Presentation on theme: "Dietary Approach To C Kidney Disease Dr Anita Saxena MD, PhD, PhD (Cambridge) Associate Professor Department of Nephrology SGPGIMS, Lucknow. India."— Presentation transcript:
Dietary Approach To C Kidney Disease Dr Anita Saxena MD, PhD, PhD (Cambridge) Associate Professor Department of Nephrology SGPGIMS, Lucknow. India
Nutrition In Renal Disease Is Complicated The term “Renal disease” embraces a number of clinical conditions whose common feature is decrease in GFR. Another common feature that these conditions share is malnutrition but each condition has a different approach in terms of nutritional therapy.
Definition of Chronic Kidney Disease Chronic Kidney Disease is defined as kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR. GFR ≤ 60 ml/min/1.73m 2 with or without kidney damage. There are 5 stages of CKD depending upon GFR (≥90, 60-89, 59-30, 29-15, <15) ml/minute.
Why Do We Need To Modify Diets? As kidney disease progresses, the capacity to respond to changes in intake of nutrients and water becomes less flexible. Solute and water excretion per nephron increases, but the fewer number of functional nephrons leads to a more restricted range of solute and water excretion. When diet exceeds daily protein requirement, the excess protein is degraded to urea and other nitrogenous wastes and these products accumulate in the body. Because the severity of uremic syndrome is proportional to the accumulation of these waste products and ions, therefore, dietary intake needs to be adjusted.
Why Modify Diets? Cont.. In kidney failure nutritional therapy allows good control of several consequences of the disease. Nausea /Vomiting Anorexia Initiation of dialysis
When Does Protein-Energy-Wasting Set In?
Males, solid lines; Females, dashed lines The MDRD Study: Association Between Dietary Intake And GFR and Serum Albumin and GFR With GFR< 60 mL/min/1.73 m 2 dietary protein and energy intake decreases and serum also albumin decreases (presence of inflammation).
When Does Protein-Energy-Wasting Set In? contd….. PEW most likely occurs during CKD stage 3 or even earlier partially due to inadequate nutritional management in predialysis phase and becomes clinically evident when GFR is < ml/min % patients on Maintenance Dialysis show signs of PEW.
Loss of Nutrients & Water soluble Vitamin in Dialysate Malnutrition Uremic toxicity Anorexia Loss of taste Unpalatable diets Dietary protein & energy intake Inflammation Infection Superimposed illness Presence of Comorbidity Metabolic Acidosis Hormonal disorders Resistance to anabolic hormones level of counter regulatory hormones regulatory hormones Glucagon, PTH Glucagon, PTH Declining Residual Renal Function Anemia loss of blood due to GI bleed, frequent GI bleed, frequent blood sampling blood sampling Inadequate Dialysis dose Malnutrition is Multifactorial
Markers of Protein-Energy Malnutrition (Predictors of Morbidity And Mortality in CKD) Progressive weight loss BMI 60 years Wasting of fat and skeletal muscle tissues reduced muscle mass 5% in 3 m Reduction in serum protein Serum albumin level <3.8 g/dL Serum pre-albumin level <30 mg/dL Serum cholesterol level <100 mg/dL Low dietary protein intake <0.6 g/kg/d or <0.8 g/kg/d on MHD and energy intake <25kcal /kg/d for at least 2 months
What Problems Are Unique To Patients with CKD?
1. Uraemic syndrome is associated with loss of appetite and a variety of gastrointestinal adverse effects, which results in reduced nutritional intake. Does CKD Have An Influence On Gastrointestinal Tract? ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure N. Canoa etal Clinical Nutrition (2006) 25, 295– % 307 HD pats Curtin et al CKD 5 predialysis pats Curtis et al PD pats Merkus et al HD pats Virga et al CKD 5 predialysis pats Murtagh et al HD pats (HEMO) Burrowes et al HD pats Carrero et al HD pats Kalantar-Zadeh et al HD pats14406 HD pats (DOPPS) Lopes et al HD pats Muscaritoli et al Anorexia 35% - 60% of MD Patients
Does CRF Have An Influence On Gastrointestinal Tract? ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure N. Canoa etal Clinical Nutri(2006) 25, 295– Patients with CRF Impaired gastric emptying Impaired intestinal motility Disturbances of digestive and absorptive functions, and Alterations in intestinal bacterial flora (Kang JY Dig Dis Sci 38:257–68) Delayed intestinal fat absorption (Drukker A Nephron 1982;30:154–60). Gastroparesis is most pronounced in patients with diabetic nephropathy.
