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The effect of use of dates on serum potassium in nondiabetic hemodialysis patients

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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.
Saudi J Kidney Dis Transpl 2009;20(6):1018-1022
© 2009 Saudi Center for Organ Transplantation
Original Article
The Effect of Use of Dates on Serum Potassium in Nondiabetic
Hemodialysis Patients
Nauman Siddiqi1, Osama El Shahat2, Ebtisam Bokhari1, Haytham Roujouleh1, M. Hisham
Hamid2, Iftikhar Sheikh2, Hassan El-Sayed2, Ayman Saleh2, Ayman Seddik2
1Consultant Nephrology, 2Registrar Nephrology, Department of Medicine,
King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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.
Introduction
Daily consumption of dates is part of the cul-
tural fabric of Saudi Arabia and the use of dates
Correspondence to:
Dr. Nauman Siddiqi
Consultant Nephrology
King Fahd Armed Forces Hospital
P.O. Box 9862, Jeddah 21159
Saudi Arabia
E-mail: hknsiddiqi@yahoo.com
dates is much higher than the rest of the world.
One of the most difficult adjustments for pa-
tients 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 un-
known.
We aim in this study to determine the effect
of ingestion of dates on serum potassium levels
Saudi Journal
of Kidney Diseases
and Transplantation
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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 pa-
tients (> 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 hypogly-
cemics or insulin, and patients receiving angio-
tensin converting enzyme inhibitors (ACEI)
and/or angiotensin receptor blockers (ARB) were
excluded.
Patients who were adequately dialyzed (month-
ly 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 erythro-
poietin 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 (HCO3).
The patients were provided breakfast that in-
cluded 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 solu-
tion 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
Table 1. Demographics of the study patients
Males Females P value
Number 7 2
Age (years) 45.6 ± 16.9 53.5 ± 12.02 NS
Dry weight (kg) 60.4 ± 13.4 81.5 ± 0.7 0.006
Duration of dialysis (hours) 4.0 ± 0.4 3.7 ± .04 NS
Previous month K 4.6 ± 0.5 4.9 ± 5.0 NS
Cr (µmol/L) 1058 ± 167 929 ± 212 NS
Eprex dose (i.u./week) 10000 ± 7266 8000 ± 5656 NS
SBP (mmHg) 135.7 ± 26.7 131 ± 14 NS
DBP (mmHg) 80.4 ± 17.6 82 ± 1.4 NS
NS: not significant
Table 2. Comparing the serum potassium levels in the patients who ingested dates and those who ingested
KCL (controls) Dates Controls P value
N 17 8
Monthly K (mmol/L) 4.6 ± 0.45 4.53 ± 0.48 NS
K pre ingestion (mmol/L) 4.6 ± 0.59 5.3 ± 0.8 0.03
K 2hrs post ingestion (mmol/L) 4.7 ± 0.6 5.1 ± 1.2 NS
K 4hrs post ingestion (mmol/L) 4.8 ± 0.6 5.3 ± 1.1 NS
NS: not significant, K: potassium, hrs: hours
Dates and serum potassium in nondiabetic HD patients 1019
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the three sessions combined and separately for
the different type of dates, and they were com-
pared to KCl ingested solution. Student’s t-test
was used to compare the means and inde-
pendent 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 par-
ticipate 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 signi-
ficantly over the four hours with either variety
of dates or with potassium solution (Table 2).
