Ramadan fast in kidney transplant recipients: a prospective comparative study

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative)

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

The Impact of Hot Ambient Temperature and Prolonged Fasting Duration during Ramadan on Patients with Chronic Kidney Disease: A Literature Review

The Islamic (lunar) calendar has 11 fewer days each year than the Gregorian (solar) calendar. Consequently, ambient temperatures during the month of Ramadan and the duration of the presunrise-to-sunset fast will change each year. At some point, individuals observing Ramadan will experience prolonged periods of fasting during the hot summer months. In this manuscript, findings published in the English-language medical literature that address the impact of prolonged fasting during the warmer summer months on patients with chronic kidney disease, including dialysis and transplantation patients, are reviewed. This is of particular concern given the accelerated pace of global warming. The limitations of the evidence that is currently available are also discussed, and an approach that might be used to standardize future evaluations of the impact of fasting on kidney health is suggested.

Fasting Ramadan in Chronic Kidney Disease (CKD), Kidney Transplant and Dialysis Patients: Review and Update

Chronic kidney disease (CKD) is a common disease in the Islamic regions. Dehydration occurs after prolonged fasting, particularly in hot and humid climates. In the Arabic months’ calendar, Ramadan is a month of maximum given deeds, where Muslims are required to fast from dawn till sunset. Depending on where you live and when the Ramadan month falls, fasting might last anywhere from 10 to 20 hours or more. In certain circumstances, such as poorly controlled diabetes and advanced CKD patients who are allowed to break their fast, the Ramadan fasting amendment is viable. Some Muslims, however, continue fasting despite these circumstances, placing themselves at risk, which is not allowed in the Islamic religion.

There are no medical recommendations that specify who should and should not fast. Nonetheless, the recommendations have been extracted from several published studies. The authors searched EMBASE, PubMed, Google Scholar, and Google for publications, research, and reviews. All authors debate and analyze the related articles. Each author was assigned a part or two of the topics to read, study, and summarize before creating the final draft of their given section. Then this comprehensive review was completed after discussion sessions.

In conclusion, by the Islamic religion view, fasting Ramadan is mandatory for every wise adult person. People who have chronic diseases or that may deteriorate by fasting are exempted from fasting. It seems that fasting and the associated disease hours are determinant factors to fasting or not fasting. Up to our knowledge, there are no established guidelines for CKD patients and physicians to follow; however, the International Diabetes Federation and Diabetes and Ramadan (IDF-DAR) Practical Guidelines 2021 have been issued for CKD diabetic patients and fasting.

Fasting during Ramadan and acute kidney injury (AKI): a retrospective, propensity matched cohort study

Background

During the month of Ramadan, Muslims abstain from daytime consumption of fluids and foods, although some high-risk individuals are exempt. Because fasting's effects on the risk of acute kidney injury (AKI) have not been established, this study assesses the relationship between fasting and risk of AKI and identifies patients at high risk.

Methods

A single-center, retrospective, propensity-score matched, cohort study was conducted with data collected from adult patients admitted to the emergency room during Ramadan and the following month over two consecutive years (2016 and 2017). AKI was diagnosed based on the 2012 definition from the Kidney Disease: Improving Global Outcomes clinical practice guideline. Multivariable logistic regression analyses were used to examine the correlation and measure the effect of fasting on the incidence of AKI, and assess the effect of different variables on the incidence of AKI between the matching cohorts.

Results

A total of 1199 patients were included; after matching, each cohort had 499 patients. In the fasting cohort, the incidence of AKI and the risk of developing AKI were significantly lower (adjusted odds ratio (AOR) 0.65;95% confidence interval (CI) 0.44–0.98). The most indicative risk factors for AKI were hypertension (AOR 2.17; 95% CI 1.48–3.18), history of AKI (AOR 5.05; 95% CI 3.46–7.39), and liver cirrhosis (AOR 3.01; 95% CI 1.04–8.70). Patients with these factors or most other comorbidities in the fasting cohort had a lower risk of AKI as compared with their nonfasting counterparts.

Conclusion

The data show a strong reduction in the risk of developing AKI as a benefit of fasting, particularly in patients with comorbid conditions. Therefore, most patients with comorbid conditions are not harmed from fasting during Ramadan. However, larger prospective studies are needed to investigate the benefit of fasting in reducing the risk of developing AKI.

