Fasting ramadan & kidney disease
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It discuss the effects of fasting on kidney diseases and what should be our advises to our Muslim patients during the month of RAMADAN
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Fasting ramadan & kidney disease
- 1. Ramadan Fasting & kidney disease Yousef BOOBES, MD, CES, FASN Consultant Nephrologist Tawam Hospital, Al Ain - UAE Al Ain February 26,2021 Ramadan Fasting in Patient with Chronic Illness - Workshop
- 2. Outline • Introduction • Medical Aspect • Effect of fasting on kidney diseases • Islamic Aspect • The definition of a disease that permits breaking the fasting • Our advise to our renal patients
- 3. Introduction
- 4. Fasting during Ramadan • It is the forth pillar of Islam and most Muslims are strictly adhering to it • The sick patients are exempted • Most of Muslim with renal diseases is very keen to observe the fast
- 5. Our advise to patients to fast or not to fast is considered a “Fatwa” • To give a correct “Fatwa” you need two elements: • Medical knowledge: Effects of fasting on kidney diseases • Islamic knowledge: The definition of the disease that permits break fasting
- 8. Tawam Study in Transplant Patients
- 9. Methods & Patients • Prospective observational study (Ramadan 1426 à Oct- Nov 2005) • Fasting time was ~ 12.5 h • Inclusion criteria were: • Transplanted for more than one year • Stable kidney function • Voluntary chose to observe the fast • Exclusion criteria were any acute illness Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 10. Methods & Patients • 22 kidney transplant recipients completed the study • 10 males and 12 females • Mean age was 47±11.6 (25-69) years • eGFR (MDRD) ml/mim/1.73m2, (Mean±SD) • 16 pts >50 • 6 pts GFR ≤50 • Blood and urine samples were taken just before “Iftar” • Comorbid conditions were • Hypertension: 20 pts • Dyslipidemia: 9 pts • Diabetes mellitus 5 pts Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 11. Results - Clinical Parameters Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200 0 20 40 60 80 100 120 140 Weight BPs BPd p= NS p= NS p= NS Pre Post During Pre Post During Pre Post During
- 12. 0 1 2 3 4 5 6 7 8 Urea 0 20 40 60 80 100 120 s. Creatinine Post During Pre Post During p = NS p = NS Pre Post During p = NS p = NS Pre Post During Results - Kidney Function Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 13. Results - Others PRE Mean ± SD DURING Mean ± SD POST Mean ± SD Pre- Dur p Pre- Post P Uric Acid mmol/l 0.4 ± 0.1 0.38 ± 0.08 0.39 ± 0.08 0.1 0.4 Na mmol/l 139 ± 3.3 137 ± 3.95 138 ± 2.5 0.18 0.37 K mmol/l 4.2 ± 0.4 4.3 ± 0.5 4.2 ± 0.4 0.3 0.8 HCO3 mmol/l 25 ± 2.9 25 ± 3.4 25 ± 3 0.9 0.4 Albumin 36 ± 3.4 36 ± 3.3 37 ± 3.8 0.7 0.02 Hemoglobin 11.9 ± 2.97 12.9 ± 1.5 13 ± 1.9 0.23 0.17 Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 14. Results – Others PRE Mean ± SD DURING Mean ± SD POST Mean ± SD Pre- Dur p Pre- Post P T. Choles mmol/l 5.04 ± 1.11 5.1 ± 1.2 5.03 ± 0.83 0.39 0.07 HDL mmol/l 1.03 ± 0.31 1 ± 0.27 1.05 ± 0.25 0.85 0.42 LDL mmol/l 3.3 ± 1.08 3.37 ± 1.02 3.08 ± 0.96 0.07 0.8 TG mmol/l 1.71 ± 0.62 1.34 ± 0.43 1.59 ± 0.44 0.0011 0.7 Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 15. Conclusion • It is safe for a kidney recipient to fast Ramadan after one year & they have stable kidney functions • It is in agreement with other studies Boobes Y, et al. SJ Kid Dis Transpl. 2009;20(2):198–200
- 16. Tawam Study During Ramadan 2005 (Oct–Nov)
- 17. Patients & Methods • Prospective observational cohort study • 31 pts • 19 male, 12 female • CKD III 14, CKD IV 12, CKD V five • 19 suffering from diabetes, 22 from HTN • Mean age 54.0±14.2 years Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 18. Results - Clinical • The fasting time (Ramadan 1426 H) was around 12.5 h • All patients managed to fast the whole of the month of Ramadan • Non of them had any undue clinical manifestation Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 19. Clinical Parameters PRE Mean ± SD DURING Mean ± SD POST Mean ± SD 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 o.21 DBP mmHg 81.3 ± 9 78.2 ± 9.3 80 ± 10 0.6 Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 20. Electrolytes PRE Mean ± SD DURING Mean ± SD POST Mean ± SD