Mostafa Abdel_Salam Mohamed, MD

Consultant of Nephrology

Adherents of Islam constitute the world's second largest religious group. According to a study in 2015,

Islam has 1.8 billion adherents, making up over 24.1% of the world population.[

Why Muslims are the world's fastest-growing religious group". Pew Research Centre. April 2017. Retrieved 24 April 2017

10% of population with CKD world wide

2 million on dialysis world wide

CKD was ranked 27th between causes of deathworldwide in 1990, but rose to 18th in 2010.

Data Source: Published By WHO 2014

WHO Excludes Cause of Death Data For the following countries: Andorra, Antigua andBarbuda, Cook Islands, Dominica, Grenada, Kiribati, Marshall Islands, Micronesia,Monaco, Nauru, Niue, Palau, Saint Kitts, Saint Lucia, Saint Vincent, Samoa, San Marino,Sao Tome, Seychelles, Tonga, Tuvalu, Vanuatu.

There are 16 islamic countries inthe top 42 countries with thehighest mortality due to CKD.

However there is no enough dataabout fasting of ramadan in islamiccountries.

J Res Med Sci 2014;19:987-92.

MEDLINE (http://www. pubmed.com) wassearched by using “Ramadan” as keyword.Found articles were categorized as originalor review article.

Reviewed articles have been published since2009 until February 2014

Based on the results of acurrently publishedmeta-analysis included 21articles, 531 men and 299women.

although studies showed thatRamadan fasting has healthprotective effects (BW, Lipidprofile, Immune state, renalmarkers, pregnancy, Diabeticstate)

Patient should consult theirmedical team for fasting duringRamadan.

More precise studies should beconducted for more reliableconclusion.

Between Science and Faith

(The Balance between Orders

and Prohibitions)

Agree

Disagree

Ramadan fasting and chronic kidney disease: A systematic review. J Res Med Sci 2014;19:665-76.

Ramadan fasting represents one of the five pillars of the Islam.

Even though patients areexempted from observing thisreligious duty, they may beeager to share this particularmoment of the year with theirfamily and peers.

However, there are no guidelines orstandardized protocols that canhelp physicians to properly addressthe issue of patients with chronickidney disease (CKD) fasting inRamadan and to correctly advisethem.

Moreover, in a moreinterconnected and globalizedsociety, in which more and moreMuslim patients live in theWestern countries, this topic is ofhigh interest also for the generalpractitioner.

For this purpose, thissystematic review wasdone and included articleswritten in Arabic, Turkish,and Persian languages.

ISI Web of Science (WoS), Scopus,MEDLINE/PubMed, Google Scholar,Directory of Open Access Journals (DOAJ),EbscoHOST, Scirus, and ProQuest.

A proper string made up of a combinationof key-words such as “fasting,” “CKD” and“chronic renal failure.”

25 original articles describing 26 studies (I add 5 new original articles since 2014)

Fifteen studies as described in 14 manuscripts focused on kidney transplant (1 new original article since 2014)

6 on renal colic (1 new original article since 2014)

5 studies concerned CKDs (3 new original articles since 2014)

+ 3 New

+ 1 New

+ 1 New

Most studies were prospectiveand observational, with theexceptions of that by Basiri etal., which is a retrospective,database-based study as well asthat by Al-Hadramy.

Al-Hadramy MS. Seasonal variations of urinary stone colic in Arabia. J Pak Med Assoc 1997;47:281-4.

Basiri A, Moghaddam SM, Khoddam R, Nejad ST, Hakimi A. Monthly variations of urinary stone colic in Iran and its relationship to the fasting month of Ramadan. J Pak Med Assoc 2004;54:6-8.

Most studies did not findany differences betweenfasters and not fasters, orbetween before and afterRamadan fasting???????

The study by Bernieh et al. they foundimprovements during the fasting and after

Only three studies presentedmixed evidences of anincreased risk for fastingpatients during Ramadan???

(plus 2 new studies)

Bakhit et al., 2017:

• Study design: Prospective cohort observational study

• Sample: 65 patients

• Age: Mean age 53 years (40 male and 25 female patients).

• Mean fasting duration: 15 h

• Patients monitoring: Data were collected within the 3 months before fasting initiation, after fasting for at least 10 days, and 3 months after Ramadan

• Inclusion criteria: stage 3 or higher chronic kidney disease (CKD).