Effects of fasting on solid organ transplant recipients during Ramadan - a practical guide for healthcare professionals

Fasting in the month of Ramadan is an obligatory act for healthy adult Muslims. It requires abstinence from food and drink from dawn to sunset. Although there are exemptions from fasting, many patients are keen to fulfil what they see as a religious obligation, even if this may be against medical advice in some cases. Solid organ transplant (SOT) recipients often ask healthcare professionals for advice on fasting. Studies on the effect of fasting in transplant patients have all been done in the Middle East and North Africa where the average fasting duration is between 12 and 14 hours. In comparison, in temperate regions in the summer, fasting duration can be as long as 20 hours. Fasting when patients have to take immunosuppression 12 hours apart with little time variation poses unique challenges. In this review, current literature is reviewed, and a decision-making tool has been developed to assist clinicians in discussing the risks of fasting in transplant recipients, with consideration also given to circumstances such as the COVID-19 pandemic. Our review highlights that SOT recipients wishing to fast should undergo a thorough risk assessment, ideally 3 months before Ramadan. They may require medication changes and a plan for regular monitoring of graft function and electrolytes in order to fast safely. Recommendations have been based on risk tiers (very high risk, high risk and low/moderate risk) established by the International Diabetes Federation and the Diabetes and Ramadan International Alliance. Patients in the 'very high risk' and 'high risk' categories should be encouraged to explore alternative options to fasting such as winter fasting or Fidyah. Those in the 'low/moderate' category may be able to cautiously fast with guidance from their clinician. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick-day rules, instructions on when to terminate their fast or abstain from fasting.

Effect of Fasting the Whole Month of Ramadan on Renal Function Among Muslim Patients With Kidney Transplant: A Meta-Analysis

OBJECTIVES

Muslim renal transplant patients often ask whether fasting during Ramadan would be harmful to their kidneys. We performed a meta-analysis on relevant studies to answer this question.

MATERIALS AND METHODS

We searched 4 databases using comprehensive search terms with predefined eligibility criteria. Two reviewers (FH and RA) independently assessed the relevance of studies obtained during the search. If disagreement occurred, a consensus would be sought; if disagreement persisted, the arbitration would be left to a third author (AAS).

RESULTS

Eight studies (549 patients) were identified as eligible; these studies measured renal function before and after Ramadan with patients acting as their own controls in 5 studies. Our pooled analyses showed no significant changes after fasting with regard to estimated glomerular filtration rate (70.1 ± 9.1 vs 68.5 ± 7.5 mL/min, respectively; P = .6) or in serum creatinine levels (105.3 ± 8.8 and 106.1 ± 6.0 μmol/L, respectively; P = .47). In 4 self-controlled studies (148 patients) that had analyzed changes in systolic and diastolic blood pressure before versus after fasting, no significant differences were shown. However, in 3 studies that assessed changes in glomerular filtration rate in fasting (n = 358) versus nonfasting patients (n = 355), there was a significant difference in change in glomerular filtration rate following Ramadan fasting (-0.13 ± 1.2 mL/min in those who fasted versus 4.2 ± 4.6 mL/min in those who did not fast; P = .039); however, these results were associated with significant publication bias (systematic heterogeneity).

CONCLUSIONS

Fasting during Ramadan did not result in significant changes in kidney function or blood pressure in posttransplant patients with good baseline kidney function when patients acted as their own controls.

Fasting outcomes in people with diabetes and chronic kidney disease in East London during Ramadan 2018: The East London diabetes in Ramadan survey

OBJECTIVES

Fasting in summer months for Muslim people with diabetes during Ramadan is challenging, particularly in temperate climates, where duration of fasting is prolonged. Risk of fasting may be greater in people with diabetes and chronic kidney disease (CKD). We aimed to prospectively monitor the outcomes of patients with diabetes and CKD stage 3 during Ramadan 2018 in East London.

METHODS

Patients with type 2 diabetes (T2D) and CKD stage 3 attending community diabetes clinics were approached prior to Ramadan 2018 to discuss fasting. Patients were risk categorised according to Diabetes and Ramadan Alliance guidelines. If they chose to fast, Ramadan education was given, and biomedical assessments were undertaken within one week prior to and one week after fasting. Outcomes between patients fasting and non-fasting groups were compared.

RESULTS

Fasting (n = 68) and non-fasting groups (n = 71) were similar apart from slightly higher insulin use in the non-fasting group. Median days fasted was 21 (range 12-29). There were no significant changes in weight, blood pressure, creatinine, glycated haemoglobin, cholesterol and urinary PCR pre- and post-Ramadan, and no significant differences between the fasting and non-fasting groups. There was no difference in adverse events (acute kidney injury, hypoglycaemia or cardiovascular events) between the fasting and non-fasting groups.

