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Journal of Nursing

Dietary Adjustments for the Chronic Hypertensive Type two Diabetic-Nephropathy Patients 

Getting a Foothold in the Nephronic Syndrome By: Dr. Gary D. Goldberg, PhD Clinical Professor of Medical Education, and Consultant Angeles College of Nursing, Los Angeles, California [email protected]


Abstract:  


Background:  Dual Dilemma


     Moderate and/or severe protein restrictions may indeed, be proposed in chronic renal failure both to fight its symptoms and to slow its progression.  In diabetic patients, whether insulin-dependent or non-insulin-dependent, have a chronic disease that has generally existed for a number of years before the onset of renal failure.  Dietary protein restrictions are effective in the progression of diabetic nephropathy, but many such patients have been observing dietary recommendations.  Usually the registry dietitian and/or treating physician will instruct the patient on the intake of both carbohydrates and fats.  In addition, there is a growing population that are unwilling to give-up their eating habits and progress from mildly obese tomorbid obesity. Furthermore, when renal failure develops, the patient may get the strong impression that the different specialists managing his or her health have contradictory objectives and give opposing nutritional advice.  It is highly important that the patient not to imagine that the diabetologist and the nephrologist are giving conflicting dietary directives when, in fact, most of the time their objectives converge.  


     Notes:  The registered nurse and/or nurse practitioner should communicate directly(e.g., add 15 min. of personalized teaching with your patient), understanding and having him and/or her repeat back the dietary information given and or explain through environmental aids that they understand and are willing to comply toward the life-style change and regiment prescribed.  Also, have your physicians’ assistant (P.A.) and /or clinical social-case-worker, involved with the support group meetings, or committee ethnic groups, that are approved through the American Diabetes Association/National  Kidney Foundation and the American College of Nutrition.        


Basic Nutritional Rules for Patients with Uncomplicated Insulin Dependent Diabetes –


     As a registered nurse, you may be aware that insulin-dependent diabetes is characterized by a loss of endocrine pancreas function; and there is no interference with the peripheral action of insulin.  In most cases studies, there appears to be a complete diminishing of production in insulin, although there is no peripheral insulin resistance.  Under such conditions, treatment simply consists of insulin therapy, covering the entire circadian cycle.  However, this insulin therapy imposes regularity in food intake, and particularly the intake of carbohydrates.  In addition, the importance of patient’s nutritional education may be limited in teaching him and/or her how to keep the same amounts of food and the same ratio balance of carbohydrate at each meal.  The other dietetic rules concerning fats and proteins are close to the same as those patients on a regular diet guideline of productive calorie usage and portion size.  [1]  The outcome is an attempt to balance the carbohydrate-lipid protein provisions and of course, an appropriate caloric intake to maintain a stable body weight as well as to foster the best possible state of health and to preserve the vascular walls which ultimately serves to protect renal function.[2] 


Basic Rules for Non-Insulin-Dependent Diabetic Patients-


     With these patients, the disease is characterized by disturbances of pancreatic function.  Sometimes consisting of a lost synchronism of secretion, this may no longer adapt to the level of circulating glucose. 


     Note:  Abnormal circulating glucose levels exist, but without exhaustion of insulin supply at least early in the course of the metabolic disorder. 


     In addition, there is indeed, an impaired response to the action of insulin, called ‘insulin resistance.’  This impairment is a hallmark of the metabolic disease.  The treatment of non-insulin-dependent diabetes consists in trying to achieve a balance between the rate of pancreatic secretion and the degree of insulin sensitivity.  The main objective is to lift the inhibition to the action of insulin, since little can be done to restore the faulty pancreatic secretion. 


     Note:  The means of going about this action mainly involves measuring militating (e.g., this action must include your complete clinical staff of trained nurses and treating practitioners), against sedentary life-style, onset of obesity (i.e., BMI of 35% or higher), and an unbalanced daily diet.


