kesteloot H, Nichols R, Claeys G, Dyer AR, Stamler R.
Inverse relation of dietary protein markers with blood pressure. Findings
Novelty and Significance
What Is New?
• This is the first cohort study of hypertensive patients establishing the
prognostic value of protein intake using the current gold standard, 24-
hour urinary urea, concerning all-cause, cardiovascular, and stroke mor-
tality.
What Is Relevant?
• After adjustment for major cardiovascular risk factors, hypertensive pa-
tients with protein intake >0.7 g/kg per day of ideal body weight had a
decreased risk of all-cause and cardiovascular death, but not of stroke
death.
Downloaded from http://hyper.ahajournals.org/ at Tulane University on April 20, 2016
for 10,020 men and women in the INTERSALT Study. INTERSALT
Cooperative Research Group. INTERnational study of SALT and blood
pressure. Circulation. 1996;94:1629–1634.
19. Altorf-van der Kuil W, Engberink MF, Geleijnse JM, Boer JM, Monique
Verschuren WM. Sources of dietary protein and risk of hypertension in a
general Dutch population. Br J Nutr. 2012;108:1897–1903. doi: 10.1017/
S0007114512000049.
20. Altorf-van der Kuil W, Engberink MF, van Rooij FJ, Hofman A, van’t
Veer P, Witteman JC, Geleijnse JM. Dietary protein and risk of hyper-
tension in a Dutch older population: the Rotterdam study. J Hypertens.
2010;28:2394–2400. doi: 10.1097/HJH.0b013e32833eff63.
21. Iso H, Sato S, Kitamura A, Naito Y, Shimamoto T, Komachi Y. Fat and
protein intakes and risk of intraparenchymal hemorrhage among middle-
aged Japanese. Am J Epidemiol. 2003;157:32–39.
22. Iso H, Stampfer MJ, Manson JE, Rexrode K, Hu F, Hennekens CH,
Colditz GA, Speizer FE, Willett WC. Prospective study of fat and protein
intake and risk of intraparenchymal hemorrhage in women. Circulation.
2001;103:856–863.
23. Prentice RL, Huang Y, Kuller LH, Tinker LF, Horn LV, Stefanick
ML, Sarto G, Ockene J, Johnson KC. Biomarker-calibrated energy
and protein consumption and cardiovascular disease risk among post-
menopausal women. Epidemiology. 2011;22:170–179. doi: 10.1097/
EDE.0b013e31820839bc.
24. Preis SR, Stampfer MJ, Spiegelman D, Willett WC, Rimm EB. Lack
of association between dietary protein intake and risk of stroke among
middle-aged men. Am J Clin Nutr. 2010;91:39–45. doi: 10.3945/
ajcn.2009.28060.
25. Sauvaget C, Nagano J, Hayashi M, Yamada M. Animal protein, ani-
mal fat, and cholesterol intakes and risk of cerebral infarction mortality
in the adult health study. Stroke. 2004;35:1531–1537. doi: 10.1161/01.
STR.0000130426.52064.09.
26. Pedersen AN, Kondrup J, Børsheim E. Health effects of protein intake in
healthy adults: a systematic literature review. Food Nutr Res. 2013;57:.
doi: 10.3402/fnr.v57i0.21245.
27. Levine ME, Suarez JA, Brandhorst S, et al. Low protein intake is associ-
ated with a major reduction in IGF-1, cancer, and overall mortality in the
65 and younger but not older population. Cell Metab. 2014;19:407–417.
doi: 10.1016/j.cmet.2014.02.006.
28. Weigle DS, Breen PA, Matthys CC, Callahan HS, Meeuws KE, Burden
VR, Purnell JQ. A high-protein diet induces sustained reductions in appe-
tite, ad libitum caloric intake, and body weight despite compensatory
changes in diurnal plasma leptin and ghrelin concentrations. Am J Clin
Nutr. 2005;82:41–48.
29. Lejeune MP, Westerterp KR, Adam TC, Luscombe-Marsh ND, Westerterp-
Plantenga MS. Ghrelin and glucagon-like peptide 1 concentrations, 24-h
satiety, and energy and substrate metabolism during a high-protein diet
and measured in a respiration chamber. Am J Clin Nutr. 2006;83:89–94.
30. Fouque D, Pelletier S, Mafra D, Chauveau P. Nutrition and chronic kidney
disease. Kidney Int. 2011;80:348–357. doi: 10.1038/ki.2011.118.
31. Vasdev S, Stuckless J. Antihypertensive effects of dietary protein and its
mechanism. Int J Angiol. 2010;19:e7–e20.
32. Watts SW, Morrison SF, Davis RP, Barman SM. Serotonin and blood
pressure regulation. Pharmacol Rev. 2012;64:359–388. doi: 10.1124/
pr.111.004697.
33. Edwards DG, Farquhar WB. Vascular effects of dietary salt. Curr Opin
Nephrol Hypertens. 2015;24:8–13. doi: 10.1097/MNH.0000000000000089.
• Normal–high protein intake had a more marked positive influence in a
subset of our population: younger patients, low salt intake, absence of
aortic atherosclerosis, or previous cardiovascular events.
Summary
Our data demonstrate that a protein intake >0.7 g/kg per day of
ideal body weight has a favorable effect, particularly in low-risk
hypertensive patients. Physicians may encourage hypertensive pa-
tients to have normal or high protein diet in addition to the usual
lifestyle changes (low salt consumption, moderate alcohol con-
sumption, and regular physical activity).
 Association Between Protein Intake and Mortality in Hypertensive Patients Without
Chronic Kidney Disease in the OLD-HTA Cohort
Pierre-Yves Courand, Chloé Lesiuk, Hugues Milon, Alice Defforges, Denis Fouque, Brahim
Harbaoui and Pierre Lantelme

