When your liver is damaged-especially from cirrhosis-fluid can start pooling in your belly. This isn’t just discomfort; it’s a warning sign. That fluid buildup is called ascites, and it affects about half of all people with cirrhosis within 10 years. It’s not just a symptom-it’s a signal that your liver is failing to keep up. Left unmanaged, ascites can lead to infections, kidney problems, and worse. But here’s the thing: the way we’ve been told to treat it might not be the whole story.
Why Does Ascites Happen?
Ascites doesn’t appear out of nowhere. It’s the result of two big problems working together: high pressure in the liver’s blood vessels (portal hypertension) and your kidneys holding onto too much salt and water. When your liver is scarred, blood can’t flow through it easily. That backs up pressure into the veins around your gut. Your body senses this as low blood volume-even though there’s too much fluid overall. So it triggers hormones that make your kidneys hang on to sodium and water, thinking you’re dehydrated. The result? Fluid leaks into your abdomen.
This isn’t just about drinking too much water. It’s about sodium. Every gram of salt you eat pulls in about 10 times its weight in water. In a healthy person, the kidneys flush out the extra. In cirrhosis, they can’t. That’s why controlling sodium isn’t optional-it’s the foundation of treatment.
The Sodium Restriction Debate
For decades, doctors told patients to cut sodium to less than 2 grams a day. That’s about 5 grams of salt-roughly one teaspoon. It sounds simple. But try living on it.
Most of the sodium we eat doesn’t come from the salt shaker. It’s in bread, canned soup, deli meats, sauces, even breakfast cereal. A single slice of store-bought bread can have 200-300 mg of sodium. That means you’re already halfway to your daily limit before lunch. Studies show fewer than 4 in 10 patients stick to this strict limit. And the harder you push it, the worse it can get.
Recent research is turning the old advice upside down. Two large studies published between 2017 and 2022 found that patients on a moderate sodium intake-around 5 to 6.5 grams of salt per day-had better outcomes than those on strict restriction. They had less fluid buildup, needed fewer hospital visits for fluid drainage, and had fewer kidney problems. Why? Because going too low can drop your blood pressure too much. That makes your kidneys shut down even more, worsening the very problem you’re trying to fix.
Dr. Pere Gines, who led one of those studies, says: “Strict sodium restriction may be counterproductive.” Meanwhile, Dr. Guadalupe Garcia-Tsao, who helped write the American guidelines, still recommends staying under 2 grams, warning that malnutrition is a bigger risk than too much salt. So who’s right? The truth is, it’s not one-size-fits-all.
Diuretics: The Real Workhorses
If sodium restriction alone doesn’t cut it-and it rarely does-then diuretics are what actually move the needle. These aren’t magic pills. They’re tools that help your kidneys dump the extra salt and water your body is clinging to.
The first-line drug is spironolactone. It blocks a hormone that tells your kidneys to hold onto sodium. Doctors usually start with 100 mg a day and bump it up every few days, up to 400 mg, until you’re losing fluid steadily. It’s slow-acting but gentle on your kidneys.
If that’s not enough, they add furosemide. This one works faster-it’s a loop diuretic that hits your kidneys harder. Start at 40 mg, max out at 160 mg. You rarely need both drugs at full dose. But combining them can be powerful. The key is balance: too much, and you risk low potassium, low blood pressure, or kidney damage.
The goal isn’t to make you lose weight fast. It’s to lose no more than 0.5 kg (1 pound) per day if you don’t have swollen legs, or up to 1 kg (2 pounds) if you do. Losing weight too fast can crash your blood pressure or damage your kidneys. That’s why doctors check your blood sodium levels twice a week when you start treatment.
What You Shouldn’t Take
Some common medications can make ascites worse. Avoid NSAIDs like ibuprofen or naproxen. They reduce blood flow to your kidneys, which your liver already struggles to support. Same goes for ACE inhibitors and ARBs-drugs used for high blood pressure or heart failure. In cirrhosis, these can increase your risk of kidney failure by more than twice.
If you’re on any of these, talk to your doctor. Don’t stop them on your own-but do ask if they’re still safe for your liver condition.
When Diuretics Don’t Work
Five to ten percent of people with ascites don’t respond to diuretics, even at maximum doses. That’s called refractory ascites. It’s serious. Survival drops to about 50% within six months without intervention.
The go-to fix here is large-volume paracentesis. That’s a procedure where a needle drains off several liters of fluid from your belly. It’s quick, effective, and often done as an outpatient. But there’s a catch: when you remove that much fluid, your blood pressure can drop. So doctors give you albumin-a protein solution-right after. For every liter of fluid removed, you get 8 grams of albumin. This keeps your circulation stable.
It’s not a cure. But it’s a lifeline. Many people need this every few weeks. Some end up on transplant lists because of it.
