Dr. Osama El-Shahat is the head of the nephrology department at New Mansoura General Hospital and vice president of the Dakahlia Nephrology Group. The document discusses kidney disease (CKD), transplantation, dialysis, and recommendations. It provides examples of how some animals fast during certain periods by not eating and reducing activity. It also discusses fasting guidelines for patients with illnesses, noting that those with more severe illnesses should generally be exempted from fasting. The document analyzes a study on the effects of Ramadan fasting on renal function in CKD patients and notes that more large studies are needed. It also reviews a case of a hypertensive patient wanting to fast for Ramadan

1. Dr. Osama El-Shahat
Head of Nephrology Department
New Mansoura General Hospital (international)
Vice president Of Dakahlia Nephrology Group
ISN Educational Ambassador

2. Introduction
CKD
Transplantation
Dialysis
Recommendations

3. (183)‫الص‬ ُ‫م‬ُ‫ك‬ْ‫ي‬َ‫ل‬َ‫ع‬ َ‫ب‬ِ‫ت‬ُ‫ك‬ْ‫ا‬‫و‬ُ‫ن‬َ‫آم‬ َ‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ا‬َ‫ه‬ُّ‫َي‬‫أ‬ ‫ا‬َ‫ي‬َ‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ى‬َ‫ل‬َ‫ع‬ َ‫ب‬ِ‫ت‬ُ‫ك‬‫ا‬َ‫م‬َ‫ك‬ُ‫ام‬َ‫ي‬ْ‫م‬ُ‫ك‬ِ‫ل‬ْ‫ب‬َ‫ق‬ ‫ن‬ِ‫م‬
َ‫ن‬‫و‬ُ‫ق‬َّ‫ت‬َ‫ت‬ ْ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬
(184)َ‫أ‬ ‫ا‬ً‫ض‬‫ي‬ِ‫ر‬َّ‫م‬ ‫م‬ُ‫ك‬‫ن‬ِ‫م‬ َ‫ن‬‫ا‬َ‫ك‬‫ن‬َ‫م‬َ‫ف‬ ٍ‫ات‬َ‫ود‬ُ‫د‬ْ‫ع‬َّ‫م‬ ‫ا‬ً‫ام‬َّ‫ي‬َ‫أ‬َ‫أ‬ ْ‫ن‬‫م‬ ٌ‫ة‬َّ‫د‬ِ‫ع‬َ‫ف‬ ٍ‫ر‬َ‫ف‬َ‫س‬ ‫ى‬َ‫ل‬َ‫ع‬ ْ‫و‬َ‫ر‬َ‫خ‬ُ‫أ‬ ٍ‫ام‬َّ‫ي‬
‫ي‬ِ‫ك‬ْ‫س‬ِ‫م‬ ُ‫ام‬َ‫ع‬َ‫ط‬ ٌ‫ة‬َ‫ي‬ْ‫د‬ِ‫ف‬ ُ‫ه‬َ‫ن‬‫و‬ُ‫ق‬‫ي‬ِ‫ط‬ُ‫ي‬ َ‫ين‬ِ‫ذ‬َّ‫ل‬‫ا‬ ‫ى‬َ‫ل‬َ‫ع‬َ‫و‬ْ‫ي‬َ‫خ‬ َ‫و‬ُ‫ه‬َ‫ف‬ ‫ا‬ً‫ر‬ْ‫ي‬َ‫خ‬ َ‫ع‬َّ‫و‬َ‫ط‬َ‫ت‬ ‫ن‬َ‫م‬َ‫ف‬ ٍ‫ن‬ْ‫ا‬‫و‬ُ‫وم‬ُ‫ص‬َ‫ت‬ ‫َن‬‫أ‬َ‫و‬ ُ‫ه‬َّ‫ل‬ ٌ‫ر‬
َ‫ن‬‫و‬ُ‫م‬َ‫ل‬ْ‫ع‬َ‫ت‬ ْ‫م‬ُ‫نت‬ُ‫ك‬‫ن‬ِ‫إ‬ ْ‫م‬ُ‫ك‬َّ‫ل‬ ٌ‫ر‬ْ‫ي‬َ‫خ‬
(185)ُ‫ه‬ ُ‫ن‬‫آ‬ْ‫ر‬ُ‫ق‬ْ‫ل‬‫ا‬ ِ‫يه‬ِ‫ف‬ َ‫ل‬ِ‫ز‬‫ُن‬‫أ‬ َ‫ي‬ِ‫ذ‬َّ‫ل‬‫ا‬ َ‫ن‬‫ا‬َ‫ض‬َ‫م‬َ‫ر‬ ُ‫ر‬ْ‫ه‬َ‫ش‬َ‫ن‬‫م‬ ٍ‫ات‬َ‫ن‬‫ي‬َ‫ب‬َ‫و‬ ِ‫َّاس‬‫ن‬‫ل‬‫ل‬ ‫ى‬ً‫د‬‫ى‬َ‫د‬ُ‫ْه‬‫ل‬‫ا‬
ْ‫م‬ُ‫ص‬َ‫ْي‬‫ل‬َ‫ف‬ َ‫ر‬ْ‫ه‬َّ‫الش‬ ُ‫م‬ُ‫ك‬‫ن‬ِ‫م‬ َ‫د‬ِ‫ه‬َ‫ش‬ ‫ن‬َ‫م‬َ‫ف‬ ِ‫ان‬َ‫ق‬ْ‫ر‬ُ‫ف‬ْ‫ل‬‫ا‬َ‫و‬َ‫ف‬َ‫س‬ ‫ى‬َ‫ل‬َ‫ع‬ ْ‫َو‬‫أ‬ ‫ا‬ً‫ض‬‫ي‬ِ‫ر‬َ‫م‬ َ‫ن‬‫ا‬َ‫ك‬‫ن‬َ‫م‬َ‫و‬ ُ‫ه‬ْ‫ن‬‫م‬ ٌ‫ة‬َّ‫د‬ِ‫ع‬َ‫ف‬ ٍ‫ر‬
‫ي‬ِ‫ر‬ُ‫ي‬ َ‫ال‬َ‫و‬ َ‫ر‬ْ‫س‬ُ‫ْي‬‫ل‬‫ا‬ ُ‫م‬ُ‫ك‬ِ‫ب‬ ُ‫ه‬ّ‫ل‬‫ال‬ ُ‫د‬‫ي‬ِ‫ر‬ُ‫ي‬ َ‫ر‬َ‫خ‬ُ‫أ‬ ٍ‫ام‬َّ‫ي‬َ‫أ‬ِ‫ْع‬‫ل‬‫ا‬ ْ‫ا‬‫و‬ُ‫ل‬ِ‫م‬ْ‫ك‬ُ‫ت‬ِ‫ل‬َ‫و‬ َ‫ر‬ْ‫س‬ُ‫ْع‬‫ل‬‫ا‬ ُ‫م‬ُ‫ك‬ِ‫ب‬ ُ‫د‬َ‫ه‬ّ‫ل‬‫ال‬ ْ‫ا‬‫و‬ُ‫ر‬‫ب‬َ‫ك‬ُ‫ت‬ِ‫ل‬َ‫و‬ َ‫ة‬َّ‫د‬
َ‫ن‬‫و‬ُ‫ر‬ُ‫ك‬ْ‫ش‬َ‫ت‬ ْ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬َ‫و‬ ْ‫م‬ُ‫ك‬‫ا‬َ‫د‬َ‫ه‬ ‫ا‬َ‫م‬ ‫ى‬َ‫ل‬َ‫ع‬