Indeed, it has been established that constant excess fat in the daily diet is a source of ‘metabolic impairment’ to the action of insulin, [3] especially when saturated fats are involved.  The dietary goals are for your patients to limit the caloric intake and to observe a proper carbohydrate-lipid-protein balance, given that the spontaneous tendency of this population is generally towards the consumption of high amounts of fats and proteins to the almost total exclusion of carbohydrates.  [4] 


The Impact of Dietary Measures on Chronic Renal Failure-


     The protein restriction proposed to patients with chronic renal failure and/or end-stage renal disease could conceivably be observed in a drastic isolated manner, without replacing protein calories by calories of another source.  This would result in a “hypo-caloric diet” and consequently malnutrition.  Such a hypothetical therapeutic proposition is of course, inconceivable. 


     On the other hand, protein restriction is in practice carried out by replacing the lost calories with carbohydrate (Cм {H₂O} ʼn) or lipid (fatty acids, acetyl-C₀Α) calories to maintain an adequate caloric intake and ensure a proper state of nutrition.  Patients should therefore increase their carbohydrate ration, also their lipid ration or both, in order to maintain a normalize provision of calories. 


     Note:  In principle, whether insulin-treated or not, diabetic patients should be urged to observe a diet defining the amount of carbohydrates and theoretically guaranteeing a balance of carbohydrates, fats, and proteins.  At this point in the treatment, there must be a clinician to patient understanding that your patient will have to make good chooses on there own, and become an active participant in the day-to-day diet planing regiment. 


     Because of the reduced protein ration, the patient has to choose whether to increase the proportion of carbohydrates or that of fats.  Otherwise, your patient if left alone with little to know follow-up will be at a higher risk for abnormalities in spiking B/P has and blood values that could range blow and/or above the normalizations.  In addition, weight gaining and lead to a higher BMI reading that will put your patient in the obesity and/or target new permanent organ damage such as heart, liver, or brain.    


Potential Effects of an Increase in the Carbohydrate or Fat Ration in Diabetic Subjects with Chronic Renal Failure-


     First, the diabetic patient who does not suffer from chronic renal failure learns from the treating clinician or diabetologist that the carbohydrate ration must be strictly observed.  In addition, quickly absorbed carbohydrates are to be banned, but that complex carbohydrates are vital to the quality of his or her metabolic stability, which they must be quantified, and above all, they must be regularly provided in sufficient quantity by the diet planner.  The same patient learns from the nurse practitioner and/or treating clinician that a high fat ration is harmful for his or her arterial walls and ultimately for his or her metabolic equilibrium, especially if he or she harbors non-insulin-dependent diabetes. Now, when the same patient subsequently sees a nephrologist, after having developed chronic renal failure, the latter will propose a restriction of protein intake adapted to the glomerular filtration rate.   As to the general food composition, protein restriction is usually associated with a restriction of fat intake and the caloric deficit must be compensated by an increase in carbohydrates. [5]   When learning that his or her usual ration of carbohydrates should increase, the patient may lose his or her bearings, with respect to the former eating habits, and the initial advice of the treating clinician.  However, this change of dietary advice is not contradictory to previous prescriptions.  The increase in the carbohydrate ration, in the absence of changes in total caloric intake, is by no means detrimental to glycaemic control. 


     Secondly, the diabetic patients with chronic renal failure should therefore be advised to go on a protein restriction, and this loss in calories (e.g., in no case be compensated by fat calories), but by an increase in the amounts of ingested carbohydrates alone. [6] This increase may even exert a beneficial effect on the patient’s diabetes.  The management of such patients calls for close collaboration between the diabetologist and/or treating clinician and the nephrologist, so that the patient will not lose confidence in the doctors and will not believe that the treatment of one disease is being abandoned in favor of another. [7]


Signs of Diabetic Nephropathy-


     The main sign of diabetic nephropathy is persistent protein in the urine. (e.g., protein may appear in the urine for 5 to 10 years before other symptoms develop).[8]  If the treating physician or clinician thinks, your patient might have this condition, a microalbuminuria (i.e., small amounts of blood protein, albumin leaks into the urine, during the early stages of kidney failure), should be done.  A positive test often means the patient may have at least some damage to the kidney from diabetes or a chronic persistent of high B/P that has gone untreated over time.  Target damage at this stage may be reversible. [9]