CONCLUSIONS

No significant differences were seen in clinical or biochemical parameters, or adverse events between fasting and non-fasting patients. Patients with T2D and stable CKD stage 3 may be able to fast safely during Ramadan.

Fasting during Ramadan in people with chronic kidney disease: a review of the literature

Chronic kidney disease (CKD) is common among Muslim patients, and many such patients are keen to fast during the month of Ramadan. Fasting for prolonged periods may be deleterious for patients with CKD, but the changing season of fasting means that the duration of fast is very variable between geographical locations. There is, furthermore, a paucity of evidence to guide patients and clinicians in management of fasting in people with CKD. In this article, we aim to review the available evidence for patients with CKD and fasting, including haemodialysis and renal transplantation. We suggest that all patients with CKD should be deemed high risk or very high risk for fasting. We conclude, however, that patients with stable mild/moderate CKD (stage 1-3) may be able to fast providing they are carefully monitored and counselled. We also suggest that patients with stable renal transplants may also be able to fast, providing they are monitored carefully by their transplant team. Patients on haemodialysis or peritoneal dialysis should not be encouraged to fast, but if they do so, they will need careful weekly monitoring. There is an urgent need for high-quality data for patients with CKD who plan to fast over Ramadan, to enable more guidance to be developed for this vulnerable group of patients.

Ramadan Fasting in Kidney Transplant Recipients: A Single-Centre Retrospective Study

Background

Fasting during the lunar month of Ramadan is mandatory to all healthy adult Muslims. Renal transplant recipients are often worried about the impact of fluid and electrolyte deprivation during fasting on the function of their allograft. We aimed to examine the effect of fasting Ramadan on the graft function in renal transplant recipients.

Methods

This retrospective cohort study included patients who underwent kidney transplantation in our tertiary referral center. Baseline pre-Ramadan estimated glomerular filtration rate (eGFR), mean arterial pressure (MAP), and urinary protein excretion were compared to those during and after Ramadan within and between the fasting and non-fasting groups.

Results

The study population included 280 kidney transplant recipients who chose to fast during the Ramadan month (June-July 2014) and 285 recipients who did not fast. In the fasting group, baseline eGFR did not change from that during or post-Ramadan (72.6 ± 23.7 versus 72.3 ± 24.5 mL/min/1.73 m2, P = 0.53; and 72.6 ± 23.7 versus 72 ± 23.2 mL/min/1.73 m2, P = 0.14, respectively). Compared to baseline, there were no significant differences between the fasting and the non-fasting groups in terms of mean percent changes in eGFR, MAP, and urinary protein excretion.

Conclusion

Fasting during the month of Ramadan did not have significant adverse effects on renal allograft function.

Effect of repeated ramadan fasting in the hottest months of the year on renal graft function

BACKGROUND

Adult Moslems are required to fast during the lunar month of Ramadan every year. Although the sick and travelers, as well as some other specified groups, are exempted from this requirement.

OBJECTIVES

To investigate the effect of repeated Ramadan fasting during the hottest months of the year on renal graft functions.

PATIENTS AND METHODS

This was a prospective cohort study comparing two groups of renal transplant receivers; one group had fasted for two consecutive Ramadan months during 2011 and 2012, while the other group had not fasted. The baseline eGFR (estimated glomerular filtration rate) was compared to the eGFR carried out 19.6 ± 1.3 months later, within and between groups. Further subgroup analysis was done according to eGFR baseline; low (< 45 mL/min/1.73 m(2)), moderate 45-75 (mL/min/1.73 m(2)), and high (> 75 mL/min/1.73 m(2)).

RESULTS

There were 43 fasting and 37 non-fasting participants with comparable; ages, gender, type of transplant, and baseline eGFR and serum creatinine (SCr). The fasting participants, however, had a longer elapsed time since their transplantation. In the fasting group, SCr and eGFR did not change from baseline after a mean follow-up period of 19.6 ± 1.3 months; SCr of 105.1 ± 55.4 and 114.2 ± 71.5 µmol/L, respectively (P-value = 0.8), and eGFR 75.6 ± 29.2 and 70.2 ± 28.1 mL/min/1.73 m(2), respectively (P-value = 0.09). Similarly, no significant changes were observed in the non-fasting group; Sr of 123.1 ± 67 and 115.8 ± 65.2 µmol/L, respectively (P-value = 0.6), and eGFR of 65.9 ± 25.9 and 68.8 ± 24.6 mL/min/1.73 m(2), respectively (P-value = 0.6). On subgroup analysis, according to the eGFR level, we found no significant differences in the eGFR, before and after 19.6 ± 1.3 months, in the severe and moderate subgroups. However, a significant but similar drop was noted in the high GFR subgroups in both the fasting subgroup (96.4 ± 15 to 84.9 ± 20.7 mL/min/1.73 m(2); P = 0.17) and in the non-fasting subgroup (92.9 ± 15.8 to 82.3 ± 18.2 mL/min/1.73 m(2); P = 0.019).

