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25. Diet in Chronic Kidney Disease

Chapter 25
Diet in Chronic Kidney Disease

The major role of kidneys is to remove waste products and purify blood. Besides this, the kidney plays an important role in removing extra water, minerals and chemicals; and regulates water and minerals like sodium, potassium, calcium, phosphorus and bicarbonate in the body.

In patients suffering from chronic kidney disease, (CKD) regulation of fluid and electrolytes may be deranged. Because of this reason even normal intake of water, common salt or potassium can cause serious disturbances in fluid and electrolytes balance.

To reduce the burden on the kidney with impaired function and to avoid disturbances in fluid and electrolytes balance, patients with chronic kidney disease should modify their diet as per the guidance of the doctor and the dietician. There is no fixed diet for CKD patients. Each patient is given different dietary advice depending on clinical status, the stage of kidney failure and other medical problems. Dietary advice needs alteration even for the same patient at different times.

The goals of dietary therapy in CKD patients are:

1. To slow down the progression of chronic kidney disease and to postpone the need of dialysis.

2. To reduce toxic effects of excess urea in the blood.

3. To maintain optimal nutritional status and prevent the loss of lean body mass.

4. To reduce the risk of fluid and electrolytes disturbances.

5. To reduce the risk of cardio vascular disease.

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General principles of dietary therapy in CKD patients are

  • Restrict protein intake to 0.8 gm/kg of body weight/day.
  • Supply adequate carbohydrate to provide energy.
  • Supply moderate amount of fats. Cutt down intake of butter, ghee and oil.
  • Limit the intake of fluid and water in case of swelling.
  • Restrict the amount of sodium, potassium and phosphorus in diet.
  • Supply vitamins and trace elements in adequate amount. High fiber diet recommended.

Details of selection and modification in diet of patients with CKD are as follows:

1. High Calorie Intake

The body needs calories for daily activities and to maintain temperature, growth and adequate body weight. Calories are supplied chiefly by carbohydrates and fats. Usual requirement of calories in CKD patients is 35 - 40 kcals/kg body weight per day. If caloric intake is inadequate, protein is used to provide calories. This break down of protein can lead to harmful effects such as malnutrition and greater production of waste products. So it is very essential to provide adequate amount of calories to CKD patients. It’s important to calculate the calories requirement to patient’s ideal body weight and not current weight. The weight may be either low or high especially so in patient’s pre-existing malnutrition or in diabetics with CKD

Carbohydrates

Carbohydrates

Carbohydrates are the primary source of calories for the body. Carbohydrates are found in wheat, cereals, rice, potatoes, fruits and vegetables, sugar, honey, cookies, cakes, sweets and drinks. Diabetics and obese patients need to limit the amount of carbohydrates. It's best

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to use complete carbohydrates from cereals like whole wheat, unpolished rise and millets like johar, bajra, ragi, nachni which would also give fibres. These should form large part of carbohydrates or all other simple sugar containing substances should form not more 20% of carbohydrate.

Fats

Fats are important source of calories for the body and provide two times more calories than carbohydrates or proteins. Unsaturated or "good" fats like olive oil, peanut oil, canola oil, safflower oil, sunflower oil, fish and nuts are better than saturated or "bad" fats such as red meat, poultry, whole milk, butter, ghee, cheese, coconut and lard. Reduce intake of saturated fats and cholesterol as they can cause heart disease and kidney damage.

Among the unsaturated fats it is important to pay attention to proportion of monounsaturated and polyunsaturated fats. Excessive amounts of omega-6 polyunsaturated fatty acids (PUFA) and a very high omega- 6/omega-3 ratio is harmful while low omega-6/omega-3 ratio exerts beneficial effects. Mixtures of vegetable oil rather than single oil usage will achieve the purpose. Trans fats containing substances like Vanaspati/ Dalda Ghee, potato crisps, doughnuts, commercially prepared cookies and cakes are potentially harmful and should be avoided.

2. Restrict Protein Intake

Protein is essential for the repair and maintenance of body tissues. It also helps in healing of wounds and fighting against infection. Protein restriction reduces the rate of decline in kidney function and thus delays the need for dialysis and kidney transplantation. But avoid undue protein restriction. Poor appetite is common in CKD patients. Poor appetite and strict protein restriction together can lead to poor nutrition, weight loss, lack of energy and reduction in body resistance; which increases the risk of death.