There was no significant difference in the po-
tassium levels with Rutab or Sukari as com-
pared to KCl. Combining the two types of
dates resulted in a trend towards higher pota-
ssium 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
Figure 1. Potassium values for the three arms in our study
Figure 2. Potassium values comparing the dates with the KCL arm in our study
1020 Siddiqi N, El Shahat O, Bokhari E, et al
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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 pro-
bably one of the first trees to be cultivated. Re-
presentations 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 cen-
turies, and they have been mentioned in the
scriptures of the three main religions. Accor-
ding 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 biolo-
gical 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, mag-
nesium 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 rela-
tively 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 con-
tent to vary significantly from 107 mg/100 gm
to 916 mg/100 gm (2.7-23.4 mEq) in the diffe-
rent 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 hyperkale-
mia, 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 pro-
cesses such as the gut, especially in ESRD pa-
tients. Gastrointestinal loss may account for
nearly 25% of daily potassium excretion com-
pared 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 pa-
tients,9-11 and it is proportional to the stool
volume; constipation may be expected to pre-
dispose these patients to hyperkalemia.10
Classically nephrologists have advised patients
to avoid dates because of fear of hyperkalemia
Table 3. Potassium content as percentage of all minerals in a variety of dates5
Sukari Sabaka Rawtan Burjee Halwa Nabta Ali
Potassium (%) 56 48 71 72 77 54
Table 4. Potassium content according to different stages of ripening for two verities of dates2
Mineral (100 g) Kimri stage Khalal Stage Rutab Stage Tamr stage (most ripen)
Lulu cultivar
633.2 mg
(16.2 mmol) 484.2 mg
(12.4 mmol) 350.3 mg
(8.98 mmol) 128.8 mg
(3.3 mmol)
Bushibal Cultivar 752.6 mg
(19.3 mmol) 510.1mg
(13.07mmol) 338.1mg
(8.67mmol) 107.4 mg
(2.75mmol)
Dates and serum potassium in nondiabetic HD patients 1021
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based on anecdotal experience. However, our
results showed that 100 grams of dates is re-
latively 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 re-
sults 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 inter-
dialytic hyperkalemia. In addition, we could
not actually quantify the actual potassium con-
tent 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 dia-
lysis sessions.
Acknowledgement
1. Dr. Manzoor Al Hazmi for help in procuring
the Arabic references and deciphering them.
2. Nada Ayman for help with the figures.
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. Physi-
ochemical 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. W.H. Barreveld in Date Palm Products. FAO
Agricultural services bulletin No. 101. 1993.
http://www.fao.org/
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 non-
diabetic and diabetic outpatients on chronic
hemodialysis. Am J Nephrol 1987;7:101-9.
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.
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.
10. Gennari FJ, Segal AS. Hyperkalemia: an adaptive
response in chronic renal insufficiency. Kidney
Int 2002;62:1-9.
11. Ahmed J, Weisberg LS. Hyperkalemia in dia-
lysis patients. Semin Dial 2001;14:348-56.
1020 Siddiqi N, El Shahat O, Bokhari E, et al
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... A standard glycoside (Digitoxin) was prepared with concentrations ranging from 0 to 50mg/ml. The absorbance was measured at 510nm [12]. ...
... A measured 3 ml of 20 % NaOH was added to the mixture and a brownish yellow colour was developed. Glycosides standard (Digitoxin), a concentration which range from 0 -50 mg/ml were prepared from stock solution the absorbance was read at 510 nm [12]. ...
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The causes of death in 84 end-stage renal failure patients, treated with dialysis, who died during a 66-month period were reviewed retrospectively. Cardiac and infectious diseases were the main cause of death (27% each). These two constituted 44% of causes of death in hemodialysis and 75% in continuous ambulatory peritoneal dialysis patients. Malignant disease (7%) and hyperkalemia (5%) were responsible for death only in hemodialysis patients. Patients who died following hyperkalemia were younger than 50 years old. Patients who died from malignant disease were dialyzed for more than 3 years. In summary, the mode of dialysis therapy, age at start of therapy, time on dialysis, and previous cardiac disease may play a role in determining the causes of death in dialysis patients.
