Impact of Ramadan Fasting on Renal Allograft Function

Shared Decision-making Model for Solid Organ Transplant Recipients during Ramadan Fasting

Fasting during the month of Ramadan is an obligatory religious practice for healthy adult Muslims. To complete a fast, individuals must abstain from eating, drinking, and taking medications from dawn to sunset. Individuals may be exempt from fasting during Ramadan on health grounds. However, some patients may still fast to fulfill their religious obligation, even if this means going against medical advice. Solid organ transplant recipients may have to follow strict fluid and electrolyte requirements, which could be challenging during Ramadan, leading to the concern that abstaining from fluid intake can lead to prerenal acute kidney injury. Furthermore, transplant recipients must take their immunosuppression at prescribed intervals to preserve graft function, drug level variability runs the risk of graft rejection. Following a review of the current literature, a shared decision-making tool has been developed to assist clinicians in supporting patients who are motivated to fast during Ramadan. All recipients wishing to fast should undergo a risk assessment. Those in the low–moderate risk category may be able to fast and safely follow medication reviews and optimize their immunosuppression regimens. In addition, they would benefit from monitoring graft function, therapeutic drug levels, electrolytes, and additional parameters such as fluid status, weight, blood pressure, and concurrent management of comorbidities. Those stratified in the higher-risk categories should be encouraged to explore alternatives, such as Fidyah or winter fasting.

Impact of Ramadan fasting on kidney function and related outcomes in chronic kidney disease and kidney transplant recipients: a systematic review and meta-analysis

OBJECTIVES

Ramadan fasting is an Islamic religious practice involving abstinence from food and drink from dawn to sunset. Its consequences on kidney-relevant outcomes in patients with chronic kidney disease (CKD) and kidney transplant recipients remain unclear.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, Global Health, CINAHL (EBSCOhost), Scopus, Web of Science and Google Scholar were searched up to 18 September 2023.

ELIGIBILITY CRITERIA

We included observational studies among non-dialysis CKD and kidney transplant recipients who fasted during Ramadan and examined changes in kidney function.

DATA EXTRACTION AND SYNTHESIS

Standardised methods were used by two independent reviewers to screen, select and extract data. Outcomes included changes in serum creatinine (SCr), estimated glomerular filtration rate (eGFR), proteinuria, blood pressure, electrolytes and adverse events-all pre- and post-Ramadan. Results were pooled using random effects modelling.

RESULTS

We included 32 observational studies with a total of 2592 participants. 21 studies reported on participants with CKD and 11 studies reported on kidney transplant recipients (studies variably including non-fasting control arms). Meta-analysis of 25 studies revealed that Ramadan fasting was not associated with changes to SCr for the following groups according to study design: CKD with a non-fasting arm (mean difference (MD)=0.82 µmol/L; 95% CI -7.22, 8.86; I2=38%); transplant with a non-fasting arm (MD=-0.17 µmol/L; 95% CI -2.50, 2.15; I2=0%) and CKD without a non-fasting arm (post-pre MD=13.84 µmol/L; 95% CI -3.78, 31.47; I2=88%). For transplant studies without a non-fasting arm, lower SCr was associated with the post-Ramadan period (post-pre MD=-5.40 µmol/L; 95% CI -10.78, -0.02; I2=0%). In the 18 studies that reported on eGFR, fasting during Ramadan was not associated with an effect on eGFR for any of the groups.

CONCLUSION

We report inconsistent effects of Ramadan fasting on kidney function in CKD or kidney transplantation. Results should be interpreted with caution due to the significant limitations of the underlying studies.

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.

Distribution and management of the pediatric refugee population with renal replacement: A German pediatric cohort

With migration rising, the pediatric nephrology community is faced with challenges concerning the management of end-stage kidney disease (ESKD) in the pediatric refugee population. Data on the care of the pediatric refugee cohort on renal replacement therapy (RRT) is not available. A survey conducted by us in 2018 showed that the group of refugee children arriving to Germany during the years 2015-2017 accounts for approximately 20% of the total pediatric dialysis population in Germany. Provision of (medical) care for these children and their families is often hampered by psychosocial problems, cultural differences, language barriers, and administrative issues. Treating centers need to provide additional human as well as financial and logistic resources. In this educational review, we raise awareness and discuss possible challenges occurring in the treatment of refugee children with ESKD.

Effect of Ramadan fasting on Muslim recipients after living donor liver transplantation: A single center study

BACKGROUND AND STUDY AIMS

Several factors affect the quality of life and personal well-being of transplant recipients, including Ramadan fasting for Muslims. This study aimed to assess the effect of Ramadan fasting on the renal and liver functions of liver transplantation recipients and to propose a protocol for adapting an Immunosuppression regimen and follow-up schedule for patients wishing to fast after liver transplantation.

PATIENTS AND METHODS

This prospective study was conducted on 45 recipients who wished to fast Ramadan from 17th May to 14th June 2018, at Ain Shams Center for Organ Transplantation, Cairo, Egypt.

RESULTS

The mean age of the patients was 55.5 ± 7.2 (37-68) years, and 84.4% were males; the mean time from liver transplantation was 51.6 ± 28 months (14-117). Thirty-seven patients (82.2%) completed Ramadan fasting, three patients (6.6%) had interrupted fasting, and five patients (11.1%) had to stop fasting because of an unacceptable rise in renal function. There was a statistically significant difference between the pre- and post-fasting states in terms of the serum creatinine level (p = 0.004).However, the serum creatinine did not exceed the upper normal value in the patients who completed fasting.

CONCLUSION

Our data seem promising for Ramadan fasting with an adapted immunosuppression protocol and regular follow-up for recipients wishing to fast. Further multicentre studies on a larger number of patients are warranted.

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.

The effect of Ramadan fasting on renal functions in patients with chronic kidney disease

Objective

We aimed to investigate the effects of Ramadan fasting on renal functions in patients with stage 3 and 4 chronic kidney disease.

Materials and methods

The study was conducted in Ramadan month which was between June and July. Patients were evaluated before Ramadan, the week immediately following the end of the Ramadan, and 3 and 6 months after Ramadan.

Results

Twenty-four fasting (mean age of 68 ± 13 years) and 55 non-fasting individuals (mean age of 69 ± 9 years) were included in this study. There was no statistically significant difference for creatinine levels in the first week after Ramadan in both groups compared to levels before Ramadan (p = 0.070, p = 0.470, respectively). The groups were compared according to the criteria of deterioration in renal function (reduction of 25% in GFR and 30% increase in serum creatinine levels). There were no statistically significant differences between the two groups according to these two criteria (p = 0.452, p = 0.660, respectively). In univariate and multivariate logistic regression analysis, the presence of diabetes mellitus and proteinuria were found to be independent risk determinants of renal dysfunction.

Conclusion

Patients with diabetes mellitus and prominent proteinuria may constitute critical patient groups for renal function deterioration during Ramadan fasting.

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.

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.