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Saudi J Kidney Dis Transpl 2010;21(5):898-902


© 2010 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Fasting Ramadan in Chronic Kidney Disease Patients:


Clinical and Biochemical Effects
Bassam Bernieh1, Mohammad Raafat Al Hakim1, Yousef Boobes1, Fikri M. Abu Zidan2

Nephrology Department1, Tawam Hospital in Affiliation with Johns Hopkins Medicine, and
Department of Surgery2, Faculty of Medicine and Health Sciences, United Arab Emirates
University, Al Ain UAE

ABSTRACT. Fasting of the month of Ramadan is a pillar of Islam. Muslim patients with chronic
kidney disease (CKD) usually fast this month. To determine the effects of fasting on renal
function in CKD patients, we prospectively studied 31 (19 males and mean age 54 ±14.2 years)
CKD patients during the month of Ramadan 1426 Hijra (4th October - 4th November 2005); 14
patients were in stage III CKD, 12 had stage IV and 5 had stage V. The mean estimated
glomerular filtration rate (e-GFR) was 29 ± 16.3 mL/min. Diabetes was the main cause of CKD
(19 (61%) patients), and hypertension was present in 22 (71%) patients. Clinical assessment and
renal function tests were performed one month prior to fasting then during and a month later.
Medications were taken in two divided doses at sunset (time of breaking the fast) and pre dawn
(before starting the fast). All patients fasted the whole month of Ramadan with a good tolerance,
tendency to weight reduction, and lower systolic and diastolic blood pressure. eGFR showed a
significant improvement during the fast and the month after. The blood sugar was high during
fasting with an increment in the Hb A1c. There was better lipid profile, reduction of the pro-
teinuria and urinary sodium. We conclude that this study demonstrates a good tolerance and
safety of fasting Ramadan in CKD patients.

Introduction and pregnant and lactating and menstruating


women yet they should fast later, when they
Fasting Ramadan is a pillar of Islam. Most have no reason for exemption.1,2 Islamic lunar
healthy adult Muslims should strictly adhere to calendar of Hijra, moves forward about 11 days
fasting during the month of Ramadan. How- every year. Ramadan can, therefore, occur in
ever, exemption is given to the sick,1 travelers, any of the four seasons and the duration of
Correspondence to: restricted food and beverage intake can vary
from 12 to 18 hours depending upon the exact
Dr. Bassam Bernieh time of sunrise and sunset in each country or
Consultant Nephrologist, region. Fasting during Ramadan is different from
Tawam Hospital, prolonged continuous fasting, in that it is done
P.O. Box 15258, Al Ain, UAE only between dawn and sunset, and people are
E-mail: bassambernieh@hotmail.com allowed to drink and eat freely after sunset till
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Fasting Ramadan in chronic kidney disease patients 899

Table 1. Mean (SD) body weight, systolic blood pressure (SBP) and diastolic blood pressure (DBP)
during the study.
Pre-Ramadan During-Ramadan Post-Ramadan P value
Weight kg 76.4 (18) 75 (17.6) 75.7 (18) 0.13
SBP mmHg 138 (13.2) 133.2 (15) 131 (26.3) 0.21
DBP mmHg 81.3 (9) 78.2 (9.3) 80 (10) 0.6