Note:  This test can result in false-positive findings, so please have the test repeated twice for confirmation.  High blood pressure often goes along with diabetic nephropathy.  Your patient may develop high blood pressure rapidly or is difficult to control and does not report to the treating clinician for a long period.  You may want to have the treating physician order some laboratory tests that may include: 


·       BUN


·       Serum Creatinine


The levels of these tests should increase, as kidney damage gets worse.  Other laboratory tests that may be done include: 


·       24-hour urine protein


·       Blood levels of phosphorus, calcium, bicarbonate, PTH (Parathyroid Hormone. i.e., a protein hormone blood test), and potassium levels.  If K- levels elevate for a long duration, this will cause high risk for“permanent organ damage” that may include the weakening of the heart muscle and valvular abnormalities. 


·       Hemoglobin


·       Hematocrit


·       Protein electrophoresis-urine


     The goals of treatment are to keep the kidney disease from progressing to end stage renal failure/disease (ESRD).  This will involve keeping your patients blood pressure under control (under 130/80).[10]  


     Also, note that it is very important to control the patient’s lipid levels. Through maintaining a healthy weight, and engage in regular physical activities. 


     As kidney failure gets worse, the body removes less insulin, so smaller doses may be needed to control glucose levels.  Dialysis may be necessary once end-stage kidney disease develops.  At this stage, a kidney transplant may beconsidered.   Another option for the patient with type 1 diabetes is a combined kidney-pancreas transplant. 


  Note:  The likely-hood of a transplantation for the obesity patient or morbid obese (a BMI of 35 and over), would be difficult and most hospitals have a protocol set in place.  The patient would have to meet each standard and go through a rigorous battery of both physical and psychological tests.  


     Nephropathy is a major cause of sickness and death in persons with diabetes.  It is the leading cause of long-term kidney failure and end-stage kidney disease in the United States, [11]  and usually leads to long-term dialysis or a kidney transplant.  In addition, complications due to chronic kidney failure are more likely to occur earlier, and get worse rapidly, when it is caused by diabetes than other causes.  Even after dialysis and/or transplantation, patients with diabetes tend to do worse, than patients without diabetes. [12]   


Renal-Diabetic Diets-


     Insulin dependent diabetes is usually characterized by a loss of endocrine pancreas function.  In addition, there is no interference with the peripheral action of insulin.  Under such conditions, treatment consists of insulin therapy, covering the entire circadian cycle. [13]  Insulin therapy imposes regularity in proper food intake and particularly the intake of complex-carbohydrates. 


Note:  Patient’s nutritional education and compliance will determine the success or failure that could result in a high-risk group for renal function and/or failure.   The goal for every physician, nurse practitioner, registered nurse, and licensed vocational nurse would be to have your patient’s keep and maintain a life-style change that would balance there carbohydrate-lipid protein provisions.  Also, appropriate caloric intake to maintain a stable body weight as well as to foster the best possible state of health and to preserve the vascular walls, which ultimately serves to protect renal function.  


      The diabetic patient who does not suffer from chronic renal failure learns from the diabetologist that the carbohydrate ration must be strictly observed, and that quickly absorbed carbohydrates are to be banned from the diet plan; but complex carbohydrates are vital to the quality of his or her metabolic stability.  In addition, that they must be quantified, and above all that, they must be regularly provided in sufficient quantity by the diet.  The same patient l earns from the interest or diabetologist that a high fat ration is harmful for his or her arterial walls and ultimately for his or her metabolic equilibrium, especially if he or she harbors’ non-insulin-dependent diabetes. 


