Letter to the Editor: Revisiting salt restriction in hyponatremic cirrhosis - a paradigm in need of refinement?

The management of decompensated cirrhosis is fraught with clinical dilemmas, often requiring a delicate balance between opposing physiological principles. One such enduring controversy is the role of dietary sodium restriction, long considered a cornerstone in the management of ascites and fluid overload. The study by Marrapu et al published in the World Journal of Methodology, directly challenges this convention in a specific and vulnerable population: Patients with cirrhosis and moderate to severe hyponatremia. Their open-label randomized controlled trial provides compelling evidence that a salt-restricted diet (5 g/day) may be harmful compared to a more liberal, salt-unrestricted diet (10 g/day), associating salt-restricted diet with a significantly higher risk of acute kidney injury, poorer nutritional and hemodynamic profiles, and increased short-term mortality, without offering a clear benefit in ascites control.