What Problems Are Unique To Patients with CKD? 3. Poor nutrition in general. 4. Lack of proper diet counseling and poor monitoring of nutritional status.
Problems Are Unique To Patients with CKD? 5. Hyperglycemia5. Hyperglycemia 6. Hyperlipidemia6. Hyperlipidemia 7. Cardiovascular involvement7. Cardiovascular involvement
Problems Are Unique To Patients with CKD? 8. High incidence of infections8. High incidence of infections 9. Late initiation & Inadequate dialysis.
Nutritional Requirements of CKD Patients
CKD Stages 1-4 Low-protein diet (LPD) + Fluid Management Low-protein diet (LPD) is a conservative treatment in patients with chronic kidney disease (CKD) to improve uremic symptoms and slow progression of renal dysfunction. (Brenner BM, Meyer TW, Hostetter TH N Engl J Med 307:652–659, 1982.)
Fluid Management Input and Output Charting Oral Intake + IV infusions & Urine Output charting Fluid intake: Water taken with meals, medications or otherwise Tea, Coffee Milk Curd And any other liquid Fluid Prescription: Previous 24 hour urine output ml if patient is dry If patient is edematous: 24 hour urine output ml
Nutrient Requirements for Stage 1 Kidney Damage (presence of protein in urine) normal GFR GFR >90 mL/min/1.73 m2 Protein: 0.8 g/kg/d Non Diabetics Energy: kcal/kg/d 35 kcal/kg/d < 60 years 30 kcal/kg/d > 60 years Diabetics : <30 kcal/kg/d Water soluble Vitamins and minerals as per RDA Principle Is Restrict Protein Do Not Say No To Protein
Prescribe Low Potassium Diet Potassium Intake in CKD 1 mEQ/kg/day Hyperkalemia (high serum K + ) Can cause arrhythmia Prescribe Low K foods: Foods containing <100 mg K /100g Apple, banana, guava, pear, orange, papaya
Reduce Potassium intake Leach/remove potassium from vegetables by soaking chopped vegetables in luke warm water for half an hour. Avoid green leafy vegetables, tomatoes, sweet lime, lemon, carrots, raw salad, mango, dry fruits fruit juice, vegetable soup, coconut water. X X X X X X X
Avoid Foods containing Sodium>100 mg/100g Low Sodium Diet for better control of blood pressure& edema Sodium intake in CKD 100 mg/100g Avoid canned foods/fruits/Pickles/fruit jam
Nutrient Requirements for Predialysis Stages 2,3 4, 5 Kidney Damage With Mild Decrease in GFR To Severe Reduction In GFR 60-89, 30-59; 15-<30mL/min/ 1.73 m 2 NutrientRequirement (conservative management) Low protein 0.6g/kg/d Guideline 24 Those unable to accept 0.75 g/kg/d Energy30-35 kcal/kg/d (35 60 years; Guideline 25 Phosphorus mg to prevent hyperphosphatemia. Non-calcium based phosphate binder with meals to prevent soft tissue calcification. Calcium mg/d Sodium<2.4 g/d Potassium1 mEq/kg Cholesterol<200 mg/d. Avoid egg yolk Water soluble Vitamins and minerals/ RDA AnemiaTreat anemia with folic acid, B12,iron supplements and ESA
Put them on Low Protein 0.6g/kg/d Weight of patient = 50 kg 50 x 0.6 = 30 g of protein Milk 150 ml = 4.5 g/protein Dal 1 bowl = 6 g protein Chappati=2 g 8 chappaties = 16 g Rice: 50 g raw = 3 g Total 29.5g Do Not Advise Your Patients Not To Take Protein
CKD stage 1-3 dietary protein intake 100% to 140% of the DRI for ideal body weight. CKD stages 4 to 5 100% to 120% of the DRI Energy intake should exceed RDA for age at least initially. Prescribe “catch up” energy supplements to achieve RDA or Higher as per chronol age for children who demonstrate energy malnutrition. If patient does not gain weight recommend Energy intake based on height age. Protein intake in Children K/DOQI Guideline