     When the same patient subsequently sees a nephrologist, after having developed chronic renal failure, the latter will propose a restriction of protein intake adapted to the glomerular filtration rate.  As to the general food composition, protein restriction is usually associated with a restriction of fat intake and the caloric deficit must be compensated by an increase in carbohydrates.  When learning that his or her usual ration of carbohydrates should increase the patient may lose his or her bearings with respect to the former eating habits and the initial advice of his or her doctors.   The radical change of dietary advice is not to be understood as contradictory to previous prescriptions.  The increase in the carbohydrate ration, in the absence of changes in total caloric intake, is by no means detrimental to glycogenic control. [14]


Diabetic patients with chronic renal failure should be advised to go on a protein restriction, and this loss in calories, should in no case be compensated by fat calories, but by an increase in the amounts of ingested carbohydrates alone.  This increase may even exert a beneficial effect on the patient’s diabetes.  The management of such patients calls for close collaboration between the specialized treating clinician or diabetologist and the nephrologist, so that the patient will not lose confidence in the doctors and will not believe that the treatment of one disease is being abandoned in favor of another.  


Basic Facts about Renal Diet Planners-


     A managed renal diet can help control the build-up of waste products and fluid, in the blood.  In addition, to decrease the workload of the kidney.  The main goal of the diet is to keep the patient as healthy as possible according to the stages of kidney function.  Acceptable renal diets will include controlling of the intake of fluids, potassium, phosphorus, and sodium. 


·       Renal Diet Fact #1 – Proteins:  Pre-dialysis patients are often asked to limit protein intake in their renal diet to slow the progression of kidney disease.  This change with the start of dialysis, the patient would now need much more protein in their renal diets.  In addition, patients on peritoneal dialysis need even higher protein, because a large amount of protein can be lost in the peritoneal fluid, which is discarded. 


Note:  Protein can be found in two types of foods: 


     In large amounts in foods from animal sources such as poultry, meat, seafood, eggs, milk, cheese and other dairy products. 


     Also, in smaller amounts in foods from plant sources such as breads, cereals, other starches and grains, plus vegetables and fruits.


·       Renal Diet Fact #2 – Potassium:  The daily intake of potassium (K), in the renal patient’s diet needs to be controlled especially if on dialysis.  This will help prevent hyperkalemia (e.g., a sudden rise and/or spike, overload of potassium if left untreated, may lead to organ target permanent damage or death).  A high level of this mineral both electrical and cellular in function is a common problem for many on dialysis.           


                Some patients will experience potassium deficiency, usually because of aging or chronic disease.  The most common problems associated with potassium (K),  deficiency are hypertension (HTN), congestive heart failure (CHF), cardiac arrhythmias (CA2₊), severe depression (D ↓), and fatigue (F≤). Therefore, potassium (K), supplements should only be taken by a nurse practitioner and/or treating physicians’ written orders.    


·       Renal Diet Fact # 3 – Sodium:   Most end stage renal disease (ESRD), patients need to control and/or in most common conditions limit their salt intake.  This helps maintain fluid balance in the body to avoid fluid retention and elevated B/P.  Sodium is very high in the following foods: 


1st    table salt and foods with added sodium such as snack foods including so-call health bars, canned soups  and processed cheese.  In addition, glass jar-food specialties, such as kosher foods have a high salt  content.  Pre-packaged foods including most frozen entrees have a very high sodium count. 


2nd  most “fast-foods” and/or snack shops (e.g., roadside service stations, corner food and drink stands, and amusement-parks eateries); contain a high amount of salt.


3rd    foods packed in brine, such as pickles, olives, and sauerkraut, will contain a very high sodium count. 


4th   smoked and cured foods, such as ham, bacon, and all deli meats have very high sodium reading.


5th   Instead of using salt, have your patients try mustard, garlic, pepper, lemon juice or dash seasonings with no salt, in order to plan the meal and make it tasty. 


·       Renal Diet Fact # 4 – Phosphate:  High phosphate (i.e., salts of phosphoric acid are widely distributed throughout the body…it is found in body fluids, blood, saliva, and urine), levels can be dangerous for the patient on dialysis and/or in end stage renal decease.  Sustained elevated phosphoric acids can cause server itchiness all over the body and in the worse case, cause permanent bone disease in the long term.   The most common sources are in dairy products (e.g., milk, cheese, yoghurt as well in eggs, bones of fish to name a few).   


