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Recommendations Summary

HF: Sodium and Fluid Intake (2017)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    HF: Individualize Sodium and Fluid Intake in Heart Failure (NYHA Classes I-IV/AHA Stages B, C and D)

    For adults with heart failure (NYHA Classes I - IV/AHA Stages B, C and D), the registered dietitian nutritionist (RDN) should individualize sodium and fluid intake, within the ranges of 2000 - 3000 mg sodium per day and 1 - 2 L fluid per day. Research reports that a sodium intake of 2000 - 3000 mg per day and fluid intake of 1 - 2 L per day resulted in improvements in quality measures (readmissions rate, length of stay and mortality rate), renal function and clinical laboratory measures (blood urea nitrogen, creatinine, brain natriuretic peptide and serum sodium), symptom burden (shortness of breath, difficulty breathing when lying flat, swelling of legs or ankles, lack of energy, and lack of appetite) and body weight.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      If the patient is hypovolemic, alterations in diuretics, fluid and sodium intake should be considered before treating for renal insufficiency.

      Regarding nutrition practice guidelines for hypertension, the registered dietitian nutritionist (RDN) should refer to the Academy of Nutrition and Dietetics Hypertension Systematic Review and Guideline. 

      Regarding nutrition practice guidelines for chronic kidney disease, the registered dietitian nutritionist should refer to the Academy of Nutrition and Dietetics Chronic Kidney Disease Systematic Review and Guideline.

      Caffeinated and alcoholic beverages should be included in overall daily fluid intake. If a patient currently drinks alcohol, and if not contraindicated, then a maximum of one drink per day for women and up to two drinks per day for men may be tolerated. This level of alcohol consumption has been demonstrated to not be harmful in heart failure patients.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      A total of four studies were included in the evidence analysis supporting the recommendations. Three studies were conducted in patients with heart failure (NYHA Classes I - IV/AHA Stages B and C) (Arcand et al, 2011; Paterna et al, 2011; Son et al, 2011) and one study in patients with advanced heart failure (NYHA Class IV/AHA Stage D) (Spaderna et al, 2013):

      • One positive-quality randomized controlled trial (Paterna et al, 2011)
      • Two positive-quality prospective cohort studies (Arcand et al, 2011; Son et al, 2011)
      • One neutral-quality prospective cohort study (Spaderna et al, 2013)
      Heart Failure (NYHA Classes I - IV/AHA Stages B and C):
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that among subjects receiving 1 L fluid per day, those consuming 2800 mg sodium per day had significantly reduced BUN, creatinine and BNP levels than those consuming 1800 mg sodium per day. In addition, subjects consuming 2800 mg sodium per day had serum sodium levels that were increased and maintained within normal limits, whereas subjects consuming 1800 mg sodium per day had a gradual reduction in serum sodium to below normal limits (Paterna et al, 2011). Further research is needed regarding the effect of sodium and/or fluid intake on renal function and clinical labs. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that among subjects receiving 1 L fluid per day, those consuming 2800 mg sodium per day had significantly reduced readmissions rate, length of stay and mortality rate than those consuming 1800 mg sodium per day (Paterna et al, 2011). However, among subjects receiving 2.0- 2.4 L fluid per day, subjects consuming 2800 mg sodium per day or more had significantly higher mortality rates than subjects consuming 1900 mg sodium per day or less, and no patient death was observed in the middle tertile of 2000-2700 mg sodium per day (Arcand et al, 2011). Further research is needed regarding the effect of sodium and/or fluid intake on quality measures. Grade III
      • In patients with heart failure (NYHA Classes I - IV/AHA Stages B and C), research reported that among subjects receiving 1 L fluid per day, those consuming 2800 mg sodium per day had significant and sustained reductions in body weight and improvements in NYHA class compared to those consuming 1800 mg sodium per day (Paterna et al, 2011). In addition, research reported that a sodium intake less than 3000 mg/day resulted in reduced symptom burden (in terms of frequency and severity of shortness of breath, difficulty breathing when lying flat, swelling of legs or ankles, lack of energy, and lack of appetite) when compared to sodium intake levels above 3000 mg/day but fluid intake was not reported (Son et al, 2011). Further research is needed regarding the effect of sodium and/or fluid intake on quality of life, signs and symptoms. Grade III
      Advanced Heart Failure (NYHA Class IV/AHA Stage D):
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), research reported that hyponatremia (<130 mg/dL) was associated with fluid intake >2 L/day (Spaderna et al, 2013). Research is needed regarding the effect of sodium and/or fluid intake on BUN, creatinine and BNP in patients with advanced heart failure. Grade III
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), research reported an increased risk of death/deterioration associated with frequent consumption of salty foods and/or increased ratio of fluids to cardiac index (Spaderna et al, 2013). Research is needed regarding the effect of sodium and/or fluid intake on readmissions rate and length of stay in patients with advanced heart failure. Grade III
      • In patients with advanced heart failure (NYHA Class IV/AHA Stage D), research reported that patients who consumed salty foods more frequently were more likely to be symptomatic, as indicated by NYHA functional class IV (Spaderna et al, 2013). Research is needed regarding the effect of sodium and/or fluid intake on quality of life in patients with advanced heart failure. Grade III 
      From the 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF):

      7. Treatment of Stages A to D
      7.2 Stage B: Recommendations

      Class I
      • In patients with structural cardiac abnormalities,  including LV hypertrophy, in the absence of a history of MI or ACS, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF. (Level of Evidence: A)
      7.3. Stage C
      7.3.1. Nonpharmacological Interventions
      7.3.1.3. Sodium Restriction: Recommendation

      Class IIa
      • Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms. (Level of Evidence: C)
      7.4 Stage D
      7.4.3. Water Restriction: Recommendation

      Class IIa
      • Fluid restriction (1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms. (Level of Evidence: C)

    • Recommendation Strength Rationale

      • Conclusion Statements in support of these recommendations were given Grade III
      • The 2013 ACCF/AHA Guidelines for the Management of Heart Failure received Levels of Evidence A and C

    • Minority Opinions

      Consensus reached.