P Value Na mmol/l 133.8±23 137±3 138±3 NS K mmol/l 4.7±0.6 4.8±0.7 4.8±0.6 NS HCO3 mmol/l 22.5±3.9 24.2±4 23±3.7 NS Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 21. Renal Function PRE Mean ± SD DURING Mean ± SD POST Mean ± SD P Value S. Creatinine µmol/l 245±128 238±109 237±127 0.17 Urea mmol/l 13.4±8 12.6±6 14±7.4 NS Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 22. Renal Function Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 23. DM Control & Hemoglobin PRE Mean ± SD DURING Mean ± SD POST Mean ± SD P Value Glucose mmol/l 8±3 13.4±8 11.2±16 0.27 Hb A1c % 6.8±1.4 6.7±1.8 7.4±2 NS Hb g/dl 12±1.5 12±1.7 12±1.6 NS Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 24. Urinary Protein Excretion PRE Mean ± SD DURING Mean ± SD POST Mean ± SD P Value Proteinuria g/l 1.7±2.3 1.4±1.8 1.6±1.7 NS Prot/creat mg/mg 2±2.6 2±3 2.4±3.1 0.11 Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 25. Conclusion • Fasting Ramadan is safe in patients with CKD (stage III – V) Bernieh B, Al Hakim MR, Boobes Y, Abu Zidan FM. SJ Kid Dis Transpl. 2010;21:898–902
- 26. Bakhit et al. Saudi Med J 2017; Vol. 37 (1): 48-52
- 27. Patients & Methods • 65 patients with CKD stage III-V , mean age of 53 years • Fasted for 15 h/d in Riyadh in the summer of 2015 • Clinical and biochemical data were collected • within the 3 months before Ramadan • after fasting for at least 10 days • 3months after Ramadan. Bakhit et al. Saudi Med J 2017; Vol. 37 (1): 48-52
- 28. Results • 22 pts (33.8%) developed WRF • 15 patients developed WRF during Ramadan • 7 patients in 3 m after Ramadan • 8 later improved, 14 continued (20.5%) • Risk factors: • More advanced CKD stage • Higher baseline systolic BP • Younger age • Improvement in mean systolic BP & HbA1C à post-Ramadan Bakhit et al. Saudi Med J 2017; Vol. 37 (1): 48-52
- 29. Conclusion • Ramadan fasting during the summer months was associated with worsening of renal function Bakhit et al. Saudi Med J 2017; Vol. 37 (1): 48-52
- 30. Results • Mean serum creatinine (SD) • 206 μmol/l (88) before Ramadan • 214 μmol/l (37) during Ramadan • 209 μmol/l (101) 3 months after fasting Bakhit et al. Saudi Med J 2017; Vol. 37 (1): 48-52
- 31. Bragazzi NL. Int J Nephrol Renovasc Dis. 2015 Jun 1; 8:53-57
- 32. eGFR in CKD Patients Before & After Ramadan Bragazzi NL. Int J Nephrol Renovasc Dis. 2015 Jun 1; 8:53-57 p=0.99
- 33. eGFR in CKD Patients Before & After Ramadan Bragazzi NL. Int J Nephrol Renovasc Dis. 2015 Jun 1; 8:53-57 p=0.73
- 34. eGFR in CKD Patients Before & After Ramadan Bragazzi NL. Int J Nephrol Renovasc Dis. 2015 Jun 1; 8:53-57 p=0.66
- 35. Journal of Research in Medical Sciences Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 37. Ramadan and Urolithiasis • 1,262 pts have been studied • Ramadan fasting does not • deteriorate health condition in subjects with renal colic • does not cause hypercalciuria • does not impair the balance between lithogenic promotors (oxalate, Ca++, uric acid, phos) and inhibitors (citrate, Mg++) Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 38. Ramadan and chronic kidney disease • Summarizing all the studies: • 140 subjects with CKD have been investigated: • 40 on hemodialysis • 18 on peritoneal dialysis (PD) • 15 on predialysis • 67 on pharmacological treatment Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 39. Ramadan and chronic kidney disease • Most studies did not find any differences between before and after Ramadan fasting • Bernieh et al. found improvements during the fasting and after • 3 studies presented mixed evidences of an increased risk for fasting patients during Ramadan, and 3 clear negative evidences Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 40. Ramadan and kidney transplant • 463 pts who received kidney transplant have been investigated • Biochemical parameters do not change significantly • No rejection or deterioration of KF were observed • One author reported of adverse effects due to cyclosporine toxicity, acute rejection episodes, and urinary infections Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 41. CONCLUSIONS • There are no evidences that Ramadan is injurious for patients with CKD willing to fast, even though further high quality research is welcome. Bragazzi NL. J Res Med Sci. 2014 Jul;19(7):665-76.
