From the Guidelines
Sodium restriction is crucial in managing ascites and liver cirrhosis, and patients should limit their sodium intake to 2 grams (2000 mg) per day or less, as recommended by the most recent guidelines 1. This approach helps reduce fluid accumulation in the abdomen by addressing the abnormal sodium handling by the kidneys, which leads to sodium and water retention in cirrhosis. When sodium intake is reduced, less fluid accumulates in the abdominal cavity, thereby helping to control ascites. Practically, patients should avoid adding salt to food, limit processed foods, canned soups, and fast food, which are typically high in sodium, and read food labels to choose fresh foods whenever possible. This dietary change should be implemented alongside diuretic therapy, typically starting with spironolactone at 100 mg daily, with or without furosemide, as guided by the American Association for the Study of Liver Diseases in 2021 1. The combination of sodium restriction and diuretics is more effective than either approach alone in managing ascites and improving outcomes in patients with liver cirrhosis. It is also important for patients to maintain adequate protein intake despite sodium restrictions, as malnutrition is common in cirrhosis and can worsen outcomes. Regular monitoring of body weight, serum creatinine, and sodium levels is necessary to assess response to treatment and detect potential adverse effects, as emphasized in the 2021 practice guidance 1.
Key considerations for managing ascites in liver cirrhosis include:
- Implementing moderate sodium restriction to achieve a negative sodium balance and net fluid loss
- Using diuretics such as spironolactone and furosemide as the mainstay of treatment
- Avoiding fluid restriction unless there is concomitant moderate or severe hyponatremia
- Regularly monitoring patients receiving diuretics to assess response and detect adverse effects
- Considering additional treatments like human albumin solution or baclofen administration in specific cases, as suggested by recent guidelines 1.
By following these recommendations and prioritizing sodium restriction alongside diuretic therapy, patients with ascites and liver cirrhosis can experience improved outcomes in terms of morbidity, mortality, and quality of life, as supported by the latest clinical practice guidelines 1.
From the FDA Drug Label
In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. ... Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis. The reason for sodium restriction in patients with ascites and liver cirrhosis is not directly stated in the label, but it can be inferred that sodium restriction is implied as part of managing fluid and electrolyte balance to prevent sudden alterations that may precipitate hepatic coma 2.
- Key points are:
- Managing fluid and electrolyte balance
- Preventing sudden alterations
- Preventing hepatic coma However, the label does not explicitly state why sodium restriction is recommended.
From the Research
Sodium Restriction in Ascites and Liver Cirrhosis
Sodium restriction is recommended in patients with ascites and liver cirrhosis due to the following reasons:
- Sodium and water retention is the basic abnormality leading to ascites formation 3
- Restriction of sodium intake and enhancing sodium excretion is the mainstay of the treatment of ascites 3, 4, 5
- Patients with cirrhosis and ascites must limit sodium intake to 2 gram per day 3
- Sodium restriction helps in reducing the amount of ascitic fluid and preventing its reaccumulation 6
Pathophysiology of Ascites
The pathophysiology of ascites involves:
- Increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation 7
- Increased natriuretic potency of spironolactone compared to loop diuretics in patients with marked sodium retention 6
Treatment of Ascites
The treatment of ascites involves:
- Dietary sodium restriction and the judicious use of distal and loop diuretics 5
- Large-volume paracentesis (LVP) associated with intravenous albumin infusion 4, 6
- Transjugular intrahepatic portosystemic shunts (TIPS) in patients who repeatedly fail LVP and have relatively preserved liver functions 3, 4, 5
- Liver transplantation as the only definitive therapy for refractory ascites with cirrhosis 4, 5, 7