Sodium Restriction is the Most Appropriate Dietary Advice
The correct answer is A: Sodium restriction to less than 2 g per day (88 mmol/day). This is the cornerstone dietary intervention for managing ascites in cirrhosis, regardless of response to paracentesis.
Rationale for Sodium Restriction
Sodium restriction is the primary dietary modification recommended for all patients with cirrhotic ascites. The mechanism of ascites formation in cirrhosis involves renal sodium and water retention due to portal hypertension and splanchnic vasodilation. 1
Specific Sodium Intake Targets
Daily sodium intake should be limited to 88 mmol/day (approximately 2000 mg sodium or 5-6.5 g salt per day). This translates practically to a "no added salt" diet with avoidance of precooked meals. 1
The 2021 Gut guidelines provide a strong recommendation (moderate quality evidence) for this level of sodium restriction in all patients with cirrhosis and ascites. 1
The 2004 Hepatology guidelines from the American Association for the Study of Liver Diseases similarly recommend 88 mmol per day (2000 mg per day) sodium restriction as first-line therapy. 1
Why Other Options Are Incorrect
Water Restriction (Option B) - NOT Routinely Indicated
Fluid restriction is NOT necessary for most patients with ascites. Water restriction should be reserved only for specific circumstances. 1
Fluid restriction to 1-1.5 L/day is indicated ONLY when patients are clinically hypervolemic with severe hyponatremia (serum sodium <120-125 mmol/L). 1
Body water is passively released by excretion of sodium in the kidney; therefore, fluid restriction is not usually necessary if sodium restriction is properly implemented. 1
Protein Restriction (Option C) - Contraindicated
Protein restriction is NOT recommended and may be harmful. Most cirrhotic patients with ascites are already malnourished. 1
Current guidelines recommend INCREASING protein intake to 1.2-1.5 g/kg/day (or even 1.5 g/kg/day in critically ill patients) to prevent malnutrition. 1
Greater dietary sodium restriction beyond recommended levels is specifically discouraged because it may worsen the malnutrition that is usually present in these patients. 1
Fat Restriction (Option D) - Not Evidence-Based
- Fat restriction has no role in the management of ascites and is not mentioned in any major guideline for this indication. 1
Clinical Implementation
Practical Dietary Counseling
Patients should receive nutritional counseling on the sodium content in their diet (strong recommendation despite weak quality evidence). 1
Educate patients to avoid precooked meals, processed foods, and adding salt to food. 1
In a study of 77 patients with hepatocellular carcinoma and ascites, active nutritional education improved patient prognosis. 1
Monitoring Dietary Compliance
Urinary sodium excretion can assess dietary compliance. Patients consuming 88 mmol sodium per day with minimal urinary excretion should retain approximately 78 mmol per day. 1
If patients require large-volume paracentesis more frequently than every 2 weeks despite appropriate diuretic therapy, they are likely not complying with the sodium-restricted diet. 1
Common Pitfalls to Avoid
Do not restrict protein in an attempt to manage ascites - this worsens nutritional status and outcomes. 1
Do not routinely restrict fluids - this is only for severe hyponatremia (<120-125 mmol/L). 1
Do not recommend sodium restriction more severe than 2 g/day - excessive restriction worsens malnutrition without additional benefit. 1
Ensure patients understand that "no added salt" still allows approximately 2 g sodium from natural food sources. 1