4. ‫وقلة‬ ‫الحرارة‬ ‫النخفاض‬ ‫الشتاء‬ ‫فترة‬ ‫في‬ ‫تصوم‬ ‫الحيوانات‬ ‫بعض‬،‫الغذاء‬
)‫ة‬َ‫ر‬ْ‫ب‬ِ‫ع‬َ‫ل‬ ِ‫ام‬َ‫ع‬ْ‫ن‬َ ْ‫اْل‬ ‫ي‬ِ‫ف‬ ْ‫م‬ُ‫ك‬َ‫ل‬ َّ‫ن‬ِ‫إ‬َ‫و‬(
‫الحيوانات‬ ‫بعض‬‫تمتن‬ ‫متوالية‬ ‫شهورا‬ ‫بل‬ ‫أياما‬ ‫جحورها‬ ‫في‬ ‫تسكن‬‫فيها‬ ‫ع‬
‫والطعام‬ ‫الحركة‬ ‫عن‬
‫الطيور‬ ‫من‬‫معينة‬ ‫مواسم‬ ‫في‬ ‫الطعام‬ ‫عن‬ ‫ويمتنع‬ ‫عشه‬ ‫في‬ ‫يكمن‬ ‫ما‬‫كل‬
‫عام‬
‫اْلسماك‬ ‫بعض‬‫ب‬ ‫معينة‬ ‫لفترة‬ ‫النهر‬ ‫أو‬ ‫البحر‬ ‫قاع‬ ‫في‬ ‫نفسه‬ ‫يدفن‬‫طعام‬ ‫دون‬
‫البرمائيات‬ ‫بعض‬‫ت‬ ‫كما‬ ‫الشتاء‬ ‫فترة‬ ‫في‬ ‫الطين‬ ‫في‬ ‫نفسها‬ ‫تدفن‬‫الضفادع‬ ‫فعل‬
‫الش‬ ‫البيات‬ ‫في‬‫توي‬

5. ‫بغ‬ ‫الطعام‬ ‫ويرفض‬ ‫الشهية‬ ‫يفقد‬ ‫المريض‬ ‫اإلنسان‬‫ريزته‬
‫يحضونه‬ ‫حوله‬ ‫من‬ ‫أن‬ ‫إال‬ ‫عليها‬ ‫هللا‬ ‫فطره‬ ‫التي‬‫على‬
‫ال‬‫ل‬ ‫ولو‬ ‫حتى‬ ‫مريضا‬ ‫يكون‬ ‫حينما‬ ‫بالطعام‬ ‫تشبث‬‫له‬ ‫تكن‬ ‫م‬
‫للطعام‬ ‫شهية‬
‫رب‬ ‫إن‬‫ف‬ ‫والشراب‬ ‫الطعام‬‫علي‬ ‫مرضاكم‬ ‫تكرهوا‬ ‫ال‬‫هم‬
‫ويسقيهم‬ ‫يطعمهم‬

6.  A young medical student has a viral
upper respiratory tract infection. His
temperature was 38.9oC. Congested
throat. Chest: clear. Day 1 Ramadan.
What is your advice?

