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| Year : 2009 | Volume
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| Issue : 6 | Page : 1018-1022 |
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| The effect of use of dates on serum potassium in nondiabetic hemodialysis patients |
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Nauman Siddiqi1, Osama El Shahat2, Ebtisam Bokhari1, Haytham Roujouleh1, M Hisham Hamid2, Iftikhar Sheikh2, Hassan El-Sayed2, Ayman Saleh2, Ayman Seddik2
1 Consultant Nephrology, Department of Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
2 Registrar Nephrology, Department of Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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| Date of Web Publication | 27-Oct-2009 |
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 Abstract | | |
Hyperkalemia is common in patients with ESRD and may contribute to mortality. Dates have been reported to be high in potassium content. One of the concerns on hemodialysis (HD) is convincing patients to give up ingestion of dates as a part of their diet. To determine the effect of dates on serum potassium on patients, we studied 9 (M: F, 6:3, mean age 47.6) non diabetic patients on chronic hemodialysis, without evidence of hyperkalemia on monthly labs. Nearly all the patients had been on dialysis for an average of four years. The average monthly potassium was 4.6 mmol/L. The patients ingested 100 gm of dates (Rothana and Sukari) on two separate dialysis sessions. Serum potassium was measured at two and four hours post ingestion along with ECG monitoring. The patients underwent their regular dialysis as scheduled. The patients acted as their own controls and underwent the same protocol with 20meq of KCl on a separate session. The potassium levels did not change significantly over the four hours with either variety of dates or with potassium solution. Combining the two types of dates resulted in a trend towards higher potassium levels than with KCl, but it did not reach statistical significance. We conclude that in selected HD patients without hyperkalemia, ingestion of a few dates does not cause significant hyperkalemia and could be allowed on days of dialysis prior to their dialysis sessions.
How to cite this article:
Siddiqi N, El Shahat O, Bokhari E, Roujouleh H, Hamid M H, Sheikh I, El-Sayed H, Saleh A, Seddik A. The effect of use of dates on serum potassium in nondiabetic hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:1018-22 |
How to cite this URL:
Siddiqi N, El Shahat O, Bokhari E, Roujouleh H, Hamid M H, Sheikh I, El-Sayed H, Saleh A, Seddik A. The effect of use of dates on serum potassium in nondiabetic hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2023 Feb 8];20:1018-22. Available from: https://www.sjkdt.org/text.asp?2009/20/6/1018/57257 |
| Introduction | |  |
Daily consumption of dates is part of the cultural fabric of Saudi Arabia and the use of dates dates is much higher than the rest of the world. One of the most difficult adjustments for patients on hemodialysis (HD) in Saudi Arabia is to cease including dates in their diet. Currently, we recommend against ingestion of dates to all patients with end- stage renal disease (ESRD). Anecdotal evidence suggests that there is a significant population with hyperkalemia but the actual incidence in our population is unknown.
We aim in this study to determine the effect of ingestion of dates on serum potassium levels in non- diabetic patients on HD.
| Methods | | |
This is an open label observational study. The protocol was approved by the Research and Ethics committee at our institution. Adult patients (> 18 years of age) on chronic HD at King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia were recruited after informed consent. Patients with hyperkalemia (> 5.5 mmol/L on their monthly laboratory investigations and those who required urgent dialysis for hyperkalemia during the last one month), diabetic patients requiring treatment with either oral hypoglycemics or insulin, and patients receiving angiotensin converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) were excluded.
Patients who were adequately dialyzed (monthly URR > 65%) and met the above criteria were asked to participate. We did not change the contents of the dialysis bath or duration of dialysis during the study period. The treating physician was allowed to adjust the erythropoietin dose, phosphate binders and vitamin D dose as deemed necessary. Antihypertensive medications other than ACEI or ARBs were allowed in case the patient required them for blood pressure control.
