When fluid builds up in your belly because of liver disease, it’s not just uncomfortable-it’s a warning sign. This fluid buildup, called ascites, happens in about half of people with cirrhosis within 10 years. And once it shows up, your chances of living another two years drop by half. The good news? You can control it-with two powerful tools: cutting back on salt and taking diuretics. But here’s the twist: what doctors have told you for decades might not be the whole story anymore.

Why Ascites Happens

Ascites isn’t just water sitting in your belly. It’s the result of a broken system. When your liver is damaged by cirrhosis, blood flow through it gets blocked. That raises pressure in the portal vein-the main blood vessel feeding the liver. When that pressure hits 12 mmHg or higher, fluid starts leaking into your abdomen. At the same time, your kidneys start holding onto sodium like it’s gold. That sodium pulls water with it, and boom-fluid pools where it shouldn’t.

This isn’t random. It’s your body’s desperate attempt to fix low blood volume. But instead of helping, it makes things worse. The more fluid you retain, the more your body tries to hold on, creating a cycle that’s hard to break without intervention.

Sodium Restriction: The Old Rule and the New Debate

For years, doctors told patients with ascites to eat less than 2 grams of sodium a day. That’s about 5 grams of salt-roughly one teaspoon. It sounds simple. But try doing it. Most of the sodium you eat doesn’t come from the salt shaker. It’s in bread, canned soup, deli meats, sauces, and even breakfast cereal. A 2021 study found fewer than 4 in 10 patients could stick to that limit.

And now, new research is shaking things up. Two major trials from 2017 to 2022 found that people who ate 5 to 6.5 grams of salt a day (about 2 to 2.5 grams of sodium) actually had better outcomes than those on strict low-sodium diets. Their ascites resolved in 45% of cases, compared to just 16% in the strict restriction group. They also needed fewer procedures to drain fluid from their bellies.

Why? Because going too low can backfire. When you cut sodium too hard, your kidneys don’t get enough blood flow. That can trigger something called hepatorenal syndrome-a dangerous drop in kidney function that’s already a risk in cirrhosis. One study showed severe sodium restriction pushed that risk from 18% to 35%.

So what’s the real answer? Experts are split. Dr. Guadalupe Garcia-Tsao, who helped write the American guidelines, still says 2 grams is the target. But Dr. Pere Gines, who led the 2022 study, says strict restriction may actually hurt more than help. Dr. Frederick Wong from Toronto suggests a middle ground: aim for 5 to 6.5 grams of salt daily-not zero, not unlimited. That’s about 1.5 to 2.5 grams of sodium. It’s enough to avoid kidney strain, but still helps diuretics work better.

Diuretics: The Engine That Drains the Fluid

Sodium restriction alone doesn’t do enough. That’s where diuretics come in. These are pills that tell your kidneys to flush out extra salt and water. The two main ones used are spironolactone and furosemide.

Spironolactone is the first-line drug. You start with 100 mg a day, and if it’s not working after three days, your doctor may bump it up-every 72 hours-until you hit 400 mg. It works slowly but steadily. Furosemide is added if you’re still retaining fluid. You start with 40 mg and can go up to 160 mg. The combo is usually reserved for people who’ve had ascites before or who aren’t responding to spironolactone alone.

Here’s the key: you don’t want to lose weight too fast. If you have swelling in your legs, you can safely lose up to 1 kg (2.2 lbs) per day. If you don’t have swelling, stick to 0.5 kg (1 lb) per day. Losing weight too fast can crash your blood pressure or hurt your kidneys.

And you need to watch your blood sodium levels. About one in three people with ascites already have low sodium. If it drops below 130, your doctor will adjust your diuretics and maybe limit fluids. If it’s too low and you’re dehydrated, you might need IV saline and lower diuretic doses.

What Not to Take

Some common medications can make ascites worse. Avoid NSAIDs like ibuprofen or naproxen. They reduce blood flow to the kidneys and can trigger kidney failure in people with cirrhosis. ACE inhibitors and ARBs-used for high blood pressure-are also risky. Studies show they raise the chance of end-stage kidney disease by more than double in cirrhosis patients.

Even over-the-counter painkillers can be dangerous. Always check with your doctor before taking anything new. Your liver is already working overtime. Don’t make it harder.

When Diuretics Don’t Work

Five to ten percent of people with ascites don’t respond to maximum doses of diuretics. This is called refractory ascites. For them, draining the fluid with a needle-called large-volume paracentesis-is the next step. Doctors remove up to 5 liters at a time and give back albumin (a blood protein) to keep blood pressure stable. It’s effective, but it needs to be done in a hospital, and there’s a 5-10% risk of infection or bleeding.

There are other drugs, like vaptans, that block water retention. But they cost $5,000 to $7,000 a course and can only be used for 30 days. They’re not practical for most people.

The Bigger Picture: Personalized Care

The old one-size-fits-all approach to sodium is fading. Hepatologists today are moving toward individualized plans. At the 2022 AASLD meeting, 65% of doctors said they adjust sodium limits based on the patient’s kidney function, appetite, and overall health-not just a rigid number.

Why? Because many people with cirrhosis are malnourished. Between 35% and 90% lack enough protein and calories. If you’re so focused on cutting salt that you stop eating, you’re trading one problem for another. Your body needs fuel to heal. Sometimes, a slightly higher salt intake that lets you eat more is better than a strict diet that leaves you weak.

Future studies like the PROMETHEUS trial (NCT04567890), expected to finish in late 2025, may finally settle the debate. Until then, the best approach is this: work with your doctor to find the lowest sodium level you can stick to without losing your appetite or energy-and pair it with the right diuretic dose.

What You Can Do Today

• Check food labels. Look for sodium content-not salt. 1 gram of sodium = 2.5 grams of salt.
• Avoid processed foods. Choose fresh meats, vegetables, and plain grains.
• Use herbs and lemon instead of salt for flavor.
• Take diuretics exactly as prescribed. Don’t skip doses or double up.
• Track your weight daily. A sudden gain of 2 kg (4.4 lbs) in a week means fluid is building up.
• Get your blood sodium checked at least twice a week when starting treatment.
• Never take NSAIDs or blood pressure meds without your doctor’s approval.

Ascites is serious, but it’s manageable. It’s not about perfection. It’s about balance. Enough salt to keep your kidneys working, enough diuretics to drain the fluid, and enough nutrition to keep your body strong. That’s the new standard.