• Exclusion criteria: patients with kidney transplants, current pregnancy, poorly controlled diabetes and poorly controlled hypertension

• Place: Riyadh (Saudi Arabia)

• Time: Ramadan 2015 (June 18-July 17)

In patients with stage 3 or higherCKD, Ramadan fasting during thesummer months was associatedwith worsening of renal function.Clinicians need to warn CKDpatients against Ramadan fasting

Mbarki et al., 2015:

• Study design: Prospective cohort observational study

• Sample: 67 patients by the end of study they become 60 patients (35 females and 25males).

• Age: 45.6 ± 15.8 years, with a range of 16–87 years.

• Mean fasting duration: 13 h

• Patients monitoring: Before Ramadan, a week after commencing the fast and at the endof the month of Ramadan.

• Inclusion criteria: Clearance >60 mL/min (Group 1), 30–59 mL/ min (Group 2) and 15–29 mL/min (Group 3).or by the existence of signs of kidney damage (proteinuria >0.3g/24 h and/or hematuria).

• Exclusion criteria: severe or resistant arterial hypertension, insulin-requiring diabetes,acute renal failure, active renal disease, repetitive urolithiasis or terminal CRF.

• Place: Hassan II University Hospital in Fez, Morocco.

• Time: Ramadan 2010 (August)

Overall, seven patients (11.7%)developed superimposed ARF whilefasting during Ramadan. Of theseseven patients, there was completerecovery of renal function tobaseline in five patients, while twopatients showed partial recovery.

The small sample of our studydoes not allow us to concludewith certainty that fastingduring Ramadan is safe andnot associated with renalinjury among CKD patients

NasrAllah et al., 2014

• Study design: Prospective cohort observational study

• Sample: 106 patients, 52 in the fasting group and 54 in the none fasting group.

• Age: Mean age 53 years (40 male and 25 female patients).

• Mean fasting duration: 15 h

• Patients monitoring: (i) Day 0 = within the 5 days preceding the month of Ramadan, (ii) Day 7 = after 1 week of fasting, (iii) Day 30 = within 5 days after the end of the month, (iv) late = 3 months after the end of Ramadan.

• Inclusion criteria: Chronic kidney disease (CKD).

• Exclusion criteria: Patients with evidence of acute cardiovascular disease or active infection as well as patients on dialysis and kidney transplant recipients

• Place: Cairo (Egypt)

• Time: Ramadan (2009-2010)1)

MACE occurred morefrequently among fasting CKDpatients with pre-existingcardiovascular disease andwere predicted by an early riseof serum creatinine.

Ramadan and chronic kidney disease

• Summarizing all the studies, 140 subjectswith CKD (plus 238 patients from new 3new studies=378) have been investigated:40 on hemodialysis, 18 on peritonealdialysis (PD), 82 on predialysis (plus 238patients from new 3 studies=320)

No severe adverse effects have beenrecorded, apart from those described by Al-Muhanna.???? However, the group ofpatients recruited in this study includedalso patients suffering from severe renalfailure and this could have an impact onthe findings of the author.Al-Muhanna et al., 1998

However two new studies (Bakhit et al.,2017, NasrAllah et al., 2014) confirmed thatpatients with stage 3 or higher CKD orthose with history of cardiovascular events

Ramadan fasting was associated eitherwith worsening of renal function and/orMACE.

Fayez et al., 2014:

• Study design: Prospective cohort observational study

• Sample: 80 patients with renal transplantation was sub divided into twogroup 43 patients who had voluntarily fasted during both consecutiveRamadan months were included and their results were compared with 37patients who had not fasted .

• Age: Mean age 45.2 ± 15.6 and 43.3 ± 15.4 years,

• Mean fasting duration: 13 h

• Patients monitoring: The eGFR was calculated within a month beforeRamadan of 2011 and 19.6 ± 1.3 months after it.

• Inclusion criteria: patients with stages 3b and 4 chronic kidney diseases(CKD).

• Place: Riyadh (Saudi Arab)ia)

• Time: Ramadan 2010 (August)

Fasting in the month ofRamadan in two consecutiveyears, and during the hottestmonths, in Riyadh, SaudiArabia, did not adversely affectkidney graft function.

Summarizing all the studiesdedicated to the relationshipbetween Ramadan fasting andrenal allograft , 463 patients (plus80 new patients= 543) whoreceived kidney transplant havebeen investigated.

The concentration ofimmunosuppressive drugs tends toremain stable and biochemicalparameters do not changesignificantly. No organ rejection ordeterioration of kidney functionswere observed.

