Glasgow Kidney Unit
Fasting During Ramadan
Medical conditions that can cause harm in the event of fasting have a clear medical and religious exemption from fasting. There is general agreement that conditions such as diabetes and chronic kidney disease (CKD) are included in this category.
It is recognised that some Muslims will choose to fast even though this exemption is in place for them.
The International Diabetes Federation and Ramadan International Alliance (IDF-DAR) have 3 categories for patients with diabetes who wish to fast:
1. Moderate / low risk (listen to medical advice)
- People with well-controlled type 2 diabetes who are on either lifestyle adjustments (e.g. diet and exercise), oral antidiabetic medication or on basal insulin only.
2. High risk (should not fast) –
- People with type 1 diabetes (regardless of how well-controlled it is)
- Poorly controlled type 2 diabetes
- Type 2 on mixed insulin regimes
- Gestational diabetes
- CKD Stage 3
- Diabetic patients with high levels of physical activity
- Taking medications that can cause drowsiness
3. Very high risk (must not fast) –
- Severe hypoglycaemic event within 3 months of Ramadan
- Unexplained diabetic ketoacidosis within 3 months of Ramadan
- History of recurrent hypoglycaemia
- History of hypoglycaemia unawareness
- Poorly controlled type 1 diabetes
- Acute illness
- Pregnancy in a patient with diabetes OR gestational diabetes on treatment
- CKD stage 4 / 5, including patients who are on haemodialysis or peritoneal dialysis.
- Old patients who are frail.
In countries near the equator, the fasting time is stable between 12 – 14 hours. However, in countries further from the equator such as the UK, the fasting time can vary from 8 hours in the winter to 20 hours in the summer. Therefore for some low risk patients in certain countries, it may be acceptable for them to fast in the winter months but not in the summer months.
- Patients with moderate to severe CKD (stages 3 – 5) could be discouraged from fasting.
- Patients with CKD and cardiovascular disease should be discouraged from fasting.
- Many patients with stable CKD stage 3 may be able to fast so long as they are monitored before, during and after Ramadan.
- Depending on their fluid status, patients may be encouraged to drink plenty of fluids during the non-fasting period.
- Regular daily weight checks will help the patient ensure they are adequately hydrated at the end of the fast.
- The renal team should check the patients’ blood results in the middle of the fasting month to help those with advanced CKD to decide if they should continue fasting. Patients may be recommended to break the fast if certain blood levels change e.g. an increase in creatinine, potassium and sodium.
- Patients should be monitored once or twice weekly and should be advised to look out for symptoms such as an increase in weight (more than 2kg above their usual weight), fluid retention, shortness of breath, dizziness, loss of appetite or weakness.
- When breaking the fast, avoidance of high potassium and high phosphate foods is recommended.
- Fasting should not be encourage in patients who are on haemodialysis and peritoneal dialysis. However, if these patients choose to fast, careful monitoring will be required.
- Patients with stable renal transplants on stable immunosuppression are probably able to fast safely, providing they are monitored carefully by their transplant team before, during and after Ramadan, are encouraged to drink fluids during the non-fasting period and are given careful advice on how to take immunosuppressive tablets.
References
Ahmad S and Chowdhury TA. Fasting during Ramadan in people with chronic kidney disease: a review of the literature. Ther Adv Endocrinol Metab 2019; 10:1-11
Hassanein M, Al-Arouj M, Hamdy O, et al.; International Diabetes Federation, Diabetes in Ramadan International Alliance. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract 2017; 126:303-316