CONCLUSIONS

Fasting in the month of Ramadan in two consecutive years, and during the hottest months, in Riyadh, Saudi Arabia, did not adversely affect kidney graft function.

Recommendations for fasting in Ramadan for patients on peritoneal dialysis

INTRODUCTION

The month of Ramadan holds great religious and social significance for Muslims all over the world. The aim of the present study was to provide a modified dialysis schedule for peritoneal dialysis (PD) patients that allows for fasting and that minimizes the effect on the patient's general health and volume status.

METHODS

We observed 31 patients under treatment at the PD unit of King Khalid University Hospital, King Saud University, Riyadh. During the 3 - 4 weeks before the start of Ramadan, all patients were counseled individually and in detail about the possibility of fasting. They were also provided with clear instructions about fluid intake (up to 1 L daily) and avoiding a high-potassium diet. Of the 31 patients, 18 (10 women, 8 men) elected to fast during the month of Ramadan. The mean duration of fast in the study year (2009) in Riyadh, Saudi Arabia, was about 14 hours: from 0415 h (before sunrise) to 1800 h (after sunset). Depending on membrane type and patient preference, the fasting group was shifted to one of two regimens: Modified continuous ambulatory PD (8 patients): 3 exchanges during the night (1.36% or 2.27%), and icodextrin for a long dwell during the day. The first dialysis exchange was performed immediately after breaking the fast (1900 h), and the next at 2300 h. The final exchange was performed in the early morning before sunrise (0300 h), when the icodextrin was infused. Modified continuous cycling PD (10 patients): exchanges (1.36% or 2.27%) were performed over 6 - 7 hours, and icodextrin was infused for a long dwell during the day. The patient connected to the cycler at 2000 h or 2100 h, and therapy finished at nearly 0300 h, with icodextrin as the last fill.

RESULTS

Of the study patients, 2 were admitted because of peritonitis (1 in each modality group), and the modified therapy was discontinued. In the modified CCPD group, 1 patient (on PD for 1 month before Ramadan) developed PD-related pleural effusion (proved by pleural fluid analysis), and PD was consequently discontinued. Hypotension developed in 2 patients of the CAPD group and 1 of the CCPD group during the first 2 weeks. In the CCPD group, 1 patient presented with lower limb edema and mild fluid overload. Overall, PD patients that opted to fast during Ramadan did not experience any serious morbidity or deterioration in renal function during their period of observance. No biochemical parameters or clearance studies showed a statistically significant p value.

CONCLUSIONS

In view of the study findings, we conclude that most stable patients on PD can fast, provided that they strictly adhere to their medications and dialysis therapy in addition to the dietary restrictions. These patients should be followed closely to detect any complications and to ensure that adequate fluid and electrolyte balance are maintained.

Effect of fasting for Ramadan on kidney graft function during the hottest month of the year (August) in Riyadh, Saudi Arabia

OBJECTIVES

To assess the effect of fasting Ramadan during the hottest month of the year in Riyadh, Saudi Arabia.

MATERIALS AND METHODS

This prospective cohort study was performed at the King Fahd National Guard Hospital in Riyadh, Saudi Arabia. We used the Modification of Diet in Renal Disease formula to estimate the glomerular filtration rate in renal transplant patients who fasted and did not fast before and after Ramadan.

