Sodium Restriction in Alcoholic Hepatitis with Ascites
Sodium restriction should be initiated immediately upon diagnosis of alcoholic hepatitis with ascites, with recommendations based on the severity of ascites. 1
Graded Approach to Sodium Restriction
The approach to sodium restriction should follow a grade-based management strategy:
| Grade | Description | Treatment Approach |
|---|---|---|
| Grade 1 (mild) | Ascites only detectable by ultrasound | Sodium restriction alone |
| Grade 2 (moderate) | Moderate abdominal distension | Sodium restriction + diuretics |
| Grade 3 (large) | Marked abdominal distension | Initial paracentesis + sodium restriction + diuretics |
Recommended Sodium Intake
- A moderately salt-restricted diet of 80-120 mmol sodium/day (4.6-6.9g salt/day) is recommended 1
- This translates to a no-added salt diet with avoidance of pre-prepared meals
- More severe restriction is unnecessary and potentially detrimental to nutritional status 2
Diuretic Management
For patients requiring diuretics (Grade 2-3 ascites):
- Start with spironolactone 100 mg/day (can increase to 400 mg/day) 2, 1
- Add furosemide 40 mg/day (can increase to 160 mg/day) if needed
- Target weight loss: 0.5 kg/day without edema, 1 kg/day with edema
Paracentesis Considerations
For Grade 3 (tense) ascites:
- Perform large volume paracentesis (LVP) as initial treatment 1
- Administer albumin (8g/L of ascites removed) when removing >5L to prevent post-paracentesis circulatory dysfunction
- Follow with sodium restriction and diuretics for maintenance therapy
Nutritional Considerations
Alongside sodium restriction, ensure:
- Adequate caloric intake (35-40 kcal/kg/day) 2, 1
- Adequate protein intake (1.2-1.5 g/kg/day)
- Smaller, more frequent meals if needed
- Consider late-evening snack of 200 kcal 2
Fluid Management
- Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 2, 1
- If hyponatremia is present (serum sodium <125 mmol/L), restrict fluid to 1-1.5 L/day
Monitoring and Follow-up
- Regular assessment of weight, fluid status, and electrolytes
- Monitor for complications including hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatic encephalopathy
- Evaluate response to therapy and adjust diuretic doses accordingly
Important Considerations and Pitfalls
- Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers as they can worsen ascites control 2
- Prostaglandin inhibitors like NSAIDs can reduce urinary sodium excretion and convert patients from diuretic-sensitive to refractory 2
- Complete abstinence from alcohol is essential for management 1
- Excessive sodium restriction may worsen malnutrition, which is common in these patients 2, 1
- Nutritional counseling and education about sodium content in foods is crucial for patient adherence
By following this graded approach to sodium restriction and comprehensive management, outcomes for patients with alcoholic hepatitis and ascites can be optimized.