Hypertension is a major public health problem and the global burden of hypertension (HTN) is mounting day by day. Over the past century, salt has been the subject of intense scientific research linked to HTN and cardiovascular (CV) mortality. By way of neurohormonal and hemodynamic responses, human body has unparalleled capability to adjust to the extremes of salt intake.

There is now consensus that different individuals have different susceptibilities to the blood pressure (BP)-raising effects of salt. While BP in the population as a whole is only modestly affected by the changes in salt intake, some individuals in response to acute or chronic salt depletion or repletion show large BP changes and are called “salt sensitive”.

Salt sensitivity appears to be a multifactorial entity with strong determinants such as genetic factors, race/ethnicity, age, gender, body mass index (BMI), associated comorbidities and diet. Salt sensitivity is an independent risk factor for CV disease and mortality above and beyond that conferred by mere HTN.

Several renal and extrarenal mechanisms are believed to play a role. Blunted activity of the renin-angiotensin-aldosterone system (RAAS), adrenal Rac1-MR-Sgk1-NCC/ENaC pathway, renal SNS-GR-WNK4-NCC pathway, defect of membrane ion transportation, inflammation and abnormalities of Na+/Ca2+ exchange have all been implicated as pathophysiological basis for salt sensitive HTN.

Low-salt educational intervention customized to individual cultures, practices and needs of population along with standard HTN medication management has been postulated to result in greater BP reduction than standard care alone. Recent observation that treatment with the specific angiotensin receptor blocker (ARB), Azilsartan may improve salt sensitivity by selectively reducing renal proximal tubule Na+/H+ exchange encourages the future potential benefits of recognizing and therapeutically addressing the salt sensitive phenotype in humans. An integrated approach, involving multiple successful approaches to BP reduction offers the best option for HTN management in patients with salt sensitivity.