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 Association Between Protein Intake and Mortality in Hypertensive Patients Without

Chronic Kidney Disease in the OLD-HTA Cohort

Short title: Protein intake and hypertension

Pierre-Yves Courand*, Chloé Lesiuk*, Hugues Milon, Alice Defforges, Denis Fouque,

Brahim Harbaoui, Pierre Lantelme

From the Cardiology Department, European Society of Hypertension Excellence center,

Hôpital de la Croix-Rousse, Hospices Civils de Lyon, F-69004, Lyon, France (P.Y.C., C.L.,

H.M., A.D., B.H., P.L.);

Université de Lyon, CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université

Claude Bernard Lyon 1; Hospices Civils de Lyon, France (P.Y.C., B.H., P.L.); and

Department of Nephrology and Nutrition, Hôpital Lyon Sud, Hospices Civils de Lyon,

CARMEN, CENS, Université Claude Bernard Lyon 1, F-69310, Pierre-Bénite, France (D.F.).

* P.Y.C and C.L. contributed equally to this work and are joint first authors.

1
Protein intake and hypertension

Supplemental Table S1. Simple Linear Regression of Protein Intake Based on 24-Hour

Urinary Urea Assessment Adjusted for Ideal Body Weight on Other Variables

Variable r P Value

Clinical characteristic

Age –0.033 0.26

Body mass index 0.110 <0.001

Systolic blood pressure –0.007 0.81

Diastolic blood pressure –0.012 0.68

Pulse pressure 0.001 0.97

Biochemistry

Estimated glomerular filtration rate 0.085 0.004

Kalemia 0.062 0.036

Natremia –0.017 0.56

Uric acid –0.034 0.26

Total cholesterol 0.086 0.004

Triglycerides –0.030 0.33

Fasting glucose 0.027 0.37

Plasma urea 0.076 0.011

24-hour urinary sodium excretion 0.264 <0.001

24-hour albuminuria –0.041 0.17

Plasma creatinine –0.059 0.047

2
Protein intake and hypertension

Supplemental Table S2. Multivariable Regression Analysis of Protein Intake Based on

24-Hour Urinary Urea Assessment Adjusted for Ideal Body Weight on Other Variables

Variable Beta P Value

Clinical characteristic

Body mass index 0.082 0.004

Biochemistry

Estimated glomerular filtration rate 0.110 0.012

Kalemia NS NS

Total cholesterol 0.080 0.006

Plasma urea 0.236 <0.001

Natriuresis 0.264 <0.001

Plasma creatinine –0.121 0.012

3
Protein intake and hypertension

Supplemental Table S3. Multivariable Cox Regression Survival Analysis at 10 Years of

Follow-Up With Adjustment for the Real Body Weight of Patients

All-Cause Mortality Cardiovascular Mortality Stroke Mortality

Variable HR (95% CI) P Value HR (95% CI) P Value HR (95% CI) P Value

Multivariable*

Per 1 g/kg 0.66 (0.42–1.05) 0.08 0.68 (0.39–1.18) 0.17 0.42 (0.13–1.30) 0.13

increase

Tertile 2 vs. 1 0.67 (0.50–0.89) 0.005 0.66 (0.48–0.93) 0.017 0.60 (0.31–1.17) 0.14

Tertile 3 vs. 1 0.76 (0.57–1.01) 0.06 0.73 (0.52–1.03) 0.07 0.65 (0.33–1.30) 0.23

Tertile 3 vs. 2 1.15 (0.83–1.58) 0.41 1.02 (0.69–1.52) 0.91 0.98 (0.43–2.24) 0.97

Tertiles 3 and 2 0.68 (0.53–0.87) 0.002 0.70 (0.53–0.93) 0.015 0.59 (0.33–1.06) 0.08

vs. 1

>0.8 vs. <0.8 g/kg 0.80 (0.63–1.01) 0.08 0.74 (0.55–0.99) 0.045 0.64 (0.35–1.19) 0.16

*Age, sex, systolic blood pressure, smoking status, diabetes, total cholesterol, estimated glomerular filtration

rate, body mass index, antihypertensive treatment and previous cardiovascular disease.

4
Protein intake and hypertension

Supplemental Figure S1. Correlation of different methods to assess protein intake: 24-hour

urinary urea, food frequency questionnaire, and urinary urea concentration on a spot urine

collection, all adjusted for ideal body weight.