7.  Generally, patients are dispensed from fasting.
The illness is the intense one that increases by
fasting, or recovery is delayed. Ahmad Bin Hanbal
was asked, when is the patient dispensed from
fasting. “If he could not” he answered. They
asked: fever, for example?. He answered: “What
disease is more severe than fever?”.
Ibn Godamah. Al-Maghny
Al-Torky & Al-Helo. eds, 1408,4:403-4

8.  Patients who are not harmed by fasting,
and their recovery is not delayed
(e.g., Type 2 DM )

9.  Patients who are harmed by fasting or
their treatment cannot be given with
fasting (e.g., pregnant lady, acute MI,
advanced liver failure).

10.  Patients who are not harmed by fasting
but their treatment could be adjusted
for proper control (e.g., hypertension,
epilepsy, OA).

11.  A 60-year-old male with long- standing
hypetension who was on irregular
treatment. He was on Metoprolol 50 mg
BD, Frusemide 40 mg QD, Diltiazem 90
mg BD. His serum creatinine was 4.5 mg,
Na 131, K 4.5. He wants to fast Ramadan.
What is your advice?

12. Am J Kidney Dis. 2016;67(1):20-30

13. Introduction
CKD
Transplantation
Dialysis
Recommendations

22.  This study done on small number of patients
 Ramadan fasting may be injurious to renal
tubules, but only for those with CKD.
 Large studies are recommended to determine the
extent of tubular injury and renal function in
CKD patients during Ramadan fasting

30.  This study done on small number of patients (31
patients).
 Done during winter months
 Some improvement in the eGFR during and past
fasting, however, fasting should be under close
medical supervision with strict attention to fluid
intake, daily activity and adjustment of drug
regimen .
 Special attention for the management of diabetic
CKD patients

34. Introduction
CKD
Transplantation
Dialysis
Recommendations

38. Introduction
CKD
Transplantation
Dialysis
Recommendations

43. Introduction
CKD
Transplantation
Dialysis
Recommendations

45.  Controversies in CKD) and hemodialysis patients
 Absence of strict guidelines
 Renal transplant recipients with stable kidney
function for 1 year post-transplantation
 Concern in hot weather for patients with kidney
stone diseases.
 CKD stages 4 and 5 and CKD stage 3 patients:
very high risk and high risk categories,
respectively: ? To be exempted from fasting.

48. ‫االيداع‬ ‫رقم‬
17003/2017

52.  I do not advise Fasting:
 Acute kidney injury
 Uncontrolled BP
 Generalized edema
 Polyuria
 Metabolic decompensation
 Fast progressors stage 3 CKD
 DKD (eGFR < 45)
 Recurrent stone passer
 Stage 4 or higher
 Dialysis
 Renal allograft dysfunction
 Polypharmacy that can’t be distributed to sunset and down

53.  I’ll advise fasting
◦ CKD stage 1 or 2 with controlled blood pressure
on ≤ 2 drugs provided that the patient is stable
after starting fast and there is no urine
concentrating defect

54.  CKD Patients Who should not Fast:
 ?? GFR < 30
 ?? GFR < 15
 CKD with other associated problems:
 Liver Disease
 Diabetes
 CVD
 Neurological Disease
 What if the patient insisted to fast??

64. Effect of Dehydration
Effect on Stone formation
Effect on renal nutrition
UTI
Effect on Immune System

66. A smallbody mass loss is a frequent, but not universal, outcome of
Ramadan. During the daylight hours of Ramadan fasting, practising
Muslims are undoubtedly dehydrating, but it is not clear whether
they are chronically hypohydrated during the month ofRamadan.
No detrimental effects on health have as yet been directly attributed
to negative water balance at the levels that maybe produced during
Ramadan.

67. International Journal of Nephrology and Renovascular Disease 2015:8 53–57
Fasting Ramadan:
CKD (n 131)

68. Hemodialysis International 2016; 20:270–276
Fasting Ramadan:
Hemodialysis (n 635)

69. Fasting Ramadan:
Hemodialysis
(n F 34: NF252)
Iranian Journal of Kidney Diseases | Volume 10 | Number 2 | March 2016

70. Iranian Journal of Kidney Diseases | Volume 9 | Number 1 | January 2015
Fasting Ramadan:
Hemodialysis

71. Diabet. Med. 2016, in press
Fasting Ramadan and DM:
Fast or Not Fast

74. Transplantation 2008;85: 141–144
Fasting Ramadan:
Renal Transplantation
Serum creatinine:
<150 umol/l

75. Fasting Ramadan:
Renal Transplantation