       Note:  Most renal diets avoid these foods as ingredients.  If your patient’s phosphate levels are too high, have him and/or her try using milk substitutes when cooking (e.g., Snopro. Milupa LPD).    


·       Renal Diet Fact # 5 – Fluids:  All renal diets recommend the control regarding the intake of fluids.  Make sure that your patient understands to count homemade soups (e.g., avoid most canned soups), all low sodium sauces, low sodium and sugar jellies, jams, and preserves’, custards, ect. , as part of there fluid allowance.


Thinking Ahead (Samples):   Smart Renal Diet Recipes-   


Renal Diet Recipes for Breakfast. 


1- Serving of fruit (4-6 oz)


1-Serving whole grain cereal (hot or cold @ 6-8 oz)


½ -Cup (125 mL.) non-fat or low-fat milk.  Note:  avoid whole milk, including homemade baking. 


1-Tbsp. (15mL.) bran natural:   (this should keep you regular).


1-Slice whole wheat, rye bread, or cracked wheat.  Avoid all white/bleached breads and watch your potassium additives if on potassium restriction.


1-Tbsp (15mL.) strawberry jams and/or sugar free or low fat preserve only. Avoid all Jellies. 


Renal Diet Recipes for Lunch (Dinner or Mid-Day Meal). 


1- Serving of meat (6 oz) extra lean cuts of red meat, pork, and chicken (Avoid skin on chicken).  In addition, you can choose lean buffalo, lamb, and ostrich.  Avoid all pre-seasoned meats due to excessive salt additives and sugar for flavor and shelf life. 


½ -1-Cup of green salads.  Avoid all deli cold pasta and potato salads.  Choose wisely regarding salad dressings.  Many fat-free or low-fat dressings will have sugar and sodium additives. 


1-2 slices of whole grain bread, or choose breads without added sugars and high amounts of sodium.  Avoid whole butter or choose a low-fat substitute that has a low sodium count and avoid sugars. 


1 Serving of fruit (4-6 oz). 


Note:  if you are not active or exercising at least 3-x week, avoid snacks. Otherwise, choose healthy and wise.  Again, avoid all types of chips, and dried fruit-bars, sodas, diet soda as well, ice creams and sherbets. They are high in processed sugars. 


1- Bran muffin (2.5-3.5 oz).  Avoid most white flower and sugar pies, cakes with the exception of an angel-food cake that is low in added sugar and sodium.  Try a kosher bakery, and ask for non-flower cakes. 


Renal Diet Recipes for Supper (or evening meal).


1-Serving of meat or boneless fish (6 oz).  Note:  Most boney fish are high in phosphatic acids.


½ -1-Cup of (125 mL. /100g) potatoes.  Note:  A baked potato of 6-8 oz is about 80-90 calories w/o any added ingredients. 


½ -1-Cup of steamed or grilled vegetables. 


1-regular size dinner roll (0.8).  Avoid sweet and white bleached dinner rolls.  Note:  use whole grain breads and cereals with discretion as they contain more phosphorus in your renal diet plan. 


A Thanksgiving renal diet planner:


Remember to portion size your meal.


Ø      Roast Turkey (remove skin)


Ø      Low Salt (sodium) Gravy


Ø      Cranberry Sauce (canned or fresh)


Ø      Savory Stuffing


Ø      Parsley Pilaf


Ø      Turnip Green Casserole or Fresh Green bean Casserole


Ø      Sliced Cucumbers with Chives, Low-Fat Yogurt and Basil


Ø      Dinner Roll and Low-Fat Margarine


Ø      I Can’t Believe It’s Not Pumpkin Pie!  with non-diary whipping cream


Ø      Tea or Coffee (avoid real sugar or cream)


A Special Supper for a Renal Diet Planner:


This sample menu includes end-stage renal disease (dialysis patients), who enjoy cooking. 


