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June 14, 2022

Electrolyte Biomarkers: Sodium Potassium Ratio

Optimal Takeaways

The ratio of sodium to potassium in the blood provides information about the relative levels of these electrolytes in the blood. Serum sodium and potassium are mainly under hormonal control at the level of the kidney where excretion or retention determines the amount of each mineral retained in the blood.

Chronic stress and compromised adrenal activity can have a profound effect on the ratio which will decrease as more sodium gets excreted and more potassium gets retained. The ratio will increase if more potassium gets excreted and sodium gets retained, which may reflect increased adrenal activity.

Conventional Lab Range: 30 - 35 ratio

Optimal Dx’s Optimal Range: 30 - 35 ratio

Low sodium:potassium ratio may reflect chronic stress and adrenal insufficiency accompanied by a decrease in aldosterone output, decreased sodium excretion, and increased potassium retention. A decreased ratio may also reflect increased cortisol output combined with decreased aldosterone.

High sodium:potassium ratio may reflect acute stress, increased adrenal activity, and increased aldosterone resulting in sodium retention and potassium excretion.


Serum levels of sodium and potassium are influenced by the adrenal hormone aldosterone which helps the kidneys retain sodium and water and excrete potassium (Pagana 2019). An increase in aldosterone, which can occur with acute stress, can decrease serum potassium, and increase serum sodium along with the sodium:potassium ratio. An increasing ratio above 34 suggests potassium depletion, while below 28 suggests sodium depletion and a possible insufficiency of magnesium and vitamin E (Wardle 2019).

Stress can trigger the HPA axis and increase ACTH, cortisol, and aldosterone. Research suggests that elevated aldosterone levels are associated with stress, anxiety, and depression, and that stress reduction techniques (e.g., transcendental meditation) can reduce serum aldosterone (Kubzansky 2010).

In a study of 549 Nigerian individuals, increased complications of hypertension were associated with an elevated plasma sodium:potassium ratio. Additional factors associated with hypertensive complications include increased hs-CRP, ferritin, malondialdehyde (MDA), urea, and BMI; and decreased bicarbonate, glutathione, catalase, superoxide dismutase, and eGFR. The mean plasma sodium:potassium ratio in hypertensives in the study was 41.32 versus 38.66 in controls (Ekun 2020).

Interestingly, a low-salt diet can activate the sympathetic nervous system and stimulate production of aldosterone. A study of 152 healthy subjects found that a low salt diet was associated with significantly increased serum aldosterone with a mean of 21 ng/dL on the low-salt diet versus 3.4 ng/dL on the high salt diet. Researchers associated a low salt diet with insulin resistance in this cohort (Garg 2011).


Ekun, Oloruntoba A et al. “Assessment of Plasma Sodium to Potassium Ratio, Renal Function, Markers of Oxidative Stress, Inflammation, and Endothelial Dysfunction in Nigerian Hypertensive Patients.” International journal of hypertension vol. 2020 6365947. 7 Dec. 2020, doi:10.1155/2020/6365947

Garg, Rajesh et al. “Low-salt diet increases insulin resistance in healthy subjects.” Metabolism: clinical and experimental vol. 60,7 (2011): 965-8. doi:10.1016/j.metabol.2010.09.005

Kubzansky, Laura D, and Gail K Adler. “Aldosterone: a forgotten mediator of the relationship between psychological stress and heart disease.” Neuroscience and biobehavioral reviews vol. 34,1 (2010): 80-6. doi:10.1016/j.neubiorev.2009.07.005

Wardle, Jon, and Jerome Sarris. Clinical naturopathy: an evidence-based guide to practice. Elsevier Health Sciences, 2019. 3rd edition

Tag(s): Biomarkers

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