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We analyzed routine serum potassium concentration measurements and conditions temporally associated with abnormalities in potassium concentration in outpatients on chronic hemodialysis (136 nondiabetics, 36 diabetics) and continuous ambulatory peritoneal dialysis (16 nondiabetics, 10 diabetics). The following potassium concentration frequencies were found: prehemodialysis, nondiabetics: normal 51.3%, severe hyperkalemia (greater than 6.0 mmol/l) 10%, severe hypokalemia (less than 3.0 mmol/l) 0.3%; diabetics: normal 57.8%, severe hyperkalemia 8.7%, severe hypokalemia 0.5%. Peritoneal dialysis, nondiabetics: normal 73.7%, severe hyperkalemia 0.6%, severe hypokalemia 4.9%; diabetics: normal 72.5%, severe hyperkalemia 0.9%, severe hypokalemia 2.9%. Normokalemia and severe hypokalemia were significantly (chi 2 test) more frequent in peritoneal dialysis than in prehemodialysis, whereas severe hyperkalemia was more frequent in prehemodialysis serum samples. No difference was found between nondiabetics and diabetics for either form of dialysis. 50% of prehemodialysis episodes of hyperkalemia were diet-induced. Hyperkalemic drugs and anuria were not associated with a higher risk of prehemodialysis hyperkalemia, but each one of 3 abnormalities, very high BUN (greater than 40 mmol/l), metabolic acidosis (TCO2 less than 15 mmol/l) and, in diabetics, severe hyperglycemia (serum glucose greater than 30 mmol/l), was associated with a statistically higher risk of hyperkalemia.
Article
Patients with chronic renal failure (CRF) are at risk for unique medical emergencies, many of which require hemodialysis for their definitive treatment. This study describes the use of emergency department (ED) hemodialysis in the management of CRF patients. A retrospective chart review was conducted of patients who underwent ED hemodialysis at a regional dialysis center between April 1994 and September 1996. Data were collected on presenting complaint, ED diagnosis, indication for hemodialysis, ED pharmacologic treatment, ED airway management, cardiovascular stability, and disposition. Fifty episodes of ED hemodialysis were identified in 37 different patients. Presenting complaints included: shortness of breath, 38 (69%); weakness, 8 (15%); chest pain, 3 (5%); and other, 6 (11%). ED diagnoses included: congestive heart failure, 36 (65%); hyperkalemia, 13 (24%); and other, 6 (11%). Indications for hemodialysis included: cardiovascular instability, 33 (38%); respiratory distress, 22 (26%); cardiac monitoring, 16 (19%), timing, 13 (15%); and other, 2 (2%). Predialysis stabilization included: nitroglycerin, 29 (26%); sublingual captopril, 17 (15%); calcium chloride, 13 (11%); sodium bicarbonate, 12 (11%); insulin/dextrose, 11 (10%); none, 12 (11%); and other, 18 (16%). Airway support included: noninvasive pressure support ventilation (NPSV), 9 (18%); and endotracheal intubation, 6 (12%). NPSV was provided with a bilevel positive airway pressure system. Three of the endotracheal intubation patients were weaned to NPSV during dialysis, and all NPSV patients were weaned from respiratory support during their hemodialysis in the ED. Some patients had more than one problem. Sixteen patients (32%) were admitted, while 34 (68%) were discharged, including 3 NPSV patients and 22 initially unstable patients. ED hemodialysis in conjunction with additional medical care is a useful emergency medicine technique that can prevent hospital admission in patients with acute renal emergencies.
Article
Serious hyperkalemia is common in patients with end-stage renal disease (ESRD) and accounts for considerable morbidity and death. Mechanisms of extrarenal disposal of potassium (gastrointestinal excretion and cellular uptake) play a crucial role in the defense against hyperkalemia in this population. In this article we review extrarenal potassium homeostasis and its alteration in patients with ESRD. We pay particular attention to the factors that influence the movement of potassium across cell membranes. With that background we discuss the emergency treatment of hyperkalemia in patients with ESRD. We conclude with a review of strategies to reduce the risk of hyperkalemia in this population of patients.