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In India, people consume mostly vegetable diet. Even those who eat non-vegetarian food don't do so on regular daily basis. The diet consume most of times both in socio-economic or better of family still fall short of protein intake advocated Indian Council of Medical Research (ICMR) which is 1gm per kg body weight. Hence, thought restriction of protein to 0.8 gm/kg is advocated for advancing stages of CKD, it is only the marginally. The emphasis should be improving the quality of protein consumed. Attention must be paid to eating protein of high biological value (0.4 to 0.6 gms/kg) containing milk products curd, paneer, refined soyabeen powder, soya granule, soya chunks, egg white etc. and for non-vegetarian egg white on daily basis and small quality of fat fish.

3. Fluid Intake

Why must patients of CKD take precautions in fluid intake?

Kidneys play a major role in maintaining proper amount of water in the body by removing the excess fluid as urine. In patients with CKD, as the kidney functions worsen, the volume of urine usually decreases. Reduced urine output leads to retention and excess fluid in the body causing puffiness of the face, swelling of the legs and hands and high blood pressure. Accumulation of fluid in lungs causes shortness of breath. If this is not controlled, it can be life threatening.

What are the clues of excess water in the body?

Excess water in the body is called fluid overload. Swelling, ascites (accumulation of fluid in the abdominal cavity), shortness of breath, and weight gain in a short period are the clues which indicates fluid overload.

What precautions patients of CKD must take to control fluid intake?

To avoid fluid overload or deficit, volume of fluid should be taken as per the recommendation of the doctor. Volume of fluid permitted may

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vary for each CKD patient and is calculated on the basis of urine output and fluid status of each patient.

How much fluid is a chronic kidney disease patient advised to take?

  • In patients without swelling and with adequate urine output, unrestricted water and fluid intake is permitted. But patients with chronic kidney disease should take large amounts of fluid to protect kidney is a misconception.
  • Patients with swelling and reduced urine output are instructed to restrict fluid intake. To reduce swelling, fluid permitted in 24hrs should be less than the volume of urine in a day.
  • To avoid fluid overload or deficit, volume of fluid usually permitted in a day = urine volume of previous day plus 500ml. Additional 500ml of fluid approximately makes up for the loss of fluid through perspiration and breathing.

Why must patient of CKD weigh themselves daily and maintain a record?

To monitor fluid volume in the body and to detect fluid gain or loss at the earliest, the patients should weigh themselves daily and record it. The body weight remains constant when the instructions of fluid intake are followed strictly. Sudden weight gain indicates fluid overload due to increase in fluid intake. Weight gain warns the patients about the need of more meticulous fluid restriction. Weight loss usually occurs as a combined effect of restriction of fluid and response to diuretics.

Useful Tips to Reduce Fluid Intake :

To restrict fluid intake is difficult, but these tips will help you:

1. Weigh yourself at a fixed time every day and adjust fluid intake accordingly.

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2. The doctor advises you on how much fluid consumption is permitted in a day. Accordingly calculate properly and drink measured volume of fluid every day. Remember fluid intake includes not only water but also tea, coffee, milk, curd, buttermilk, juice, ice-cream, cold drinks, soup, thin dal etc. While calculating fluid intake you must also calculate the hidden fluids in your food. Beware foods such as watermelon, grapes, lettuce, tomatoes, celery, gravy, gelatin, frozen treats like popsicles etc. as they have high water content.

3. Reduce salty, spicy and fried food in your diet as they increase thirst, leading to greater consumption of fluids.

4. Drink only when you are thirsty. Do not drink as a habit or because everyone is drinking.

5. When you are thirsty take a small amount of water or try ice. Take a small ice cube and suck it. Ice stays longer in the mouth than liquid, so it is more satisfying than the same amount of water. Do not forget to account for ice as consumed fluid. For easy calculation, freeze the allotted amount of water into an ice tray.

6. To take care of dryness of mouth, one can gargle with water without drinking it. Dryness of mouth can be reduced by chewing gums, sucking hard candy, lemon wedge or mints and the use of mouthwash to moisten mouth.