MDRD Study Low Protein Diet + Keto Analogues Delay progression of kidney disease in the Predialysis period. Reduce uremic symptoms Preserve residual renal function Delay onset of dialysis Preserve nutritional status. Improve metabolic complications due to renal insufficiency Essential amino acid tablet contain all amino acids essential for uremic patients (50 mg /tablet; dose 5 mg/kg/d). (Barsotti G, etal. Kidney Int 24:Suppl 16, S278–S284, Gretz N, Korb E, Strauch M Kidney Int 24:Suppl 16, S263–S267, 1983) COST
Dietary Nephrotic Syndrome Dietary Recommendations: Low fat, Low salt diet+ Fluid restriction Restrict Fluid: depending upon presence of edema Energy: 35 kcal/kg b.w./d Protein g/kg b.w. with 1 g for each gram of albumin lost in urine. In children protein - according to RDA for chronological age. Restrict Sodium to 2.4 g/d. Low Fat diet: Fat <30% of total calories (PUFA 10%) Cholesterol < 200mg/d Soy protein is beneficial for kidneys Avoid egg yolk, cream, red meat, fried foods
Diabetic Nephropathy Dietary Recommendations (Up-To-Date, 2006) 1. Protein intake of 0.8 g/kg/d reduces albuminuria and stabilizes kidney function (Egg white HBV for protenuria). 2. As GFR decreases restrict protein 0.6 g/kg/d. 3. Energy: <30 kcal/kg/d for weight management. 4. Total fat should be restricted: 30% total Kcals. (<10% calories from SFA; <10% calories from PUFA; 10-15% calories from MUFA) 5. Dietary cholesterol <200 mg daily along with n-3 polyunsaturated fats. 1. Achieve Normoglycemia 2 Manage dyslipidemia 3. Manage Weight 4. Good Blood Pressure control (<130/80 mmHg) 5. Bring down Proteinuria with use of ACE/ARB
Diabetic Nephropathy Dietary Recommendations (Up-To-Date, 2006) 1. Advise small meals at frequent intervals that consist of low-fat and complex carbohydrates meals and 2 snacks 3. Avoid meals with high-fiber content. BF/Dinner
Pregnancy, Diabetes and CKD Discontinue Treatment of DKD with RAS inhibitors HbA1C as close to normal as possible (<1% above upper limit of normal) Use Insulin to control hyperglycemia if necessary Liberalize dietary protein g/kg preconception Weight/d Treat High blood pressure > / mm Hg Target BP <130/80 mm Hg because of CKD. Avoid hypotension No studies on Preg Diabetics CKD Stage 5. Strategies for management of hyperglycemia, hypertension, and dyslipidemia may be extrapolated from the recommendati ons for women with earlier stages of CKD.
RENAL STONE DISEASE
Drink plenty of fluid: 3-4 litres/day (half of which should be water) Continuous intake rather than acute bursts of drinking will ensure required urinary SG of <1.01. Take a glass of water before going to bed to maintain specific gravity < Avoid hard tap water In adults, urine volume should be>2 L/day Low salt diet Low protein diet Prefer vegetarian diet. If urine pH >6.0 avoid citrate supplements. Prefer refined cereals and flours. RENAL STONE DISEASE Composition: calcium, oxalate, phosphate, uric acid
RENAL STONE DISEASE Composition Calcium, Oxalate, Phosphate, Uric acid Patients can take a total of mg of calcium/day from natural foods. Milk intake should not exceed 2 glasses/day. Avoid calcium supplements as tablets. Allow lemon juice. Avoid orange juice as it raises oxalate level. Avoid cola beverages. Avoid Cranberry juice. Calcium phosphate stones are treated successfully with high-phosphate diets. In this case prefer whole grains. Weight reduction and all forms of physical activity should be encouraged. CranberryJuice X X X X
Gout (Hyper-Uricemia ) Avoid Foods Containing High Uric Acid Low protein diet Poultry and organ meats Fish Herring, Fish Roe, Salmon, Sardine Kidney, Liver, Meat Soup Extract s Legumes (Dry Peas Beans, Soyabean) Mushrooms Asparagus.