What About Other Treatments?
You might hear about vaptans-drugs like tolvaptan that block water retention. They sound promising. But they’re expensive ($5,000-$7,000 per course), only approved for 30 days, and come with serious liver risks. They’re not first-line. They’re last-resort.
There’s also research into new biomarkers-like measuring sodium in your urine-to guide treatment. Instead of guessing your sodium needs, you’d know exactly how much your body is holding onto. That’s the future. But for now, we’re still stuck with the old tools: diet, diuretics, and drainage.
What Should You Do?
Here’s what works in real life, based on current evidence:
- Start with moderate sodium restriction: aim for 4-6 grams of salt per day (not the strict 2 grams). That’s easier to stick to and safer for your kidneys.
- Use spironolactone first. If you’re not losing fluid after a week, add furosemide.
- Track your weight daily. A sudden gain of 2 kg (4.4 lbs) in a few days means fluid is building up again.
- Avoid NSAIDs and blood pressure drugs unless your doctor says they’re safe.
- If diuretics stop working, ask about paracentesis. Don’t wait until you’re in pain.
- Watch for signs of infection: fever, belly pain, confusion. That could be spontaneous bacterial peritonitis-deadly if missed.
The biggest mistake? Thinking you can fix this with diet alone. You can’t. Sodium restriction helps, but diuretics are what make the difference. And even then, some people need more.
The Bottom Line
Ascites management isn’t about following a rigid rulebook. It’s about adapting to your body. The old advice-cut sodium to 2 grams a day-is outdated for many. The new thinking? Less extreme restriction, smarter diuretic use, and early intervention when things stall.
Work with your hepatologist. Get your sodium levels checked. Track your weight. Know when to push for drainage. And don’t be afraid to question the rules-if your doctor says “no salt at all,” ask why, and what the evidence says.
Because when your liver is struggling, every gram of salt, every pill, every liter drained matters. Not because of dogma-but because science is finally catching up to what patients are really experiencing.
How much sodium should I really limit if I have ascites?
The old guideline of less than 2 grams of sodium per day is hard to follow and may not be right for everyone. Current evidence suggests a moderate limit of 4-6 grams of salt per day (about 1.6-2.4 grams of sodium) works better for most people. This reduces fluid buildup without increasing the risk of kidney problems. Always check with your doctor, especially if you have low blood sodium levels.
Can I eat out if I have ascites?
Yes-but you need to be smart. Avoid soups, sauces, processed meats, and fried foods. Ask for meals without added salt. Choose grilled chicken or fish, steamed vegetables, and plain rice. Request dressings and condiments on the side. Most restaurants will accommodate if you ask early. Planning ahead is key.
Why do I need to check my weight every day?
Daily weight is the most sensitive way to track fluid changes. A gain of 1 kg (2.2 lbs) in a day means you’re retaining fluid. A gain of 2 kg (4.4 lbs) in 3 days means your treatment isn’t working. Early detection lets your doctor adjust your diuretics before you need a hospital visit. Weigh yourself at the same time each day, after using the bathroom and before eating.
What are the side effects of spironolactone and furosemide?
Spironolactone can raise potassium levels and cause breast tenderness or menstrual changes in women. Furosemide can cause low potassium, dizziness, or dehydration. Both can lower blood pressure too much. Your doctor will check your blood levels regularly-especially sodium and potassium-to make sure you’re not going too far. Never skip these tests.
Is ascites reversible?
In early stages, yes-if you catch it early and stick to treatment, fluid can fully resolve. But if cirrhosis is advanced, ascites usually comes back. That doesn’t mean treatment isn’t worth it. Managing it well can keep you out of the hospital, avoid infections, and give you more time-sometimes years-before needing a transplant.
Can I drink alcohol if I have ascites?
No. Alcohol directly damages liver cells and worsens portal hypertension. Even small amounts can accelerate fluid buildup and increase your risk of liver failure. Abstinence is non-negotiable. If you’ve struggled to quit, ask your doctor about support programs. Your liver doesn’t have to be perfect to heal-but it does need peace.
When should I go to the hospital for ascites?
Go right away if you have fever, new belly pain, confusion, or yellowing skin. These could mean infection (spontaneous bacterial peritonitis) or kidney failure. Also go if you’ve gained more than 2 kg (4.4 lbs) in 3 days despite taking diuretics, or if you’re too dizzy to stand. Don’t wait for it to get worse.
What’s Next?
A major clinical trial called PROMETHEUS is set to finish in late 2025. It’s comparing strict sodium restriction with a more relaxed approach in hundreds of patients. The results could finally settle the debate. Until then, the best approach is personalized: work with your care team, track your numbers, and don’t accept outdated advice just because it’s been around a long time.