Ø      Caesar Salad 


Ø      Ginger Asparagus Chicken


Ø      Rice


Ø      Dill-icious Green Beans


Ø      Strawberries with Balsamic Vinegar


Ø      Mocha Meringue Kisses


       Note:  As a nurse practitioner and/or clinician, your patients with both renal/diabetes type 2, should receive individual renal-diabetic diet plans from the dietitians from their dialysis centers or from your education department.  The patient must be willing to change there life-style in order to prevent future organ-target damages.  From the authors experience with family members with end-stage renal disease that was triggered from prolonged uncontrolled high B/P and not willing to comply with the regiment that follows, the patient will suffer and shorten their life-span, guaranteed.


Simple rules to use as a guideline in your patient’s everyday life:   


Ø      If your patient has diabetes, avoid foods that are high in sugar.


Ø      Do not add salt to your foods.  Use herbs and non-salt spices (e.g., try Mrs. Dash’s salt-free spices).  In addition, do not use salt substitutes like the plague:  their main ingredient is potassium chloride. 


Ø      Limit high-quality protein foods to eight ounces (8 oz) daily (remember that one serving is equal to three to four oz.).  Stay away from all processed cheese and high salt counts.  Also, canned and cured meats. 


Ø      Limit your milk, yogurt, ice cream or sherbet to one ½ cup daily or just a few days a week.


Ø      Stay away from other high potassium and phosphorus foods. 


     Note:  The chronic renal/diabetic patient must have a good understanding that for them an increased risk of prolonged potassium will indeed, cause permanent organ damage that will lead to a complete abnormal coronary function, even death.


Ø      Limit yourself to no more three fruit servings a day.  One serving is one medium fruit or ½ cup.


Ø      Limit vegetables to two servings a day.


Ø      Use extra virgin olive oil or a very low-count of sodium and sugar based margarine (try low fat Smart Balance).  Avoid foods with a mayonnaise base. 


Low and High Potassium Foods for the Renal/Diabetic Diet Planner-


     All dialysis patients need to be concerned about too much potassium (K), in their foods.


     Fruits that are low in K include apples, blueberries, cherries, cranberries, coconut, fruit cocktail, grapefruit, grapes, peaches (canned in light syrup), pears (canned in light syrup), pineapple, strawberries, and tangerines. Some juices include apple, grape, and cranberry.  Vegetables that are acceptable to consume are asparagus, beans (green), beets, bell peppers, broccoli, cabbage, carrots, cauliflower, celery, chili peppers, corn, cucumbers,  eggplant, green (collard, mustard, and kale), lettuce, mushrooms, onions, peas, radishes and squash. 


     Dialysis patients should avoid either all together or in very tiny amounts of the following high potassium fruits:  apricots, avocado, banana, cantaloupe, honeydew melon, kiwi, nectarines, oranges, papaya, pears (fresh only), peaches (fresh only), prunes, and watermelon.  [15]̕ [16]̕ [17]


Note:  Juices (canned and/or bottled) that must be avoided are grapefruit, orange, pineapple and prune.  They contain high-added amounts of K and sugar boosters.  Also, avoid the eateries that contain so-called health juices.  They add boosters with K and phosphate.  Vegetables to avoid should include artichokes, baked BBQ beans, Brussels sprouts, lentils, lima beans, pumpkin (fresh and/or canned), squash, spinach, succotash, tomatoes, and mixed vegetable juices. 


  Short Bio of Dr. Gary D. Goldberg, PhD


Over 30 years experience in the Medical field, At UCLA and Pacific Hospital of the Valley, as a Chief Technologist and Analyst, Visiting Professor and Instructor for continuing education at UCLA School of Nursing and Writer/Speaker at the School of Medicine from 1995-2008.


From 2003-2008 Dr. Goldberg has collaborated and published through Blackwell Publishing Co. (Medical Division), and Journal of American College of Cardiology plus 15, published abstracts through UCLA Dept. of Internal Medicine and the Dept. of Cardiology.


Current title: Clinical Professor of Medical Education with Angeles College of Nursing, in Los Angeles, CA.  


Dr. Goldberg has written two major academic course textbooks for Angele College of Nursing and has represented advanced nursing education course curriculum through the State Dept. of California and approved by the ANA for CEU(s) and the AMA CMU Level 1 Credit for physicians.