Autosomal Dominant Polycystic Kidney Disease (ADPKD) LOW SALT RESTRICT FLUID CONTROL BLOOD PRESSURE
Autosomal Dominant Polycystic Kidney Disease (ADPKD) Low Protein 0.8g/kg/d As creatinine increases reduce it to 0.6 g/kg/d Low SALT diet Restrict Fluid intake Good control of Blood pressure Long Term Coverage With Antibiotics if infected Soy protein (slows progression of PKD inanimals) (Aukema, et al. J Am Soc Nephrol.10: , 1999) Avoid foods with higher amounts of oxalic acid. (spinach, rhubarb, beets, eggplants, cocoa, and chocolate) Omega-3-fatty acids (Flax seeds/oil ): anti- hypertensive, lipid-lowering and anti- inflammatory effects. SOY
Management Of Patients On Maintenance Dialysis Hemodialysis CAPD
Malnutrition At Initiation Of Dialysis Is A Strong Predictor Of Subsequent Increase In Relative Risk Of Death Carrero JJ, J Renal Nutr 2013 Vol 23, issue 2, Pages Hakim RM and Lazarus JM. JASN 1995; 6:1319–28 Abdu A et al Afr J Clin Nutr 2011;24(3): Flanigan MJ. Perit Dial Int. 1998;18:
Chung SH Peritoneal Dialysis International, Vol. 20, pp. 19–26 Malnutrition was present in 45% of 91 patients commencing CAPD as assessed by SGA. Initial nutritional status appears to exert a powerful influence on CAPD patient survival. By Kaplan–Meier analysis, patient survival rate is significantly lower in malnourished patients than in normal patients (67.1% vs 91.7% p = 0.02)
Relative risk of death increases with 1. Lower serum albumin and 2. Worse nutritional status as assessed by SGA and %LBM CANUSA Study NDT1998; 13 (Suppl 6):158–63.
Loss Of Protein Protein intake should be increased to > g/kg/d Estimating energy, protein & fluid requirements for adult clinical conditions June 2012 Qeensland Govt Krediet RT, Zuyderhoudt FM, Boeschoten EW, Arisz L: Peritoneal permeability to proteins in diabetic and non-diabetic continuous ambulatory peritoneal dialysis patients. Nephron 42: 133–140, Imholz AL, Koomen Peritonitis/24 h 15.1 gm CAPD/Day 5-15 g/24h 4 g of which is albumin HD/ session 1-3 g/ session The loss of serum proteins in stable continuous ambulatory peritoneal dialysis (CAPD) patients averages 5 g per 24 hours, 4 g of which is albumin
Dietary Protein & Energy Intake for Patients on MHD NKF-K/DOQI Guideline 15, 16 S Albumin ≥ 4.0g/dL Guidelines 3 S Prealbumin ≥30 mg/dL Guidelines 4 Prescribe 1.2g/kgbw/d protein to clinically stable patients on HD Guideline 15 Prescribe 1.3g/kgbw/d protein to patients on PD necessary to ensure neutral or positive nitrogen balance. Guideline 16 Energy Kcal/kg/d depending upon age 60 y At least 50% of protein should be of HBV
Increasing Protein Intake in Dialysis: The Phosphate Paradigm Mortality decreases when protein intake increases up to 1.4 g/kg/day (lower panel) despite a slight increase in serum phosphate (Shinaberger JH et al.,1982). nPNA, appearance. Protein has linear relation with phosphate 1 g protein brings 13–15 mg phosphate (of which 30–70% is absorbed through the intestinal lumen).
Increasing Protein Intake in Dialysis: The Phosphate Paradigm Mean peritoneal phosphate clearance (L/wk/1.73 m 2 BSA) according to peritoneal membrane transport category and peritoneal dialysis modality. CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous cyclic peritoneal dialysis; H, high transport category; HA, high- average transport category, LA & L: combined low-average and low transport category. 1-day peritoneal dialysis clears ~300 mg phosphate. 1 regular hemodialysis session clears 500–600 mg phosphate This results in a net balance of 1800 mg every other day in HD pateints, an amount that cannot be eliminated through dialysis Phosphate binders are a must for such a patient.