The patients were evaluated on the day of their dialysis session. Vital signs were obtained along with a base line electrocardiogram (ECG). Predialysis blood samples were drawn for baseline serum chemistry including sodium, potassium, chloride and bicarbonate (HCO 3 ). The patients were provided breakfast that included 100 gm of dates. Serum potassium was measured at two and four hours post ingestion. The patients underwent their regular dialysis as scheduled. The ECGs were repeated at the end of dialysis sessions.
The patients received the Rothana type of dates, Rutab, in the meals served during the first session, while they were served a different type of dates, Sukari, in the second session. Lastly, they received 20meq of KCl oral solution instead of the dates as a control during the third session. Each session was conducted on a separate day of dialysis.
| Statistical Analysis | | |
Statistical analysis was performed using SPSS 10.0 (SPSS Systems, USA). The means of the serum potassium levels were calculated for all the three sessions combined and separately for the different type of dates, and they were compared to KCl ingested solution. Student's t-test was used to compare the means and independent sample "t" test was used to compare different values. The level of significance was set at P< 0.05.
| Results | | |
After screening, 10 patients consented to participate in the study. One patient was dropped after the Rutab session as he was shifted to peritoneal dialysis. Nine patients completed all the three parts of the study, seven males and two females. The mean age was 47.6 years with female participants slightly older (53.5 vs. 45.6 years p NS). Nearly all the patients had been on dialysis for an average of four years. The average monthly potassium was 4.6 μmol/ L. The demographics are shown in [Table 1].
The potassium levels did not change significantly over the four hours with either variety of dates or with potassium solution [Table 2]. There was no significant difference in the potassium levels with Rutab or Sukari as compared to KCl. Combining the two types of dates resulted in a trend towards higher potassium levels than with KCl, but it did not reach statistical significance [Figure 2].
One patient in the KCl arm developed hyperkalemia during the study but he had come in with higher potassium levels, had already taken the KCl, and there was a delay in the lab results for the pre dialysis samples. However, He exhibited no symptoms and no abnormal ECG changes. In addition, he did not have any episodes of hyperkalemia prior to this event, and he later admitted to taking in juices the night before the dialysis session. His potassium on the intake of dates (both Rutab and Sukari) was within a normal range.
| Discussion | | |
The date palm has been known since the ancient times as the "tree of life" and is probably one of the first trees to be cultivated. Representations of the date palm dating 3000BC appear on Sumerian temples in current Iraq. Dates have been part of the diet and culture of the people of the Arabian Peninsula for centuries, and they have been mentioned in the scriptures of the three main religions. According to the Qur'an, dates have always been considered beneficial to mothers. When Mary gave birth to the Prophet Jesus (may peace be upon Him) under a palm tree, she heard a voice telling her:
"Shake the trunk of the palm tree towards thee: it will drop fresh, ripe dates upon thee. Eat, then, and drink, and let thine eye be gladdened!"[1]
The date palm is one of the three economically important crops of the palm family. The biological name for dates is Phoenix dactylifera. Dates ripen in four stages, which are known throughout the world by their Arabic names kimri (unripe), khalal (full-size, crunchy), rutab (ripe, soft), and tamr (ripe, sun-dried).
As for the nutritional content of dates, the sugar content in ripe dates is about 80%; the remainder consists of protein, fat and mineral products including copper, sulphur, iron, magnesium and fluoric acid. Dates are high in fiber and an excellent source of potassium. A 100 gram portion (approximately 10 dates) of fresh dates is a premium source of vitamin C and supplies 230 kcal (960 kJ) of energy, nearly all from carbohydrates. Since dates contain relatively little water, they do not become much more concentrated upon drying. [3] The sucrose content decreases as the date ripens, the highest being in the kimri stage. [4]
The mineral content of dates varies according to the type and stage of ripening. [2],[5] Of the dates present in Saudi Arabia, the potassium content varies from 808 mg/100gm of dried pulp to 905 mg/100 gm [Table 3]. [5]
Al Shihab et al reported the potassium content to vary significantly from 107 mg/100 gm to 916 mg/100 gm (2.7-23.4 mEq) in the different kinds of dates [Table 4]. This means that nearly 10 dates would deliver this amount of potassium. Interestingly they also showed that the potassium content decreases as the dates ripen. [2]
Nearly 10% of HD patients have hyperkalemia, which is the cause for emergency dialysis in nearly 24%, [6],[7] and death in approximately 3-5%. [8]
Potassium is mainly excreted by kidneys; smaller portion is excreted by extra renal processes such as the gut, especially in ESRD patients. Gastrointestinal loss may account for nearly 25% of daily potassium excretion compared to 5-10% in healthy persons. [9],[10] This is usually mediated by a nearly two to three fold increase of colonic excretion in dialysis patients, [9],[10],[11] and it is proportional to the stool volume; constipation may be expected to predispose these patients to hyperkalemia. [10]
Classically nephrologists have advised patients to avoid dates because of fear of hyperkalemia based on anecdotal experience. However, our results showed that 100 grams of dates is relatively safe in HD patients.