7. Always use small size cup and glass for your beverages to limit fluid intake.

8. Take medicines after meals when you are taking water to avoid extra water consumption for medicine.

9. A patient must keep himself busy with work. A patient who has little to occupy himself feels the desire, to drink water more often.

10. High blood sugar in diabetic patients can increase thirst. So a stringent control of blood sugar is essential to reduce thirst.

11. Since hot weather increases one’s thirst, any measure taken to live in cooler comfort is desirable and recommended.

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How to measure and consume precisely the prescribed amount of fluid per day?

  • Fill a container with water. equal to the exact amount of fluid prescribed by the doctor for daily intake.
  • The patient must bear in mind that no more than that amount of fluid intake is permitted for the day.
  • Each time the patient consumes a certain amount, fluid should be observed. The same amount of water should be removed from the water container and discarded
  • When the container has no more water, the patient realizes that his limit of fluid intake for the day has been reached and no more is to be drunk. The patient is advised to distribute total fluid intake evenly throughout the day to avoid the need of additional fluid.
  • This control method is to be repeated every day.
  • By this simple but very effective method the prescribed volume of fluid can be precisely delivered to the patient and fluid intake can be restricted.

4. Salt (Sodium) Restriction in Diet

Why are CKD patients advised low sodium diet?

Sodium in our diet is important for the body to maintain blood volume and to control blood pressure. Kidneys play an important role in the regulation of sodium. In patients with CKD, kidneys cannot remove excess sodium and fluid from the body so sodium and water build up in the body.

Increased amount of sodium in the body leads to increased thirst, swelling, shortness of breath and increase in blood pressure. To prevent or reduce these problems, the patients of CKD must restrict sodium intake in diet.

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What is the difference between sodium and salt?

The words sodium and salt are routinely used as synonyms. Common salt is sodium chloride which contains 40% sodium. Salt is the principle source of sodium in our diet. But salt is not the only source of sodium. There are quite a few other sodium compounds in our food, such as:

  • Sodium alginate: Used in ice-cream and chocolate milk.
  • Sodium bicarbonate: Used as baking powder and soda.
  • Sodium benzoate: Used as a preservative in sauce.
  • Sodium citrate: Used to enhance flavor of gelatin, desserts and beverages.
  • Sodium nitrate: Used in preserving and coloring processed meat.
  • Sodium saccharide: Used as artificial sweetener.
  • Sodium sulfite: Used to prevent discoloration of dried fruits.

The above mentioned compounds contain sodium but are not salty in taste. Sodium is “hidden” in these compounds.

How much salt should one take?

Average intake of salt in Indian population is about 6 to 8 grams per day. Patients with CKD should take salt according to the recommendation of the doctor. CKD patients with swelling and high blood pressure are usually advised to take about three grams of salt per day.

Which foods contains high amount of sodium?

Foods high in sodium are:

1. Table salt (common salt), baking powder.

2. Papad, salted pickles, salted chutney, sauce, chat masala and sambharas.

3. Baked food items like biscuits, cakes, pizza and breads.

4. Foods containing cooking soda or baking powder e.g., Indian foods

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such as ganthiyas, pakodas, dhoklas, handwa, samosa, ragda patties, dahi vadas etc.

5. Wafers, chips, popcorn, salted groundnuts, salted dry fruits like cashew nuts, pistachios, canned foods etc. and also avoid Readymade salted Indian snacks like sev, chivada, chakri, mathri, etc.

6. Commercial salted butter and cheese.

7. Instant foods like noodles, spaghetti, macaroni, cornflakes etc.

8. Vegetables like cabbage, cauliflower, spinach, fenugreek leaves, radish, beetroot, coriander leaves etc.

9. Salted lassi, masala soda, fresh lime and coconut water.

10. Drugs like sodium bicarbonate tablet, antacid, laxatives etc.

11. Non-vegetarian foods like meat, chicken and animal body organs like kidney, liver and brain.

12. Sea food like crab, lobster, oyster and shrimp and oily fish like columbi, kurang, kekda, bangada etc and dried fishe.