Patients on Maintenance Dialysis Require Extra Protein Supplement Insufficient Protein Intake Renal Specific Protein Supplements in powder or biscuit form. Peptide based supplements for sick patients. The Renilon Multicentre Trial: Use of a renal- specific oral supplement by HD patients who have low protein intake does not increase need for phosphate binders and prevents decline in nutritional status and quality of life. Serum albumin and prealbumin changes associate positively with the increment in protein intake ( The Renilon Multicentre Trial Fouque D etal NDT Sep;23(9): )
Serum albumin (SA) levels before, during, and after the nutrition supplement in hemodialysis (HD) and peritoneal dialysis (PD) patients. Daily Supplement: 20 – 30 g protein and approx 500 calories Significant improvement in albumin level during months 4 – 6 in HD patients but not in PD Patients. It takes 3months of supplementaion to show improvement in S albumin In PD patients s albumin levels declined after supplementation was stopped Nutrition Supplements in Dialysis Patients: Use in Peritoneal Dialysis Patients and Diabetic Patients R Poole Adv Peritoneal Dial, Vol. 24, 2008
If oral supplements are not tolerated or effective and malnutrition is present (<20 Kcal/kg/d and Protein intake is <0.8 kg/g/d) consider tube feeding to increase protein intake. Overnight supplement can improve nutritional status and overall well- being. Bolus feeding: Start ml feed, then increase to ml per feeding. Continuous feeding: Start with ml/hr, then increase 20ml every 2-8 hrs until requirement is met. Guideline 19 – Indications for Nutrition Support in dialysis dependent patients
Practical Rules For Preventing Protein En Energy Wasting/ Malnutrition
1. Monitor Nutritional Status Identify Nutritional deficiencies before they become clinically evident. (K/DOQI,AJKD.2000;35:S Enia G, etal. NDT. 1993;8:
Monitor Nutritional Status (Predialysis* and Dialysis Depenedent** Patients) Measure Frequency of Measurement Total protein 3 monthly* Monthly** Serum albumin 3 monthly* Monthly** Na 3 monthly* Monthly** K 3 monthly* Monthly** Ca 3 monthly* Monthly** P 3 monthly* Monthly** % of usual post-drain body weight Monthly** % of standard (NHANES II) body weight Monthly** Subjective Global Assessment Every 6 months Dietary interview and/or diary Monthly nPNA Every 3-4 months Anthropometry As needed Body composition DEXA As needed
Prevent Monitor Treat Complications
Slow Progression of CKD Reduce Albuminuria to slow progression of CKD, particularly in diabetics. Supplement with vitamin B complex (AHA) Folic Acid, Vitamin B6 and B12 supplements to prevent hyperhomocystenemia Serum albumin < 4.0 g/dL, prior to initiation of dialysis, predict morbidity and mortal(Kaysen et al, 2008).
Slow Progression of CKD Control Blood Pressure to slow progression of CKD and lower CVD risk. Target BP ≤130/80 mmHG Limit sodium intake. Prescribe diuretics to treat fluid overload Advise Weight reduction if required. Monitor serum potassium in patients on renin angiotensin aldosterone system (RAAS) antagonists. Limit dietary potassium intake.
Slow Progression of CKD Manage Diabetes Target HbA1c should be <7.0% (ADA Guidelines 2007). Good control of newly diagnosed diabetes may slow progression of CKD. Blood glucose control may help slow progression of CKD (DCCT,1993; UKPDS,1998)
2. Correct Uremic Symptoms If patient is on dialysis individualize dialysis prescription. Give adequate dialysis Maintain Kt/V urea of 1.2 for HD 1.7/week CAPD ADEMEX Trial (2001)
Nutritional Effects Of Increasing Delivered Dialysis Dose In Malnourished PD Patients - 12 m - 6 m m + 4 m + 6 m p Wt, kg MAC, cm nPNA, g/kg/d DPI, g/kg/d Oral calories, cal/kg/d P. albumin, g/L SGA Open, prospective, longitudinal intervention: Open, prospective, longitudinal intervention: Davies et al K Int 57:1743, 2000 Patients had evidence of declining nutrition over 12 months With 25% increase in delivered PD dose for 6 mont hs Total Kt/V 1.67 1.93 ( 18%)
3. Treat Anorexia: Eliminate/Treat any potentially reversible or treatable condition or medication that might interfere with appetite or cause malnutrition. Phosphate binders may induce loss of appetite. Discontinue use of phosphate binders for 2 weeks to see if appetite improves. Discontinue use of iron supplements if there are repeated GI upsets Discontinue calcium supplements if bowel movements are irregular Reduce salt intake for better control of blood pressure to minimize requirement of antihypertensive medication.