RESULTS

There were 43 fasters and 37 nonfasters of comparable ages, with fasters having longer posttransplant times compared with nonfasters (P = .0001). The 2 groups had similar mean estimated glomerular filtration rates before Ramadan: 75.6 ± 29.2 and 65.9 ± 25.9 mL/min (P = .1) and similar mean estimated glomerular filtration rates 6 months after Ramadan: 77.2 ± 29.7 and 64.1 ± 29 mL/min (P = .21). Mean changes in the estimated glomerular filtration rate were similar in the 2 groups: -1.5 ± 10.9 and -2.8 ± 19.3 (P = .7) as was the percentage change (-0.2.2 ± 13.4 and 1.8 ± 15.9; P = .4). In the fasting group, serum creatinine and estimated glomerular filtration rate were similar before and 6 months after Ramadan: 105.1 ± 55 and 105.14 ± 61 μmol/L (P = 1.0) and 75.6 ± 29 and 72.2 ± 29.7 mL/min (P = .36). No significant changes were observed in the nonfasting group. No significant differences were detected regarding fasting in the estimated glomerular filtration rate before and 6 months after Ramadan in the 3 groups with the low, moderate, and high glomerular filtration rates at baseline.

CONCLUSIONS

Fasting for Ramadan in August does not adversely affect graft function at a mean follow-up of 7.6 ± 1.3 months.

Ramadan fasting in kidney transplant recipients with normal renal function and with mild-to-moderate renal dysfunction

BACKGROUND

Fasting during Ramadan is prescribed for every healthy Muslim after the age of puberty. However, many patients ask their physicians whether it is safe for them to fast.

AIM

The aim of this study was to evaluate the influence of voluntary Ramadan fasting on patients with transplanted kidneys.

METHODS

We conducted a prospective study on 41 kidney transplant recipients who chose to fast during Ramadan and 41 recipients who had not fasted at five transplant centers in the month of Ramadan (September-October 2007). All 82 recipients underwent transplantation at least 1 year prior to the study, and all had had stable renal function for at least 6 months prior to the study.

RESULTS

The mean ages of the fasting and control groups were 42 +/- 12 years and 43 +/- 12 years, respectively, and the corresponding duration since transplantation was 10-210 (average: 65) months and 11-180 (average: 69) months. Our results showed that estimated GFR did not significantly change during Ramadan for either group (mean estimated GFRs pre- and post-Ramadan were 72.8 +/- 27.8 and 73.1 +/- 29.3 ml/min in the fasting group, and 73.4 +/- 18.8 and 73.1 +/- 18.5 ml/min in non-fasters, respectively). In patients with GFR < 60 ml/min, renal function remained stable during Ramadan.

CONCLUSION

The results did not show any adverse effects of fasting, especially on allograft function, in kidney recipients who had normal as well as mild to moderate impaired but stable renal function prior to fasting.

Does repeated Ramadan fasting adversely affect kidney function in renal transplant patients?

This is a prospective cohort study in renal transplant patients who fasted or who did not fast for three consecutive Ramadans. The baseline estimated glomerular filtration rate (GFR), mean arterial pressure (MAP), and urinary protein excretion before the first Ramadan were compared to those after the third Ramadan in 35 fasters and 33 nonfasters. The effect of age, time after transplantation, presence of diabetes mellitus (DM), and proteinuria on changes in the GFR were studied. The two groups were comparable in gender, age, donor source, time posttransplantation, presence of DM, hypertension, proteinuria, serum creatinine, and MAP. Among the fasters, there was no change in estimated GFR after fasting for three Ramadans (56.4 mL/min versus 55.4 mL/min, P=0.8) even after adjusting for age, DM, baseline GFR, proteinuria, or time after transplantation. There were no significant differences between the fasters and the nonfasters in the changes in GFR, MAP, and urinary protein excretion between baseline and the third Ramadan.

Impact of Ramadan Fasting on Renal Allograft Function

Fasting during the holy month of Ramadan is a religious duty for all healthy adult Muslims. They are only allowed to eat and drink between sunset and dawn. This study was designed to find the effect of Ramadan fasting on allograft function. We prospectively studied 19 kidney transplant recipients who voluntarily chose to fast during Ramadan versus 20 matched recipients, who had not fasted for 3 consecutive years. Data were recorded before, during, and after the fasting month. The mean posttransplant periods in the fasting and control groups were 52.6 +/- 30.3 and 56.6 +/- 30.0 months, respectively. A statistical analysis showed no significant changes in serum creatinine concentrations before and after Ramadan 1.07 +/- 0.24 versus 1.08 +/- 0.22 mg/dL (P > .05) and 1.00 +/- 0.24 versus 1.03 +/- 0.28 mg/dL (P > .05) in fasting and control groups, respectively. The results did not show any adverse effects of fasting in recipients with stable renal function. In conclusion, our study suggests that fasting during the month of Ramadan is safe and has no significant harmful effects on kidney transplant recipients with normal renal function.