Practical Tips to Reduce Sodium in Food

1. Restrict salt intake and avoid extra salt and baking soda in diet. Cook food without salt and add permitted amount salt separately. This is the best option to reduce salt intake and ensure consumption of prescribed amount of salt in everyday diet.

2. Avoid food with high sodium content (as listed above).

3. Do not serve salt and salty seasonings at the table or altogether remove the salt shaker from the dining table. Do not add salt in food like salad, buttermilk, rice, chapatti, bhakhary, parathas etc.

4. Carefully read labels of commercially available packaged and processed foods. Look not only for salt but also for other sodium containing compounds. Carefully check the labels and choose “sodium-free” or “low-sodium” food products.

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5. Check sodium content of medicine.

6. Boil vegetables with high sodium content. Throw away the water. This can reduce sodium content in vegetables.

7. To make low salt diet tasty, one can add garlic, onion, lemon juice, amchur, bay leaf, tamarind pulp, vinegar, cinnamon, cardamom, cloves, saffron, green chilies, nutmeg, black pepper, cumin, fennel, poppy seeds etc.

8. Caution! Avoid the use of salt substitutes as they contain high amount of potassium. High potassium content of salt substitute can raise the potassium levels in blood to dangerous levels in CKD patients.

9. Do not drink softened water. In the process of water softening, calcium is replaced by sodium. Water purified by reverse osmosis process is low in all minerals including sodium.

10. While eating at restaurants select food that contains less sodium.

5. Potassium Restriction in Diet

Why are CKD patients advised to restrict potassium in diet?

Potassium is an important mineral in the body. Potassium is needed in the body for the proper functioning of muscles and nerves and to keep heartbeat regular.

Normally, the level of potassium in body is balanced by eating potassium containing foods and removal of excess potassium in the urine. Removal of excess potassium in the urine may be inadequate in a patient with chronic kidney disease which can lead to high level of potassium in the blood (a condition known as hyperkalemia). Between the two kinds of dialysis patients, the risk of hyperkalemia is lesser in peritoneal dialysis compared to that in hemodialysis. The risk differs in both groups because the process of dialysis is continuous in peritoneal dialysis while it is intermittent in hemodialysis.

High potassium levels can cause severe muscle weakness or an irregular heart rhythm which can be dangerous. When potassium is very high,

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the heart can stop beating unexpectedly and cause sudden death. High potassium level can be life threatening without noticeable manifestations or symptoms (and therefore it is known as a silent killer).

To avoid serious consequences of high potassium, CKD patients are advised to restrict potassium in diet.

What is normal potassium level in blood? When is it considered high?

  • Normal level of potassium in blood is 3.5 mEq/l to 5.0 mEq/l.
  • When the level of potassium reaches 5.0 to 6.0 mEq/l, it needs modification in diet.
  • When the level of potassium is greater than 6.0 mEq/l, it is dangerous and needs active intervention to reduce it.
  • When the level of potassium is greater than 7.0 mEq/l, it can be life threatening and needs urgent treatment.

Classification of eatables according to potassium levels

To maintain proper control of potassium in blood, food intake must be modified as per the doctor’s advice. On the basis of potassium contents, foods are classified in three different groups (high, medium, and low potassium containing foods). High potassium = More than 200 mg/ 100 gms of food Medium potassium = 100 to 200 mg/ 100 gms of food Low potassium = Less than 100 mg/ 100 gms of food

Foods - High in Potassium

  • Fruits: Amla, fresh apricot, ripe banana ripe, cherries, chikoo, fresh coconut, custard apple, grapes, gooseberry, kiwi fruit, lemon, ripe mango, musk melon, mosambi, peach, plum and sapota.
  • Vegetables: Amaranth, brinjal, broccoli, cluster beans, colocasia, coriander, drumstick, mushroom, raw papaya, potato, spinach, sweet potato and yam (suran).
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  • Dry fruits: Almond, cashew nut, dates, dry figs, raisins and walnut.
  • Cereals: Bajra, ragi and wheat flour.
  • Pulses: Black gram dal, bengal gram dal, bengal gram (whole), chana, chana dal, green gram dal, lentil dal, masoor dal, mung, red gram, red split lentils and tur dal.
  • Masala: Cumin seeds, coriander seeds, dried red chili and fenugreek seeds.
  • Non-vegetarian food: Fish like anchovy, mackerel, rohu, white pomfret; shell fish like prawns, lobster and crabs and beef.
  • Drinks: Bournvita, coconut water, coffee, condensed milk, drinking chocolate, fresh fruit juices, rasam (dal), soup, beer, wine and many aerated drinks.
  • Miscellaneous: Chocolate, cadbury, chocolate cake, chocolate ice cream, Lona salt (salt substitute), potato chips and tomato sauce.

