How long do patients with alcoholic hepatitis need to have fluid and sodium restrictions?

Fluid and Sodium Restrictions in Alcoholic Hepatitis

Patients with alcoholic hepatitis should maintain sodium restriction (≤2g/day or 88mmol/day) indefinitely while ascites is present, while fluid restriction is only necessary when serum sodium is <120-125 mmol/L. 1

Sodium Restriction Guidelines

Sodium restriction is a cornerstone of ascites management in alcoholic hepatitis:

• Moderate dietary sodium restriction of 2g (90 mmol/day) should be maintained to achieve negative sodium balance and net fluid loss 2
• This restriction should continue indefinitely while ascites is present 1
• Practical implementation includes:
  • No added salt diet
  • Avoidance of pre-prepared meals
  • Patient education on sodium content of foods 2, 1

Fluid Restriction Guidelines

Unlike sodium restriction, fluid restriction is not routinely required:

• Fluid restriction is not indicated unless hyponatremia is present 2
• Only recommended when serum sodium drops below 120-125 mmol/L 1
• When needed, restrict fluids to 1-1.5 L/day 1

Treatment Approach Based on Ascites Grade

Grade	Description	Treatment Approach	Duration
Grade 1 (mild)	Only detected by ultrasound	Sodium restriction alone	Indefinite while ascites present
Grade 2 (moderate)	Moderate abdominal distension	Sodium restriction + diuretics	Indefinite while ascites present
Grade 3 (large)	Marked abdominal distension	Initial paracentesis + sodium restriction + diuretics	Indefinite while ascites present

Diuretic Management

When diuretics are needed alongside sodium restriction:

• Start with spironolactone 100 mg/day, which can be increased up to 400 mg/day 2
• Add furosemide 40 mg/day if needed 2, 1
• Target weight loss:
  • 0.5 kg/day in patients without peripheral edema
  • Up to 1 kg/day in patients with edema 2, 1

Important Monitoring Parameters

Regular monitoring is essential:

• Daily weight monitoring (same time each day) 2
• Serum electrolytes, especially during first weeks of treatment 2
• Renal function tests 1
• Consider 24-hour urinary sodium excretion to guide therapy 2
  • Alternative: spot urine Na/K ratio >1 indicates adequate natriuresis 2

Common Pitfalls to Avoid

1. Excessive fluid restriction: Not routinely needed and may worsen patient comfort unnecessarily 2, 1
2. Excessive sodium restriction: Below 2g/day can worsen malnutrition 1
3. Too rapid diuresis: Weight loss exceeding 0.5 kg/day (without edema) or 1 kg/day (with edema) can lead to plasma volume contraction, renal failure, and hyponatremia 2
4. Inadequate nutritional support: Ensure adequate caloric (35-40 kcal/kg/day) and protein intake (1.2-1.5 g/kg/day) while maintaining sodium restriction 2, 1

Special Considerations

• Patients with alcoholic hepatitis often have underlying cirrhosis at diagnosis 2
• Abstinence from alcohol is the cornerstone of treatment 2
• Regular screening for spontaneous bacterial peritonitis is essential, particularly in hospitalized patients 2, 1

Remember that sodium restriction should continue as long as ascites is present, while fluid restriction is only necessary in cases of significant hyponatremia.