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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1018-1022
The effect of use of dates on serum potassium in nondiabetic hemodialysis patients


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 Publication27-Oct-2009
 

   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 2020 Sep 22];20:1018-22. Available from: http://www.sjkdt.org/text.asp?2009/20/6/1018/57257

   Introduction Top


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 Top


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 Top


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 Top


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 Top


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 Top


  1. Dr. Manzoor Al Hazmi for help in procuring the Arabic references and deciphering them.
  2. Nada Ayman for help with the figures.
[Figure 1]

 
   References Top

1.Qur'an 19:25-26.  Back to cited text no. 1      
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.  Back to cited text no. 2      
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.  Back to cited text no. 3      
4..H. Barreveld in Date Palm Products. FAO Agricultural services bulletin No. 101. 1993.   Back to cited text no. 4      
5.Ar Raqeyye Ibrahim bin Mohammad. Al munatayat atthamnweeyah lil nakheel wa tamoor. Al Uloom wa technieqiyah. Shawal 1422 (Arabic).  Back to cited text no. 5      
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.  Back to cited text no. 6  [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.  Back to cited text no. 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.  Back to cited text no. 8      
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.  Back to cited text no. 9  [PUBMED]    
10.Gennari FJ, Segal AS. Hyperkalemia: an adaptive response in chronic renal insufficiency. Kidney Int 2002;62:1-9.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Ahmed J, Weisberg LS. Hyperkalemia in dia­lysis patients. Semin Dial 2001;14:348-56.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Nauman Siddiqi
Consultant Nephrology, King Fahd Armed Forces Hospital, P.O. Box 9862, Jeddah 21159
Saudi Arabia
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PMID: 19861864

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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    Abstract
    Introduction
    Methods
    Statistical Analysis
    Results
    Discussion
    Acknowledgement
    References
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