- 42. Islamic aspect
- 43. • ﺷ َ ﮭ ْ ر ُ ر َ ﻣ َ ﺿ َ ﺎ ن َ ا ﻟ ﱠ ذ ِ ي أ ُﻧ ز ِ ل َ ﻓ ِ ﯾ ﮫ ِ ا ﻟْ ﻘ ُ ر ْ آ ن ُ ھ ُ د ً ى ﻟ ِّ ﻠ ﻧ ﱠ ﺎ س ِ و َ ﺑ َ ﯾ ِّ ﻧ َ ﺎ ت ٍ ﻣ ِّ ن َ ا ﻟْ ﮭ ُ د َ ى ٰ و َ ا ﻟْ ﻔ ُ ر ْ ﻗ َ ﺎ ن ِ ◌ ۚ ﻓ َ ﻣ َ ن ﺷ َ ﮭ ِ د َ ﻣ ِ ﻧ ﻛ ُ م ُ ا ﻟ ﺷ ﱠ ﮭ ْ ر َ ﻓ َ ﻠْ ﯾ َ ﺻ ُ ﻣ ْ ﮫ ُ ◌ ۖ و َ ﻣ َ ن ﻛ َ ﺎ ن َ ﻣ َ ر ِ ﯾ ﺿ ً ﺎ أ َ و ْ ﻋ َ ﻠ َ ﻰ ٰ ﺳ َ ﻔ َ ر ٍ ﻓ َ ﻌ ِ د ﱠ ة ٌ ﻣ ِّ ن ْ أ َ ﯾ ﱠ ﺎ م ٍ أ ُ ﺧ َ ر َ ◌ ۗ ﯾ ُ ر ِ ﯾ د ُ ا @ ﱠ ُ ﺑ ِ ﻛ ُ م ُ ا ﻟ ْ ﯾ ُ ﺳ ْ ر َ و َ ﻻ َ ﯾ ُ ر ِ ﯾ د ُ ﺑ ِ ﻛ ُ م ُ ا ﻟ ْ ﻌ ُ ﺳ ْ ر َ و َ ﻟِ ﺗ ُ ﻛ ْ ﻣ ِ ﻠ ُ و ا ا ﻟْ ﻌ ِ د ﱠ ة َ و َ ﻟِ ﺗ ُ ﻛ َ ﺑ ِّ ر ُ و ا ا R ﱠ َ ﻋ َ ﻠ َ ﻰ ٰ ﻣ َ ﺎ ھ َ د َا ﻛ ُ م ْ و َ ﻟ َ ﻌ َ ﻠ ﱠ ﻛ ُ م ْ ﺗ َ ﺷ ْ ﻛ ُ ر ُ و ن َ ) 185 ( • But whoever of you is ill or on a journey, then ˹let them fast˺ an equal number of days ˹after Ramaḍân˺. Allah intends for you ease, and He does not want to make things difficult for you (Baqara-185)
- 45. The Fiqh Encyclopedia The definition of a disease that permits breaking the fasting • A disease that increases with fasting • If the pt fears that the disease will increase by fasting, or if it is not harmful but difficult; He may break his fast. It is the doctrine/view of the majority of scholars : Hanafi, Maliki and Hanbali • A disease that harmed by fasting with fears of perishing • If the disease harms the fasting person, and he fears death because of it; Break fast is obligatory • This is the doctrine of the majority: Hanafi, Maliki, and Shafi’i, and a group of Hanbali • A mild disease • A disease in which fasting does not affect, or it is not harmful - such as easy headache or a toothache – • it is not permissible to break his fast, and this is according to the agreement of the four fiqh schools
- 46. Our advise to our patient
- 47. In general, Fasting Ramadan is good for health • Fasting Ramadan has many Social, Psychological & Physical Health Benefits • May promote insulin sensitivity: … • May promote healthy guts: which in turn aids immune and digestive processes • Can help lower of blood sugar & cholesterol • Increasing boost of will power.
