What dietary approach is recommended for managing ascites, specifically regarding meal frequency and sodium intake?

From the Guidelines

For managing ascites, patients should follow a low-sodium diet of 5-6.5 g/day while consuming smaller, more frequent meals throughout the day rather than three large meals. This approach helps reduce fluid accumulation in the abdomen by decreasing sodium retention, as excess sodium leads to water retention in the body 1. Patients should avoid obviously salty foods like processed meats, canned soups, and fast food, while focusing on fresh fruits, vegetables, and unseasoned meats. Reading nutrition labels is essential to track sodium intake.

Key Recommendations

• Sodium intake should be restricted to 5-6.5 g/day, as recommended by the guidelines on the management of ascites in cirrhosis 1
• Fluid restriction is generally not necessary unless sodium levels are very low, as stated in the KASL clinical practice guidelines for liver cirrhosis: ascites and related complications 1
• Consuming smaller, more frequent meals helps prevent feeling uncomfortably full, improves nutrient absorption, and reduces pressure on the abdomen, making breathing easier
• Patients should also maintain adequate protein intake to prevent malnutrition, which is common in advanced liver disease, with recommended intakes of 1.2–1.5 g/kg/day protein and 35–40 kcal/kg/day caloric intake 1

Additional Considerations

• Diuretic medications like spironolactone and furosemide can help eliminate excess fluid and should be used in conjunction with dietary changes 1
• Monitoring for diuretic adverse events and temporarily discontinuing diuretics if necessary is crucial to prevent complications 1
• Nutritional education and support are essential to help patients manage their dietary sodium intake and maintain adequate nutrition 1

From the Research

Dietary Approach for Managing Ascites

• The recommended dietary approach for managing ascites involves restricting sodium intake to 2 grams per day 2.
• A low-sodium diet is central to the clinical management of ascites, but its efficacy is limited by poor adherence 3, 4.
• Medically tailored meals with less than 2,000 mg of sodium, more than 2,100 kcal, and more than 80 g of protein, including a nocturnal protein supplement, may be beneficial in managing ascites 3.
• Patients with cirrhosis and ascites may benefit from a salt-restricted meal-delivery program, which can help reduce the number of paracenteses and improve health-related quality of life 4.

Meal Frequency and Sodium Intake

• There is no specific recommendation for meal frequency in the management of ascites, but eating small, frequent meals may help reduce symptoms 2.
• Sodium intake should be limited to 2 grams per day, and patients should aim to enhance sodium excretion through the use of oral diuretics 2.
• The use of diuretics, such as spironolactone and furosemide, can help increase sodium excretion and reduce ascites formation 2, 5.

Treatment Options for Refractory Ascites

• Refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment 2, 6.
• Treatment options for refractory ascites include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), peritoneovenous shunt, and liver transplantation 2, 6, 5.
• Large-volume paracentesis associated with intravenous albumin infusion is a effective and safe therapy for ascites, and may be preferred over peritoneovenous shunting due to the high incidence of complications associated with the latter 6, 5.