the onset of dawn.3 Several studies have con- active peptic ulcer, history of renal stone; and
cluded that fasting during Ramadan does not mandatory medications more than twice a day.
have any adverse effect on healthy adults.4-6 All the study patients were given three ap-
Ramadan fasting, in both type I and type II dia- pointments: in the month preceding Ramadan,
betes mellitus is safe.7,8 The safety of fasting during the last week of Ramadan, and in the
has also been demonstrated in renal transplant month after Ramadan. During these interviews,
patients, one year after transplantation.9-12 How- the patients were assessed clinically along with
ever, the effect of the fasting Ramadan in chro- kidney function tests, blood sugar, HbA1c, to-
nic kidney disease (CKD) patients has been tal protein, albumin, lipids profile, hemoglo-
only recently reported in a pilot study inclu- bin, urine chemistry, proteinuria, and protein
ding only 12 patients.13 to creatinine ratio.
The aim of this study is to evaluate the cli- The estimated glomerular filtration rate (e-
nical and biochemical safety of fasting Ramadan GFR) was calculated by using the Cockcroft-
in patients with chronic kidney disease. Gault formula. Mean (SD) eGFR was 29 (16.3)
mL/min, with a range of 8 to 58. Accordingly,
Patients and Methods the staging of CKD included 14 patients with
stage III, 12 with stage IV, and 5 with stage V.
A total number of 45 out patients followed up Diabetes mellitus (DM) was the leading cause
in the nephrology clinic of our tertiary teac- of CKD in this population (61%). Other etio-
hing hospital were registered, only the data of logies (26%) were chronic glomerulonephritis,
31 (69%) were analyzed, because the remai- systemic lupus nephritis, and unknown in
ning 14 patients missed one or more of the (13%). Hypertension and hyperlipidemia were
three visits, and were not eligible for statistical the main co-morbidities encountered in 71%
data analysis. There were 19 males, having a and 26%, respectively.
mean (SD) age of 54 (4.2) years, and a range
of 23 to 81 years. The study was approved by Management of DM during Ramadan
Al Ain medical district ethical committee. Almost all the diabetic patients who were
included in the study had type 2 DM; 50% of
Inclusion criteria them were managed with oral hypoglyce-
We included patients with CKD (stage II to miants agents, 40% with insulin and 10% with
V) of different etiologies, age more than 18 both. In the visit prior to Ramadan, the diabe-
years, and who were planning to fast, during tic patients were counseled and educated about
Ramadan 1426 Hijra, corresponding to October/ self-care, including signs and symptoms of
November 2005. hyper- and hypoglycemia, blood glucose mo-
nitoring, meal planning, physical activity, me-
Exclusion criteria dication administration, and management of
We excluded from the study patients with acute complications.
kidney transplant, history of acute tubular nec-
rosis due to dehydration, uncontrolled or poorly Oral hypoglycemic agents
controlled hypertension or diabetes mellitus, Metformin was maintained in patient with se-
pregnancy, concurrent disorders such as chro- rum creatinine ≤ 132 µmol/L (1.5 mg/dL); two
nic liver disease, advanced cardiac disease, thirds of the total daily dose to be administered
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900 Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM

Table 2. Mean (SD) of renal and biochemical studied variables.


Pre-Ramadan During-Ramadan Post-Ramadan P value
Serum creatinine (µmol/L) 245 (128) 238 (109) 237 (127) 0.17
Urea (mmol/L) 13.4 (6) 12.6 (6) 14 (7.4) 0.52
Estimated GFR* 29.7 (16.3) 30.9 (15.7) 32.7 (17.4) 0.01
Na+ (mmol/L) 134 (23) 137 (3) 138 (3) 0.27
K+ (mmol/L) 4.7 (0.6) 4.8 (0.7) 4.8 (0.6) 0.35
HCO3 (mmol/L) 22.5 (3.9) 24.2 (4) 23 (3.7) 0.39
Glucose (mmol/L) 8 (3) 13.4 (8) 11.2 (1.6) 0.27
Hb A1c (%) 6.8 (1.4) 6.7 (1.8) 7.4 (2) 0.05
Hemoglobin (g/dL) 12 (1.5) 12 (1.7) 12 (1).8 0.74
Total Cholesterol (mmol/L) 4.5 (1) 4.6 (1) 4.9 (1) 0.06
HDL (mmol/L) 0.85 (0.8) 0.9 (0.3) 0.9 ( 0.3) 0.05
LDL (mmol/L) 2.8 (1) 2.9 (0.9) 3.2 (1) 0.04
Triglycerides (mmol/L) 1.7 (1) 1.9 (1.1) 1.6 (0.8) 0.37
*eGFR (mL/min) calculated by using Cockcroft-Gault formula.

Statistical Analysis

Repeated measurement analysis of variance


was used to study the within group change
over time.14,15 Data were analyzed using the
Statistical Package for the Social Sciences
(SPSS 15 for windows, SPSS Inc, Illinois,
USA). A probability of less than 0.05 was
accepted as significant.

Results

All the 31 patients included in the study


managed to fast the whole month of Ramadan.
Figure 1. Mean (SEM) of estimated glomerular The fasting time was around 12 hours and the
filtration rate. With significant increase overtime atmosphere temperature was from 18-28º C.
(P= 0.017, repeated measurement analysis). None of the patients displayed any new
clinical symptoms or signs. The body weight
immediately before the sunset meal, and the and blood pressure in the three periods of the
other third with the predawn meal. The main study are shown in table 1. Renal function and
Sulfonylureas used during the study included electrolytes and other biochemical measured
gliclazide MR and glimepiride; the dose was variables, pre, during and post Ramadan are
given before the sunset meal and adjusted ac- illustrated in table 2. The changes in the eGFR
cording to the glycemic control and the risk of during the study are shown in figure 1. Urine
hypoglycemia. Thiazolidinediones were used electrolytes, urine osmolality, proteinuria and
at sunset meal without changing the dose. protein to creatinine ratio are illustrated in
table 3.
Insulin therapy There was a reduction in the body weight and
Pre-mixed insulin 70/30 was used in most of in the systolic blood pressure at the end of
the patients on insulin. The usual morning Ramadan compared to values before it, but it
dose was administered at the sunset meal and did not reach statistical significance (P= 0.13,
half of the usual evening dose at the predawn P= 0.21 respectively). There was a statistically
meal. significant improvement of the eGFR, during
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Fasting Ramadan in chronic kidney disease patients 901

Table 3. Mean (SD) of spot urine electrolytes, protein and osmolality.