- 48. In general, Fasting Ramadan is good for health • (ex.) A study at the University of Texas conducted on the effects of intermittent fasting, found that it • reduces inflammation • improves blood lipids • helps in weight loss • Participants did not reduce their total calories – just the time frame in which they consumed them Tinsley GM, et al. Effects of intermittent fasting on body composition. Nutr Rev. 2015 Oct;73(10):661-74.
- 49. In general, Fasting Ramadan is good for health • Fasting Ramadan has many Social, Psychological & Physical Health Benefits • Increasing boost of will power. • A Study demonstrated that fasting Ramadan have been effective in diminishing stress, anxiety, and depression levels (statistically significant) • .. Koushali AN, et al. Iran J Nurs Midwifery Res. 2013;18(3):232-236.
- 50. ﯾ ُ ر ِ ﯾ د ُ ا 3 ﱠ ُ ﺑ ِ ﻛ ُ م ُ ا ﻟ ﯾ ُ ﺳ ر َ و ﻻ َ ﯾ ُ ر ِ ﯾ د ُ ﺑ ِ ﻛ ُ م ا ﻟ ﻌ ُ ﺳ ر َ • (Allah intends for you ease, and He does not want to make things difficult for you) • Islam is a religion of ease, and ease is a supreme goal of of Sharia
- 51. Doctor Will Give the Advice “Fatwa” to Patient • The ruling on fasting of Ramadan for Kidney disease patients varies from obligation to allowable to forbidden, depending on the severity of the disease and the effect of fasting
- 52. Rule of Fasting • Stable vs unstable or acutely ill • All studies looked on the effect of fasting in stable patients
- 53. Rule of Fasting • CKD stage I and stage II • They fast Ramadan as healthy • CKD stage III • CKD IIIa: They could not fast but fasting would be better • CKD IIIb: They could not fast and this would be better • CKD stage IV and stage V (pre dialysis) • They could not fast (preferable & we encourage them to not fast) • if they choose to fast – it should be done under medical supervision • If they develop significant worsening of kidney function (>25%) due to fasting à become forbidden
- 54. Rule of Fasting • ESRD on Hemodialysis • Dialysis days: It is allowable to not fast (highly recommended) if HD done during the day • They will be very weak • HD breaks fasting (in one fatwa), and it does not (in other one) • Some ask to switch to night shift • Other days: It is allowable to not fast
- 55. Rule of Fasting • Transplant patients (CKD TII-TIII): • It is allowable to not fast. • Fasting during the 1st 6 months post op strongly discouraged and could be forbidden • If they missed Sahoor’s IS doses, they should break fast and take these medications
- 56. If kidney disease patient choose to fast à he should do it under close observation à General Recommendations
- 57. General Recommendations • CKD stage I to V • They should drink enough fluids during the night with much diet control • They are not working outdoor (under the sun) • Check s. creatinine before fasting and 7 days after the beginning of the fast, especially If eGFR <20. • If stayed stable, they can continue their fast; • otherwise they should break their fast
- 58. General Recommendations • Transplant patients: • They could attempt fasting providing that they drink enough fluids during the night with much diet control • They are not working outdoor (under the sun) • Cyc/Tac trough level should be checked before they break fast • It is advisable to check s. creatinine before fasting and within 7 days after the beginning of the fast. If it is not stable, pt should break their fast. • Consider switching pt from Prograf to Advagraf before Ramadan • Fasting Ramadan during summer in some northern countries might be impossible -à forbidden
- 59. ﯾ ُ ر ِ ﯾ د ُ ا 3 ﱠ ُ ﺑ ِ ﻛ ُ م ُ ا ﻟ ﯾ ُ ﺳ ر َ و ﻻ َ ﯾ ُ ر ِ ﯾ د ُ ﺑ ِ ﻛ ُ م ا ﻟ ﻌ ُ ﺳ ر َ • (Allah intends for you ease, and He does not want to make things difficult for you) • Islam is a religion of ease, and ease is a supreme goal of of Sharia
- 60. Thank You