The limitations of this study include firstly the small number of patients, but by repeating the measurement of the serum potassium levels that number was nearly tripled. Secondly, as seen in one of our patients, the effect of other dietary indiscretions has to be taken into account before any recommendations can be made. Thirdly, we cannot extrapolate the results from days of dialysis to non-dialysis days. Lastly, it would be interesting to evaluate the stool content of potassium in patients without hyperkalemia compared to those with interdialytic hyperkalemia. In addition, we could not actually quantify the actual potassium content of the 100 grams of dates. A larger study evaluating the impact of different foods on the biochemical profile of our patients would help us to provide more evidence based guidance to our patients.
In summary, in selected patients without hyperkalemia, ingestion of a few dates can be allowed on days of dialysis prior to their dialysis sessions.
| Acknowledgement | | |
- Dr. Manzoor Al Hazmi for help in procuring the Arabic references and deciphering them.
- Nada Ayman for help with the figures.
[Figure 1]
| References | | |
| 1. | Qur'an 19:25-26.  |
| 2. | Al-Shahib W, Marshall RJ. The fruit of the date palm: its possible use as the best food for the future. Int J Food Sci Nut 2003;54:247-59. |
| 3. | Ismael B, Haffar I, Baalbaki R, et al. Physiochemical characteristics and total quality of five varieties of dates grown in the United Arab Emirates. Int J Food Sci Tech 2006;41:919-26. |
| 4. | .H. Barreveld in Date Palm Products. FAO Agricultural services bulletin No. 101. 1993. |
| 5. | Ar Raqeyye Ibrahim bin Mohammad. Al munatayat atthamnweeyah lil nakheel wa tamoor. Al Uloom wa technieqiyah. Shawal 1422 (Arabic). |
| 6. | Tzamaloukas AH, Avasthi PS. Temporal profile of serum potassium concentration in nondiabetic and diabetic outpatients on chronic hemodialysis. Am J Nephrol 1987;7:101-9. [PUBMED] |
| 7. | Sacchetti A, Stuccio N, Panebianco P, Torres M. E D hemodialysis for treatment of renal failure emergencies. Am J Emerg Med 1999; 17:305-7. [PUBMED] [FULLTEXT] |
| 8. | Morduchowicz G, Winkler J, Dranzne E, et al. Causes of death in patients with end-stage renal disease treated by dialysis in a center in Israel. Isr J Med Sci 1992;28:776-9. |
| 9. | Hayes CP Jr, McLeod ME, Robinson RR. An extra renal mechanism for the maintenance of potassium balance in severe chronic renal failure. Trans Assoc Am Physicians 1967;80: 207-16. [PUBMED] |
| 10. | Gennari FJ, Segal AS. Hyperkalemia: an adaptive response in chronic renal insufficiency. Kidney Int 2002;62:1-9. [PUBMED] [FULLTEXT] |
| 11. | Ahmed J, Weisberg LS. Hyperkalemia in dialysis patients. Semin Dial 2001;14:348-56. [PUBMED] [FULLTEXT] |
Correspondence Address:
Nauman Siddiqi
Consultant Nephrology, King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 19861864 
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4] |
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