Article
Hyperkalemia is a common feature of chronic renal insufficiency, usually ascribed to impaired K+ homeostasis. However, various experimental observations suggest that the increase in extracellular [K+] actually functions in a homeostatic fashion, directly stimulating renal K+ excretion through an effect that is independent of, and additive to, aldosterone. We have reviewed relevant studies in experimental animals and in human subjects that have examined the regulation of K+ excretion and its relation to plasma [K+]. Studies indicate that (1) extracellular [K+] in patients with renal insufficiency correlates directly with intracellular K+ content, and (2) hyperkalemia directly promotes K+ secretion in the principal cells of the collecting duct by increasing apical and basolateral membrane conductances. The effect of hyperkalemia differs from that of aldosterone in that K+ conductances are increased as the primary event. The changes in principal cell function and structure induced by hyperkalemia are indistinguishable from the effects seen in adaptation to a high K+ diet. We propose that hyperkalemia plays a pivotal role in K+ homeostasis in renal insufficiency by stimulating K+ excretion. In patients with chronic renal insufficiency, a new steady state develops in which extracellular [K+] rises to the level needed to stimulate K+ excretion so that it again matches intake. When this new steady state is achieved, plasma [K+] remains stable unless dietary intake increases, glomerular filtration rate falls, or drugs are given that disrupt the new balance.
Article
The fruits (dates) of the date palm (Phoenix dactylifera L.) contain a high percentage of carbohydrate (total sugars, 44-88%), fat (0.2-0.5%), 15 salts and minerals, protein (2.3-5.6%), vitamins and a high percentage of dietary fibre (6.4-11.5%). The flesh of dates contains 0.2-0.5% oil, whereas the seed contains 7.7-9.7% oil. The weight of the seed is 5.6-14.2% of the date. The fatty acids occur in both flesh and seed as a range of saturated and unsaturated acids, the seeds containing 14 types of fatty acids, but only eight of these fatty acids occur in very low concentration in the flesh. Unsaturated fatty acids include palmitoleic, oleic, linoleic and linolenic acids. The oleic acid content of the seeds varies from 41.1 to 58.8%, which suggests that the seeds of date could be used as a source of oleic acid. There are at least 15 minerals in dates. The percentage of each mineral in dried dates varies from 0.1 to 916 mg/100 g date depending on the type of mineral. In many varieties, potassium can be found at a concentration as high as 0.9% in the flesh while it is as high as 0.5% in some seeds. Other minerals and salts that are found in various proportions include boron, calcium, cobalt, copper, fluorine, iron, magnesium, manganese, potassium, phosphorous, sodium and zinc. Additionally, the seeds contain aluminum, cadmium, chloride, lead and sulphur in various proportions. Dates contain elemental fluorine that is useful in protecting teeth against decay. Selenium, another element believed to help prevent cancer and important in immune function, is also found in dates. The protein in dates contains 23 types of amino acids, some of which are not present in the most popular fruits such as oranges, apples and bananas. Dates contain at least six vitamins including a small amount of vitamin C, and vitamins B(1) thiamine, B(2) riboflavin, nicotinic acid (niacin) and vitamin A. The dietary fibre of 14 varieties of dates has been shown to be as high as 6.4-11.5% depending on variety and degree of ripeness. Dates contain 0.5-3.9% pectin, which may have important health benefits. The world production of dates has increased 2.9 times over 40 years, whereas the world population has doubled. The total world export of dates increased by 1.71% over 40 years. In many ways, dates may be considered as an almost ideal food, providing a wide range of essential nutrients and potential health benefits.
Al munatayat atthamnweeyah lil nakheel wa tamoor. Al Uloom wa technieqiyah
  • Ar Raqeyye Ibrahim Bin
  • Mohammad
Ar Raqeyye Ibrahim bin Mohammad. Al munatayat atthamnweeyah lil nakheel wa tamoor. Al Uloom wa technieqiyah. Shawal 1422 (Arabic).
Physiochemical characteristics and total quality of five varieties of dates grown in the United Arab Emirates
  • B Ismael
  • I Haffar
  • R Baalbaki
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.