Dietary salt in liver cirrhosis: With a pinch of salt!

Abstract

Patients with liver cirrhosis are advised to limit their sodium consumption to control excessive fluid accumulation. Salt is the most common form in which sodium is consumed daily. Consequently, various recommendations urge patients to limit salt intake. However, there is a lack of consistency regarding salt restriction across the guidelines. Moreover, there is conflicting evidence regarding the efficacy of salt restriction in the treatment of ascites. Numerous studies have shown that there is no difference in ascites control between patients with restriction of salt intake and those without restriction. Moreover, patients with cirrhosis may have several negative effects from consuming too little salt, although there are no recommendations on the lower limit of salt intake. Sodium is necessary to maintain the extracellular fluid volume; hence, excessive salt restriction can result in volume contraction, which could negatively impact kidney function in a cirrhotic patient. Salt restriction in cirrhotic patients can also compromise nutrient intake, which can have a negative impact on the overall outcome. There is insufficient evidence to recommend restricted salt intake for all patients with cirrhosis, including those with severe hyponatremia. The existing guidelines on salt restriction do not consider the salt sensitivity of patients; their nutritional state, volume status and sodium storage sites; and the risk of hypochloremia. This opinion article aims to critically analyze the existing literature with regard to salt recommendations for patients with liver cirrhosis and identify potential knowledge gaps that call for further research.

Keywords: Ascites; Cirrhosis; Hyponatremia; Malnutrition; Salt; Sodium.

Figure 1

Adverse consequences of too little and too high salt consumption. Salt consumption < 5 g/d appears to have no advantage on the control of ascites. Severe salt restriction (< 3 g/d) as well as very high salt consumption (> 10 g/d) can produce many deleterious consequences in cirrhosis patients. The World Health Organization has recommended a daily salt intake of approximately 5 g/d in the general population which is similar to the recommendation for cirrhosis patients with ascites.