Pre-Ramadan During-Ramadan Post-Ramadan P value
Na+ (mmol/L) 66 (27) 61.4 (33) 61.2 (21) 0.24
K+ (mmol/L) 40.6 (20) 41 (19) 36 (12.7) 0.14
Osmolality (mosml/L) 451 (161) 393 (92) 384 (83) 0.77
Proteinuria (g/L) 1.7 (2.3) 4 (1.8) 1.6 (1.7) 0.54
Protein/Creatinine (g/mg) 2 (2.6) 2 (3) 2.4 (3) 0.11

Ramadan and one month thereafter (P= 0.017). intake. Finally, modest directional changes in
serum creatinine and weight result in an incre-
Discussion ment in eGFR.
We did not notice any serum electrolytes dis-
The safety of fasting in healthy and diabetics turbances during fasting. Hyperkalemia due
has been demonstrated in numerous studies.4-8 the consumption of huge amount of potassium
All patients in our study tolerated fasting of rich food at breaking the fast has been noticed
Ramadan very well. This finding is compa- in CKD, kidney transplant, and hemodialysis
rable with another recent study.13 The main patients.13,16,22 There was a reduction in the
positive clinical finding, in our study was the urinary sodium excretion during Ramadan and
tendency of weight reduction and the decrease the following month compared to the month
in systolic and diastolic blood pressure. The before Ramadan indicating that the kidneys of
mean weight reduction was 1.4 kg, and 0.7 kg the studied patients were responding well to
(P= 0.13) in Ramadan and the following month, the reduced fluid intake during fasting. These
respectively. This weight reduction has also results are similar to those of the kidney
been documented in several studies;17-19 and it transplant patients who fasted.9 The changes in
is attributed to the reduction of meal frequency urinary protein excretion, protein to creatinine
during Ramadan, which often results in re- ratio and urine osmolality were not significant
duction of energy intake and loss of body mass during the three periods of the study.
and body fat. Other contributing factors are However, the high blood sugar during the
extracellular volume contraction secondary to three periods of the study, particularly in
lower sodium and fluids intake, and the mo- Ramadan, is explained by the fact that diabetes
derate degree of dehydration. is the leading cause of CKD in our study. In-
Our finding of a better control of blood pre- creased blood sugar during fasting was noted
ssure has also been documented by others.20 specially in diabetics with poor control before
The positive effect of the fasting on blood pre- Ramadan.23 In a large epidemiological study
ssure persisted for a month after Ramadan. conducted in 13 Islamic countries on 12,243
The reduction in the blood pressure did not individuals with diabetes, those who fasted
reach statistical significance possibly because during Ramadan had a high rate of acute com-
of the small number of patients included in plications, mainly hypo and hyperglycemia.24
this study. None of our diabetic patients revealed such
Moreover, there was a significant improve- metabolic complications during fasting. More-
ment in the estimated GFR, which could be over, despite that Hb A1c was within the target
explained by several mechanisms: First, the level, its changes during the three study pe-
reduction in the blood pressure during fasting riods were significant. Total cholesterol, HDL
with a positive effect on the kidney function in and LDL were significantly increased in Ra-
CKD patients,21 Second, weight loss indicating madan compared to the pre fast period, yet
reduction in the relative overhydration, with they remained within the normal level. These
subsequent improvement of cardiac function lipids changes have been documented in other
and better renal perfusion. Third, dietary reduc- studies.19,23
tion of protein intake and exogenous creatinine In conclusion, fasting Ramadan is safe in sta-
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902 Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM

ble CKD patients. We have observed some im- 13. El-Wakil H, Desoky I, Lotfy N, Adam AG.
provement in the eGFR during and post fas- Fasting the month of Ramadan by Muslims:
ting. However, fasting should be under close Could it be injurious to their kidneys? Saudi J
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fluid intake, daily activity, and adjustment of
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drug regimens with a special attention for the Cardiovasc Res 1994;28:303-11.
management of diabetic CKD patients. 15. Munro BH. Repeated measures analysis of
variance. In: Munro BH, (ed). Statisitcal methods
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