Ascites Management: How Sodium Restriction and Diuretics Really Work

When your liver is damaged by cirrhosis, fluid doesn’t just sit where it should-it leaks into your belly. This is ascites, and it’s not just uncomfortable. It’s a sign your liver is failing. About half of people with cirrhosis will develop ascites within 10 years, and once it shows up, your chances of living another two years drop to 50%. That’s not a scare tactic-it’s what the American Association for the Study of Liver Diseases says. The good news? You can manage it. The tricky part? The rules have changed, and doctors aren’t all on the same page anymore.

Why Fluid Builds Up in Your Belly

It starts with high pressure in the veins around your liver. This pressure forces fluid out of your blood vessels and into your abdomen. But here’s the twist: your kidneys don’t just let it go. They start holding onto sodium and water like they’re running out of supply. That’s because your body thinks your blood volume is low-even though there’s fluid pooling in your belly. It’s a cruel trick. Your liver can’t filter toxins, your kidneys can’t flush fluid, and your body keeps making the problem worse.

The Old Rule: Eat Less Salt

For decades, the go-to advice was simple: cut salt to under 2 grams a day. That’s less than a teaspoon of table salt. The logic? Less sodium means less fluid retention. It sounds straightforward. But here’s the catch: most of the sodium you eat doesn’t come from the salt shaker. It’s in bread, canned soup, deli meats, sauces, and packaged snacks. Trying to hit under 2 grams a day means reading every label, cooking everything from scratch, and avoiding restaurants entirely. Studies show fewer than 4 in 10 people can stick to it.

The New Debate: Is Salt Really the Enemy?

Recent studies are flipping the script. In 2022, a major trial found that patients with ascites who ate 5-6.5 grams of salt per day (about 2-2.5 grams of sodium) actually had less fluid buildup than those on strict low-salt diets. Their ascites resolved in 45% of cases-nearly three times higher than the 16% who followed the old 2-gram rule. Why? Because when you cut salt too hard, your kidneys go into survival mode. They slow down blood flow to the kidneys, which can trigger something even worse: hepatorenal syndrome. That’s when kidney function crashes, and survival drops to under 6 months.

Dr. Pere Gines, who led that 2022 study, says strict salt restriction might actually hurt more than help. He’s not saying eat pizza every day. He’s saying: don’t panic. Moderate salt intake-with the right diuretics-works better than extreme restriction.

Diuretics: The Real Workhorses

Salt restriction alone won’t fix ascites. Diuretics do. The two main ones are spironolactone and furosemide. Spironolactone is the first-line drug. You start at 100 mg a day, and your doctor will bump it up every 3 days-up to 400 mg-if needed. It works by blocking the hormone that tells your kidneys to hang onto sodium. Furosemide comes in second. You start at 40 mg a day, maxing out at 160 mg. It’s stronger and faster, but it can mess with your electrolytes if used alone.

Together, they’re powerful. About 90% of people with simple ascites see improvement when both are used correctly. But there’s a catch: you can’t rush it. Your doctor will want you to lose no more than 0.5 kg (1 pound) per day if you don’t have swollen legs, and 1 kg (2 pounds) if you do. Lose weight too fast, and you risk kidney failure or low blood pressure.

What to Watch For: Hyponatremia and Drug Risks

About 1 in 3 people with ascites have low sodium in their blood-hyponatremia. That doesn’t mean you need more salt. It means your body is holding onto too much water. If your sodium drops below 130, your doctor will adjust your diuretics and may limit fluids. Never take NSAIDs like ibuprofen or naproxen. They can crash your kidney function. Same with ACE inhibitors and ARBs-blood pressure meds that sound harmless but can speed up kidney damage in cirrhosis. One study found these drugs triple the risk of needing dialysis.

When Diuretics Don’t Work

About 1 in 10 people don’t respond to diuretics, even at max doses. That’s called refractory ascites. If you’re in this group, your only real option is a procedure called large-volume paracentesis. A needle is inserted into your belly to drain the fluid-up to 5 liters at a time. But here’s the catch: you need to get an IV infusion of albumin afterward. Without it, your blood pressure drops, and your kidneys can fail. This isn’t a cure-it’s a rescue. It needs to be done in a hospital, and it carries a 5-10% risk of infection or bleeding.

What About Other Treatments?

There are drugs called vaptans that block water retention. They sound perfect. But they cost $5,000 to $7,000 per course-and you can only use them for 30 days. They’re not for long-term use. Transplant is the only cure, but not everyone qualifies. For now, diuretics and smart sodium intake are your best tools.

The Middle Ground: A Practical Approach

So what should you do? Don’t go full keto on salt. Don’t eat a bag of chips a day. Aim for 4-6 grams of salt total per day-that’s about one and a half teaspoons. Focus on whole foods: fresh meat, vegetables, fruits, rice, beans. Avoid processed stuff. Read labels. If a food has more than 300 mg of sodium per serving, skip it. Cook at home. Use herbs, lemon, vinegar instead of salt.

And never stop your diuretics without talking to your doctor. Even if you feel better, stopping them suddenly can make fluid come back fast. Your doctor will check your blood sodium at least twice a week when you start. That’s not overkill-it’s essential.

What’s Coming Next?

A big trial called PROMETHEUS is underway, comparing strict salt restriction with no restriction in cirrhosis patients. Results are due by the end of 2025. Until then, the debate continues. But one thing is clear: ascites management isn’t about following a rigid rule. It’s about balance. Your liver is weak. Your kidneys are stressed. Your body is trying to survive. The goal isn’t perfection-it’s control. Enough salt to keep your kidneys working. Enough diuretics to drain the fluid. And enough monitoring to catch trouble before it’s too late.