Only one author reported of adverseeffects due to cyclosporine toxicity (2cases), acute rejection episodes(2cases), and urinary infections (2cases). No kidney loss has beendocumented

Said et al., 2003 (6/71=8.5%)

Cevik et al., 2016

• Study design: Prospective cohort observational study

• Sample: 176 patients (n:89 in before Ramadan, n:87 in Ramadan

• Mean fasting duration: 14 h

• Inclusion criteria: patients who were admitted to our ED; age 18 years or older with renal colic

• Exclusion criteria: age younger than 18 years; patients who refused to be involved in the study; patients whose renal colic diagnoses were unclear, patients with co-morbid diseases such as chronic kidney disease, metabolic disorder, cardiovascular disease, liver or endocrine disorder.

• Place: Ankara (Turkey).

• Time: May 28 and July 27, 2014 during 2-month period

This study has shown thatfasting in Ramadan doesnot change the number ofrenal colic visits.

Summarizing all the collectedevidences, 1,262 subjects (plus 176from one new study= 1438) havebeen studied using bothprospective studies andretrospective database-basedsurveys.

Ramadan fasting does not seem to deterioratehealth condition in subjects with renal colic,does not cause hypercalciuria and does notimpair in a statistically significant andclinically relevant way the balance betweenlithogenic promotors (that is to say, oxalate,calcium, uric acid, phosphates) and inhibitors(citrate, magnesium).

Moreover, any renalchanges are fullyreversible after 10 daysfrom the end of thefasting

+ 4

+ 1

Recommendations against fasting

• Hypotension

• Acute infections

• active peptic ulcer

• Acute tubular necrosis,

• Polyuria (urine volume ≥2.5 L/day)

• Uncontrolled or poorly controlled diabetes mellitus

• Diabetes insipidus

• Other dysmetabolic disorders

• Uncontrolled hypertension

• Acute cardiovascular events

• Chronic liver disease)

Patients should take regularly their treatmenttwice daily (with suhoor and iftarrespectively)

If they should need to take drugs more than2/day, they should consider switching to theformer regimen (consulting their physician).If not possible, they should not fast.

Clinical recommendations for patients willing to fast

They should break the fasting if

• The plasma creatinine increases by the30% above the baseline values

and/or

• You observe clinical symptoms due tochanges in serum potassium and sodium

Patients should be monitored during Ramadan

• and

should be instructed to recognize some alarm symptoms

• such as

facial swelling, shortness of breath, dizziness

anorexia, Hyporexia, Fatigue,weakness , sense of lethargy.

• Body weight, blood pressure, biochemical parameters such as fluidand electrolytes should be regularly checked throughout theRamadan.

Regular follow-up every 1-2 weeks, before, during and after Ramadan.

When breaking the fasting, they should avoid highpotassium and phosphorous diet (such as dates,apricots, fried food, nuts, cheese, juices and drinks, tea,coffee).

Moreover, they should drink up to 1-2.5 L of water inorder to re-hydrate themselves and compensate a fluiddepletion, but avoid exceeding in liquid amount, thusoccurring into fluid imbalance and overload

Water drinking is indeed a good method for preventingand treating both nephrolithias and recurrent renalcolic, as proven by a recent systematic review andmeta-analysis of randomized clinical trials.

Most of the authors of the studies included in thissystematic review agree that suggesting and advisingpatients to take an adequate amount of fluids duringthe breaks of the fasting is a good clinical practice.

If they have a tendency tohyperkalemia, they shouldtake some calciumresonium powder (30 g/diewith lactulose once a day).

Particular attention shouldbe paid to infections, sincesome fasting patients areon immunosuppressivetherapy.

Clinical consultations withpharmacologists andinfectious diseases specialistsare highly recommended inthese cases.

There are now a debate that Ramadan isinjurious for patients with CKD willing to fastspecially in those with advanced CKD andfurther high quality research is welcome.

Randomized clinical trials are particularlyencouraged since there is a lack of evidencebased guidelines and protocols whichcorrectly address the issue of the impact ofthe fasting on CKD patients and propercounsel and advise them.

In conclusion, if stable and at the least forthe categories included in the reviewedstudies

Patient’s eagerness to fast should be takeninto account and even encouraged, sincespirituality plays a key role in CKDs.

The patient feels indeed himself/herselfmore active being involved in the religiousactivities, and less depressed and isolated

For those with renaltransplantation andhistory of renal stonesthere is nocontraindication offasting withprecautionS