AbstractIn the past, refractory ascites was considered to be the only indication for insertion of an ascites valve with a peritoneo‐jugular shunt. Such patients required a prolonged hospital stay prior to surgery and often succumbed to acute renal failure. In the present study, every patient entering with massive ascites was placed on a low‐salt diet for 2 weeks. Eleven patients did not respond in a 2‐week period and were placed on a regimen of continued medical therapy starting with aldactone. Although most of these patients lost weight, onehalf of them died within 6 months. Only 1 patient in the entire group survived more than a year.Sodium clearance is a simple measurement which differentiates hepatorenal syndrome from acute tubular necrosis. The absence of natriuresis on diuretic therapy is an indication that surgery is required. Sodium and water retention are no longer problems in postshunt patients.In the absence of contraindications, failure of a patient to lose weight on a salt‐restricted diet would appear to be a useful guide for the shunt operation.