Anorexia cont.. In patients on Peritoneal Dialysis Glucose Absorption from dialysate Induces abdominal discomfort Suppression of Appetite (patient absorbs g/d kcal/d ) Encourage patient to take small but frequent meals. Peritoneal Dialysate
Rule 4 Correct Of Metabolic Acidosis Reduce Protein Catabolism, Increase Albumin Synthesis Degradation Of Essential BCAA. Serum Bicarbonate level at 22 mmol/L Evaluate Monthly NKF/KOQI Guideline 13/14 Replace Sevelamer HCL With Sevelamer Carbonate To Prevent Acidosis
Treat comorbid conditions like diabetes, gastrointestinal disorders, and infection which increase malnutrition. Combined presence of co-morbidities such as cardiovascular disease and vascular complications in diabetic CAPD patients along with malnutrition increases mortality of PD patients. Dong J, Wang T, Wang HY. Blood Purif 2006; 24:517–23 The Impact Of New Comorbidities On Nutritional Status In CAPD Patients. Rule 5. Practical Rules For Preventing PEW
Treat Diabetic Gastroparesis: characterized by delayed gastric emptying & Upper GI symptoms Ajumobi AB, Griffin RA, Hospital Physician March 2008 Maintain Glucose levels below 180 mg/dL Average blood glucose should not exceed 150 mg/dl (Use Insulin therapy) Prevent Hypoglycemia: Blood glucose should not be less than 110 mg/dl (to). Prescribe Medium-chain triglycerides. Avoid meals containing Fat to avoid delayed gastric emptying. Give high-calorie liquid supplements if patient is not in Volume Overload. if patient is sick consider parenteral nutrition.
6. Prevent Infections especially in PD To Maintain Good Nutritional Status Infections lead to ed appetite Impart Intense training to patient & attendant for maintaining hygiene. Peritonitis Exit site infection
Anorexia is more common in patients who have lost RRF and has significant independent effect on dietary protein intake. Patients with RRF have higher mean DPI and nPNA than patients without RRF (1.08 ±0.31vs 0.89 ± 0.31g/kg/d and 62.1 ±12.4 vs 54.9 ±15.3g.d). ( Wang etal JASN 2001 Nov 12 (11) ) Every 1ml/min/1.73m 2 increase in GFR associated with fold increase in DPI and fold increase in DCI. ( Cross sectional study on 242 CAPD patients Caravaca etal 1999, Per Dial Int. Vol ) 7. Preserve Residual Renal Function for Proper clearance of middle molecules Anorexia In PD
Avoid Contrast and Other Toxins Worsen renal function Avoid Nonsteroidal anti-inflammatory drugs, aminoglycoside antibiotics, and oral phosphate solutions. Aminoglycoside antibiotics used for treatment of peritonitis and catheter infections should be used with caution (ISPD). Prevent peritonitis, because peritonitis is also associated with a decline in RRF. STATEGIES FOR PRESERVING RRF cont..
8. Anemia also causes generalized weakness & loss of appetite Correct Iron Profile Supplement Folic Acid Correct Vitamin B12 deficiency Treat chronic infections and secondary hyperparathyrpoidism Prescribe optimal dose of ESA/EPO Use L-Carnitine in EPO resistant anemia.
9. Reverse Protein Loss Give High Protein Diet to Patients on Dialysis
: Galland et al. Kidney Int 2001 Daily Hemodialysis Increases Protein and Energy Intake Rule 10. Practical Rules For Preventing PEW
TAKE HOME MESSAGE Prevent Malnutrition From Setting In
1. Correct uremia and metabolic acidosis to prevent protein catabolism. 2. Monitor closely nutritional status and nutrient intake. 3. Individualize diet prescriptions. 4. Do not completely stop protein intake. Restrict Protein intake to 0.6 g/kg/d in predialysis patients. 5. Ensure high protein diet for patients on Maintenance Dialysis. 6. Eliminate drugs which cause GI upset and anorexia. Protein of High Biological Value
Foods With High Phosphorus Content Useful In Treating Stone Disease Milk and milk products, khoa liver, egg yolk, fish, meat products, soft drinks, whole grain cereals and flours, Mustard leaves cauliflower, carrot peanut, Kidney beans, soyabean, til water chestnut,. Chocolate dry fruits dry coconut