Keywords: Ramadan fasting, Moslems, Renal transplant recipients, Organ donor, Chronic renal failure, End-stage renal disease.
|How to cite this article:|
Al-Khader AA. Ramadan fasting and renal transplantation. Saudi J Kidney Dis Transpl 1994;5:463-5
Fasting in the month of Ramadan is one of the five pillars of Islam. Observing the fast is a fundamental duty and is mandatory for all adult Moslems  . However, those who are ill and cannot fast are exempted from keeping the fast according to The Holy Quran  . Patients with concurrent illness, those in whom fasting is deemed to be deleterious to their health and those in whom the nature of their therapy necessitates breaking the fast, e.g., those who require intravenous medications or nutrition and those who require frequent oral medications are all among those exempted.
When a patient is unable to fast during Ramadan because of health reasons, it is incumbent on him to fast the same number of days he missed, during the succeeding months, if he recovers his health. However, if he has a chronic illness that is unlikely to recover and is likely to make fasting untenable on a permanent basis, then he has to give alms to the needy in lieu of fasting, as has been specified by the Holy Quran  . It is preferable that the advice regarding the fitness of a patient to fast is given by a competent Moslem doctor. When a doctor is asked whether a patient can fast he should ask himself:
- Is the patient medically unfit to fast?
- Will his health deteriorate because of fasting?
- Is the treatment regimen such that fasting will interfere with its proper implementation? Can the treatment be altered to suit fasting cycle e.g., once daily medication instead of multiple doses?
- If it is deemed necessary for the patient not to fast, can he compensate this at a later period i.e., when the weather is cooler and/or the fasting time (from dawn to dusk) is shorter?
A physician should also bear in mind other factors such as, the season in which Ramadan is in that year, the nature of the patients work i.e., sedentary, manual, outdoor etc.
It should be pointed out that in many illnesses, fasting can actually be a positive element in improving health. In renal diseases the adverse effects from fasting is generally related to water deprivation and not to nutritional deprivation. In fact, partial nutritional deprivation may actually be beneficial in some cases particularly in relation to protein and potassium restriction. However, one should point out that indulgent eating after breaking fast can lead to hyperkalemia  . Water and salt deprivation may lead to worsening of renal failure especially in patients with sodium/water losing nephropathy as in those having one or other forms of interstitial nephritis. These patients lose their ability to concentrate urine due to destruction of their tubular mechanisms and have some degree of nephrogenic diabetic insipidus. The fluid depletion and electrolyte disturbance that may ensue can prove to be harmful.
With regards to kidney transplant recipients, the advice regarding fasting has been controversial and information to base decisions on is sparse. The general view has been to advise against fasting. Until recently, not many transplants were carried out in Moslem countries and those carried out in Moslem patients have been done by non Moslem doctors where advice tended to be against fasting based on expedient reasoning. Over the last 10 years there has been marked increase of renal transplants carried out on Moslem patients and the question of fasting has become more significant. Many of the patients who were advised not to fast did observe fasting and in many cases had no adverse effects. This was an eye opener which made us realize that fasting may not be as injurious in these patients as thought previously. Thus there are various factors one has to consider while giving advise on fasting for renal patients as well as for kidney donors.
Do we have real answers? In this issue of the Journal there are two excellent articles which help us in answering the questions of fasting after renal transplantation for both donors and recipients. In the article by Shehab et al (Page 474), 25 kidney donors were studied, three months following unilateral nephrectomy for early compensatory changes in the remaining kidney. They used ultrasound to measure compensatory hypertrophy and isotopic method to measure the functional changes in glomerular filtration rate (GFR) in the remaining kidney. Their findings show that significant hypertrophy occurs by as early as three months. This was associated with a mean increase in GFR by 34% in the remaining kidney. These results demonstrate that acceptable compensatory changes occur quite early after donor nephrectomy. It is during this compensatory hypertrophy that one would expect reduction in renal blood flow to be injurious to the kidney which therefore may impair its compensatory mechanisms. Since these changes, appear to be complete during the early post donation period itself, one can assure that it is safe to advise the donor to fast, one year after the nephrectomy.
In the other article, Bernieh et al (page 470) studied 11 transplant recipients with stable graft function (mean creatinine 120 (µmol/L) and found that renal function was not worsened by fasting in spite of the fact that eight of those patients were also hypertensive. There was a mild increase in potassium due to increased intake of potassium containing diet during Ramadan, which however, remained within normal limits still. They also found that the fractional excretion of sodium was reduced during fasting showing that the ability of sodium conservation was maintained in the kidney transplant recipients. Similar study was done by Rafi, et al  in 11 transplant patients with stable function and again fasting did not alter their renal function.
A very useful and relevant study was conducted by Rashed et al  in 43 transplant patients with stable renal functions. They showed that after a day-long fast these patients managed to concentrate their urine in a fashion similar to 23 healthy controls. Mean urinary osmolality recorded after the fast was 873 and 826 mosmol/kg in healthy controls and transplant recipients respectively. Studies have also shown that a well functioning renal transplant, hypertrophies normally after a period of 3-6 months as well as during pregnancy and in diabetics  showing that the humoral, neurogenic and metabolic changes necessary for renal physiological compensatory hypertrophy is preserved following renal transplantation. An another relevant study is the one by Badrah et al  , which showed that cyclosporine can be taken during Ramadan along with "Sahour" (predawn meal taken before beginning the fast) and just after breaking the fast immediately after sunset, without significant changes in blood or urinary level of cyclosporine or its metabolites.
The above studies suggest that it is safe for a kidney donor to fast after one year of donation. The same is true for a kidney recipient with good renal function. Cyclosporine and other immunosuppressive therapy and antihypertensive therapy can safely be taken during the non-fasting period. However, the numbers studied were small and studies involving larger number of patients are needed.
On the other hand, no studies are available on the effect of fasting on transplant recipients with impaired renal function. This question should be looked into with more detailed studies since renal impairment is associated with concentration ability defect. The Saudi Center for Organ Transplantation is planning a multicenter study to evaluate the practice of nephrologists regarding the advice given to renal patients about fasting as well as to study the effect of fasting on a large number of patients with various levels of renal function and varying post-transplant follow up period.
I suggest that until the results of such a study is available and when the physician cannot be sure about the risk of fasting in. a given patient, or when the patient insists on fasting, urinary osmolality should be done at the end of a day's fast. If the patient can concentrate urine normally, then fasting can be assumed to be safe for him/her.
| References|| |
|1.||Surah Al-Baqarah (Chapter 2) verses 183185. The Holy Quran. |
|2.||Al-Khader AA, Al-Hasani MK, Dhar JM, Al-Sulaiman M. Effects of diet during Ramadan on patients orr chronic hemodialysis. Saudi Med J" 1991;12:30-31. |
|3.||Rafi A, Al-Ahmed F, Al-Muhanna F, AlKhursany I. Effect of Ramadan fasting on various biochemical and hematological parameters in renal transplant recipients. Saudi Kidney Dis Transplant Bull 1993;4:S96. |
|4.||Rashed AH, Siddiqui SA, Aburomeh SH. Clinical problems during the fast of Ramadan. Lancet 1989;1:1396. |
|5.||Absy M, Metreweli C, Matthews C, AlKhader A. Changes in transplanted kidney volume measured by ultrasound. Br J Radiol 1987;60:525-9. |
|6.||Badrah HM, El-Sheikh HA, El-Fituri MN. Cyclosporin-A (Cyc-A) variability in fasting kidney transplant patients. Saudi Kidney Dis Transplant Bull 1993;4:S96. |
Abdullah A Al-Khader
Consultant Nephrologist, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159