Foods - Medium in Potassium

  • Fruits: Lichee, sweet lime, pomegranate and water melon.
  • Vegetables: Beet root, raw banana, bitter gourd, cabbage, carrot, celery, cauliflower, french beans, okra (ladies finger), onion, pumpkin, radish, sweet corn, safflower leaves and tomatoes.
  • Cereals: Barley, general purpose flour (maida), jowar, noodles made from wheat flour, rice flakes (pressed rice, poha) and wheat vermicelli.
  • Non-vegetarian food: Cital, hilsa, katla, magur, liver.
  • Drinks: Cow milk and curd.
  • Miscellaneous: Black pepper, cloves, cardamom, garam masala (mixture of Indian spices).
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Foods - Low in Potassium

  • Fruits: Apple, blackberries, cherries, guava, oranges, ripe papaya, pear, pineapple, rose apple (jambu fruit) and strawberries.
  • Vegetables: Bottle gourd(dudhi), broad beans (papdi), capsicum, ridged gourd (turiya), cucumber, fenugreek leaves (methi), garlic, lettuce, green peas, raw mango and pointed gourd (parvar), tinda (tender).
  • Cereals: Rice, rava and wheat semolina.
  • Pulses: Green.peas
  • Non-vegetarian food: Beef, lamb, pork, chicken and egg.
  • Drinks: Buffalo milk, coca-cola, fanta, lemonade, lime juice in water, limca, rimzim and soda.
  • Miscellaneous: Dried ginger, honey, mint leaves, mustard, nutmeg and vinegar.

Practical Tips to Reduce Potassium in Food

1. Take one fruit per day, preferably with low potassium.

2. Take one cup of tea or coffee per day.

3. Vegetables with potassium should be taken after reducing the amount

of potassium (as mentioned below).

4. Avoid coconut water, fruit juices and foods with high potassium contents (as listed above).

5. Almost all food contains some potassium, so the key is to choose food with a low potassium level, when possible.

6. Restriction of potassium is necessary not only for predialysis CKD patients, but is also necessary even after initiating dialysis.

How to reduce potassium content in vegetables?

Peel, and cut vegetables in to small pieces.

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  • Wash them with lukewarm water and put them in a large pot.
  • Fill the pot with hot water (the quantity of water must be four to five times the volume of vegetables) and soak them for at least one hour.
  • After soaking the vegetables for 2 - 3 hours, rinse them three times with warm water.
  • Subsequently boil the vegetables with extra water. discard the water.
  • cook the boiled vegetables as desired.
  • In this way you can reduce the amount of potassium in vegetables, but not completely. So it is preferable to avoid high potassium containing vegetables or take them in small quantity.
  • As vitamins are lost in cooked vegetables, vitamin supplements should be taken as per the doctor’s advice.

Special tips for leaching potassium from potatoes

  • Dicing, slicing or grating potatoes into smaller pieces is important. Maximize surface of the potatoes exposed to water by this method.
  • The temperature of the water used to either soak or boil the potatoes makes the difference.
  • Using large amount of water to soak or boil potatoes is helpful.

6. Phosphorus Restriction in Diet

Why must CKD patient take low phosphorus diet?

  • Phosphorus is a mineral essential to keep bones strong and healthy. Usually extra phosphorus present in food is removed in urine and thereby the blood phosphorus levels are maintained.
  • Normal value of phosphorus in blood is 4.0 to 5.5 mg/dl.
  • In CKD patients the extra phosphorus taken in food is not excreted in urine and so the blood level rises. This increased phosphorus drains out calcium from the bones making them weak.
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Increase in phosphorus level can lead to many problems like itching, weakness of muscles and bones, bone pains, bone stiffness and joint pain. The stiffness of bone results in increased susceptibility to fracture.

consumption of which food with high phosphorus content should be reduced or avoided?

