What dietary recommendations are suggested for patients with cirrhosis (liver scarring)?

Dietary Recommendations for Patients with Cirrhosis

Patients with cirrhosis and ascites should consume a moderately salt-restricted diet of 5-6.5 g of salt daily (87-113 mmol sodium), which translates to a "no added salt" diet with avoidance of precooked meals, combined with adequate protein (1.2-1.5 g/kg/day) and caloric intake (35-40 kcal/kg/day). 1

Sodium Restriction: The Critical Balance

The evidence strongly supports moderate—not severe—sodium restriction for patients with ascites:

• Avoid overly restrictive diets (<5 g salt/day), as recent RCTs demonstrate that severe salt restriction (<5 g/day) compared to moderate restriction (5-6.5 g/day) resulted in worse outcomes: only 16% vs 45% ascites resolution, and dramatically higher 1-year mortality (82.5% vs 45-60%). 1

• Severe salt restriction causes significant complications including hyponatremia, reduced caloric intake, renal impairment (14% vs 0%), hepatic encephalopathy, hepatorenal syndrome, and increased mortality. 1

• The target of 5-6.5 g salt daily (approximately 2 g sodium or 87-113 mmol) represents the optimal balance between ascites control and avoiding malnutrition. 1, 2

• Sodium intake should never fall below 60 mmol/day, as this makes food unpalatable and compromises energy and protein intake. 1

Important Caveat on Salt Restriction

Only about one-third of cirrhotic patients actually comply with salt restriction, with an additional 45% incorrectly believing they are compliant. 1 This practical reality underscores the importance of mandatory nutritional counseling on sodium content rather than simply prescribing restrictions. 1, 2

Protein and Caloric Requirements

Adequate nutrition is paramount and takes priority over sodium restriction:

• Protein: 1.2-1.5 g/kg/day from any source (animal or vegetable protein). 1

• Carbohydrates: 2-3 g/kg/day. 1

• Total calories: 35-40 kcal/kg/day. 1

• In critically ill or actively decompensated patients, increase to 1.5 g/kg/day protein and 40 kcal/kg/day calories. 1

Meal Frequency and Timing

• If three meals daily don't provide adequate nutrition, implement smaller, more frequent meals. 1

• A late-evening snack of 200 kcal improves nutritional status in patients with cirrhosis and intractable ascites, helping to prevent overnight protein catabolism. 1

• Cirrhotic patients deplete hepatic glycogen and resort to protein catabolism much earlier than healthy individuals—as early as after an overnight fast—making frequent feeding critical. 1

Special Nutritional Considerations

For Hepatic Encephalopathy

• Branched-chain amino acid (BCAA) preparations may be considered when hepatic encephalopathy is present, though protein restriction is NOT recommended. 1

• Nutritional intervention (30-35 kcal/kg/day with 1.0-1.5 g vegetable protein/kg/day for 6 months) improved neuropsychiatric performance in patients with minimal hepatic encephalopathy. 1

Micronutrient Supplementation

• Assess and supplement vitamin D if levels are <20 ng/ml, targeting >30 ng/ml, as deficiency is highly prevalent and may adversely affect outcomes. 1

• Consider supplementation of vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, and zinc in cases of suspected deficiency. 1

• Zinc supplementation may improve ascites and encephalopathy as it's involved in albumin and BCAA metabolism. 1

• Avoid supplements containing manganese, as cirrhotic patients have elevated total body manganese with potential basal ganglia accumulation. 1

Fluid Restriction: When and How Much

Fluid restriction is NOT routinely necessary for most cirrhotic patients with ascites:

• Reserve fluid restriction (1-1.5 L/day) only for patients with severe hyponatremia (serum sodium <125 mmol/L) who are clinically hypervolemic. 1, 2

• Body water is passively released through sodium excretion; therefore, appropriate sodium restriction with diuretics typically obviates the need for fluid restriction. 1

Critical Pitfalls to Avoid

1. Never prioritize sodium restriction over adequate caloric and protein intake. Studies show that strict salt restriction often leads to reduced caloric intake, worsening malnutrition and mortality. 1

2. Do not assume patient compliance without verification. Only one-third of patients actually adhere to prescribed sodium restrictions. 1

3. Avoid generic dietary handouts. Patients overwhelmingly desire specific, non-generic nutritional information and report inadequate dietary education in clinical practice. 3

4. Monitor closely when implementing sodium restriction, as it increases risk of hyponatremia, renal impairment, and hepatic encephalopathy. 1

Practical Implementation

The "no added salt" approach is most practical:

• No salt added during cooking or at the table
• Avoid precooked/processed meals (which are high in sodium)
• Provide specific nutritional counseling on reading food labels
• Ensure adequate palatability to maintain caloric intake 1