His wife, Cindy L. Capute-Goldberg, has been a registered nurse for over 18 years and has managed a 200-bed acute care facility with over 100 professional nurses from RN’s through CNA in the Los Angeles area.  She has co-authored with Dr. Goldberg in 2005, a manuscript presented to the Cardiology-Electrophysiology Research Group (i.e., DMPG), that has changed the dynamics of electro-static reading concerning acute atrial anomalies. 


This finding allowed the author to publish the ‘Goldberg Protocol’ for Cardiac placements in the field and under the Dept. of Medicine Chair, in using a tilt-table with the 12 +3 Leads or the vector positioning for additional cardiac patient information.


To reach Dr. Gary D. Goldberg, for comments and/or consultation, please use e-mail address: [email protected] or cell phone contact:  818-610-9017. 





[1] American Diabetes Association.  Nutrition recommendations and principles for people with diabetes mellitus.  Diabetes Care 1999; 22:  542-545.




[2] Predini, M. Levey, A. Lau, J. Chalmers, T. Wang, P., The effect of dietary protein restriction on the progression of diabetic and non-diabetic renal diseases:  a meta-analysis.  Ann Intern Med 1996; 124:  627-632.




[3] American Diabetes Association.  Nutrition recommendations and principles for people with diabetes mellitus.  Diab Care 1999; 22:  542-545.




[4]  Ashley, C., Patterson, K., Stark, D., Daily Dietary Intakes Incorporating Nutraceuticals and Functional Food Strategies to Increase n-3 Highly Undersaturated Fatty Acids.  J Am Coll Nutr 2008; 27:  538-546. 




[5] Fouque, D., Laville, M., Boissel, J.P., Chiffet, R. Controlled low protein diet in chronic renal insufficiency a meta-analysis.  Br Med J 1999:  304:216-220.




[6] Ciavarclla, A., Dimizio, G., Stefoni, S., Borgnino, L. C., Vannini, P. Reduced albuminuria after dietary protein restriction in insulin-dependent diabetic patients with clinical nephropathy.  Diab Care 1997:  10; 407-413.




[7]  Rigalleau, V., Blanchetier, V., Combe, C. et al.  A low protein diet improves insulin sensitivity of endogenous glucose production in predialytic uremic patients.  Am J Clin Nutr 1999:  65; 1512-1516.   




[8] American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2009.  Diab Care 01/2009; 32:S13-S61.




[9]  Parving, H., Mauer, M., Ritz, E. Diabetic Nephropathy.  In:  Brenner, B.M., and Rector’s The Kidney. 8th ed.  Philadelphia, PA:  Saunders Elsevier; 2007: ch. 36. 




[10] A.D.M., Inc. is accredited by URAC, also known as the American Accreditation Health Care Commission http://www.urae.org  David Zieve, MD MHA, Medical Dir. A.D.A.M., Inc. Deborah Wexler, MD, Assistant Professor of Medicine, Harvard Medical School, Endocrinologist, Massachusetts General Hospital 2009.




[11]  American Diabetes Association (ADA); Nephropathy in diabetes.  Clinical Practice Recommendations 2004.  Diab Care 27(Suppl 1):  S79-S83. http://www.diabetesjournals.org




[12]  ADA; Nephropathy in diabetes.  2004. http://www.diabetesjournals.org  




[13]  American Diabetes Association.  Nutrition recommendations and principles for people with diabetes mellitus.  Diabetes Care 1999; 22:  542-544. 




[14] Rigalleau, V., Blanchetier, V., Combe, C., et al.  A low protein diet improves insulin sensitivity of endogenous glucose production in predialytic uremic patients.  Am J Clin Nutr 2000; 75: 1612-1615.




[15]  The Kidney Purifier Reviews.  Abacus Consulting Services at Los Angeles Chinese Learning Centers, 2005.  http://www.chinese-school.netfirms.com/reviews/kidney-purifier-reviews




[16] National Kidney Foundation 30 East 33rd St. New York, NY 10016  http://www.kidney.org 




[17] National Kidney Disease Education Program 3 Kidney Information Way Bethesda, MD 2089













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