Food containing high phosphorous are:

  • Milk and dairy products: butter, cheese, chocolate, condensed milk, icecream, milk shake, paneer.
  • Dry fruits: cashew nuts, almonds, pistachios, dry coconut, walnut.
  • Cold drinks: dark colas, Fanta, Mazza, Frooti, beer.
  • Carrot, colacasia leaves, corn, groundnut, fresh peas, sweet potato.
  • Animal protein: meat, chicken, fish and egg.

7. High Vitamin and Fibers Intake

CKD patients suffer from inadequate supply of vitamins during predialysis period due to reduction of food intake, special method of cooking to remove excess potassium and poor appetite. Certain vitamins – especially water soluble vitamins B and C, folic acid etc – are lost during dialysis.

To compensate for inadequate intake or loss of these vitamins CKD patients usually need supplementation of water-soluble vitamins and trace elements. High fiber intake is beneficial in CKD. So patients are advised to take more fresh vegetables and fruits rich in vitamin and fibers.

Designing the Daily Food

For CKD patients daily food intake and water intake is planned and charted out by the dietitian in accordance with the advice of the nephrologist.

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Common principles for the diet plan are:

1. Water and liquid food intake: Fluid intake restriction must be as per the doctor’s advice. Daily weight chart must be maintained. Any improper gain in weight indicates increased fluid intake.

2. Carbohydrate: To ensure that the body gets adequate calories along with cereals and pulses, the patient can take sugar or glucose containing food, provided he/she is not diabetic.

3. Protein: Milk, cereals, pulses, eggs, chicken are the main source of protein. Those patients of CKD who are yet not on dialysis are advised to curtail protein in diet. They are advised to take 0.8 grams per kilogram of body weight per day. Once dialysis is started, patient needs high-protein diet (especially the patients on peritoneal dialysis).

Avoid eating animal proteins such as meat, chicken and fish which contain high protein, potassium and phosphorous. All animal protein can be harmful to CKD patients.

4. Fat: The amount of fat in food must be reduced but total curtailing of butter; ghee etc from food can be dangerous. Generally soyabean oil, groundnut oil is useful for the body but it is desirable to take these oils in limited quantity.

5. Salt: Most patients are advised to take low salt diet. Do not add salt at the table. Do not take food cooked with baking powder; and if you take it see that it is taken in restricted amount. Avoid use of salt substitutes as they contain high amount of potassium.

6. Cereals: Rice or rice products like flattened rice (poha), kurmura (puffed rice) can be taken. To avoid monotony of taste one can take various cereals like wheat, rice, poha, sago, semolina, all purpose flour, cornflakes in rotation. Barley, bajra, and corn can be taken but in a small quantity.

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7. Pulses: Various dals should be taken in right quantities in rotation so that the change in taste can make food palatable. As dal is liquid, the amount of fluid consumed with it must be taken into account. If possible it is preferable to make dal thicker in consistency rather than with more water. The amount of dal must be taken as per the doctor’s instructions.

8. To reduce potassium from dals it is essential that after washing, they must be soaked in hot water and the water discarded. Subsequently boil them with water and discard extra water after boiling. The dal, can now be cooked as per your taste. As an alter- native to dal and rice, one can take khichadi or dosa.

9. Vegetable: Vegetables with low potassium can be liberally taken. But vegetables with high potassium must be processed to remove potassium before consumption. To improve taste lemon juice can be added.

10. Fruits: Fruits with low potassium content like apple, papaya, berry can be taken but only once a day. On the day of dialysis patient can take any one fruit. Fruit juice and coconut water must be avoided.

11. Milk and milk products: 300 to 350 ml of either milk or milk products like kheer, ice cream, curd, maththa can be taken. Again, to avoid the extra liquid, limit the volume of these products.

12. Cold drinks: Pepsi, Fanta, Frooti must be avoided. Do not take fruit juice or coconut water.

13. Dry fruits: Dry fruits, groundnut, sesame seeds, fresh or dry coconut must be avoided.