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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 417-420
Ramadan fasting and transplantation: Current knowledge and what we still need to know


1 Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Dr. Taheri Medical Research Group, Tehran, Iran

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Date of Web Publication26-Apr-2010
 

   Abstract 

Ramadan fasting is one of the most appreciated Islamic rituals in Islamic culture. Although non-healthy as well as weak people are allowed not to fast in this month, some trans­plant recipient patients are willing to fast but are concerned about adverse effects on their health. Due to answering this question, a number of studies have been conducted. In this literature review we review the existing data on this issue and attempt to reach to a conclusion on what we know and what we still need to know.

How to cite this article:
Khedmat H, Taheri S. Ramadan fasting and transplantation: Current knowledge and what we still need to know. Saudi J Kidney Dis Transpl 2010;21:417-20

How to cite this URL:
Khedmat H, Taheri S. Ramadan fasting and transplantation: Current knowledge and what we still need to know. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Dec 8];21:417-20. Available from: http://www.sjkdt.org/text.asp?2010/21/3/417/62693

   Ramadan and its Significance in the Islamic Culture Top


Ramadan is commonly considered as one of the most sacred Islamic rituals that takes place during Ramadan, the ninth month of the Arabic calendar in which the holy Qur'an was re­vealed to Islam's holy Prophet. In Ramadan, Muslims refrain from eating and drinking any­thing from dawn until sunset. The philosophy of fasting in the Islamic culture is to teach to­lerance and train patience and to feel for the sufferings of the poor. [1] Moreover, Muslims prac­tice self-restraint and good activities.

Although, unfortunately, there is paucity of scientific data on the psychological and social impacts of Ramadan fasting, the general con­ception is that this impact is extremely high both on individuals and the society: people who are permitted not to fast including pregnant and menstruating women, mothers nursing their newborn, persons who are weak, elderly, or sick (physically or mentally), young children, and tra­velers may eagerly wish to fast in this month.


   Impact of Ramadan Fasting on the Human Physiology Top


In healthy persons, fasting Ramadan does not induce abnormalities of urinary volume, osmo­lality, pH, and solute and electrolyte excretion. [2] Changes in serum urea and creatinine are usu­ally insignificant, [3],[4] and the alterations in se­rum sodium and potassium are negligible. [4] How­ever, in chronic kidney disease (CKD) patients, Ramadan fasting is shown to induce adverse impact on renal function.[5]

Previous studies have reported that carbohy­drate metabolism is slowed down by Ramadan fasting in human subjects while fat oxidation is significantly increased. [6] On the other hand, there are observations suggesting that similar models of Ramadan type fasting in the rat mo­dels result in intense provocation of enzymes engaged in several metabolic activities such as the tricarboxylic acid cycle, gluconeogenesis, and glycolysis in the gastrointestinal tract as well as in the liver. [7] Moreover, in rat models, 30 day-Ramadan- type fasting resulted in a de­crease of blood cholesterol and glucose as well as a minor lowering of body weight as ob­served after Ramadan fasting in human sub­jects. [2],[3] Whole blood lactate and pyruvate levels also fell during Ramadan fasting in human subjects. [2],[3] Although a variety of changes in urine volume, osmolarity, solutes, ions, and urea were observed after Ramadan fasting in humans, there is no evidence of any adverse impact on kidney functions. [4]

While it is presumed that prolonged intermi­ttent abstinence from water and food concomi­tantly for 12 hours daily for 30 days may stress the kidneys and alter their metabolic and trans­port functions, [7] serum creatinine and blood urea nitrogen as well as creatinine clearance were not unaltered by this feeding pattern, sug­gesting that normal kidney function remains intact.

Prolonged intermittent Ramadan type fasting induces a significant decrease in lactate dehy­drogenase and malate dehydrogenase activities in renal cortex and medulla [8] as well as the en­zymes involved in both the glucose degradation and production including glucose-6-phospha­tase and fructose-1,6-bisphosphatas. In addition, reversible increased liver and intestine enzy­matic activities have also been reported during Ramadan type fasting. [7]


   Ramadan Fasting and Allograft Recipients Top


Transplant patients are at increased risk of adverse effects related to fasting due to their underlying illness and immunosuppressive me­dication. Prior to the commencement of Rama­dan Muslim patients ask their doctors whether they can fast. [9] The major concern in these pa­tients is that if dehydration and accumulation of metabolites may result in irreversible dete­rioration in renal function or facilitate rejection episodes via inducing changes in immune sys­tem. One study did not find any change in cir­culating immune complexes during Ramadan fasting [10] in the normal population, and another reported a decrease in complement C3 levels and an increase in C4 levels in renal transplant recipients. [11]

With increasing the number of renal trans­plants performed in Islamic countries as well as improved quality of life, the question of the safety of fasting Ramadan is asked more often. Several investigations have addressed this issue and found no significant adverse effects of Ra­madan fasting on transplant patients or allo­grafts; Argani et al [11] studied 24 patients and found no significant increase in body weight, blood pressure, 24-hour urine volume, protein to urine creatinine ratio or blood urea nitrogen. In addition, T-cell and white cell counts, he­moglobin levels, and low density lipoprotein did not change significantly after completion of 30 days of Ramadan fasting. B cells counts, serum IgM concentration, serum C 3 levels, and serum very-low-density lipoproteins value all significantly decreased after fasting compared to pre-fast period. Higher levels of high density lipoprotein and serum C4 values were also observed after Ramadan fasting. The uthors finally concluded that Ramadan fasting was not harmful to stable renal transplant patients with a 12-hour fasting pattern. However, they proposed that patients should be observed ca­refully by their physicians while fasting.

Einollahi et al [12] studied 19 kidney transplant recipients who voluntarily fasted Ramadan and compared them with 20 matched recipients who did not fast. All the patients had serum creatinine values below 1.5 mg/dL at entry to the study. No significant change in serum crea­tinine concentrations before and after Ramadan was observed in both groups. The authors con­cluded safety of fasting Ramadan in recipients with stable renal function and followed it with another study [13] of 41 Ramadan fasting kidney transplant recipients who were compared to matched controls. The mean of estimated glo­merular filtration rate (GFR) did not signifi­cantly change after 30 days of fasting (72.8 ± 27.8 and 73.1 ± 29.3 mL/min in the fasting group, and 73.4 ± 18.8 and 73.1 ± 18.5 mL/min in the controls, pre and post 30 days of fasting, respectively). The authors concluded that for patients with GFR higher than 60 mL/min, Ra­madan fasting did not cause impairment of allo­graft function.

Abdualla et al [14] studied 17 renal transplant re­cipients with normal function and 6 with stable but impaired allograft function (plasma crea­tinine levels not exceeding 300 mmol/L). No significant changes were observed in any of the studied parameters before, during, and af­ter Ramadan. The authors concluded that fas­ting Ramadan did not cause any significant ad­verse effects on kidney transplant recipients with normal or impaired graft function and suggested that it is safe for those patients to fast during Ramadan after one year of renal transplantation.

Ghalib et al [15] studied 68 renal transplant re­cipients; 35 patients in a fasting study group and 33 in a non-fasting control group. When the fasters acted as their own controls, the mean GFR after the third Ramadan did not differ significantly from that at baseline (56.4 and 55.4 mL/min). The differences in GFR over this period remained insignificant after multivariate adjustment for age, presence of diabetes mel­litus (DM), baseline GFR, proteinuria, or dura­tion postransplant. Furthermore, no rejection episodes or renal function deterioration were observed during or soon after Ramadan.

Said et al [16] studied 145 kidney transplant re­cipients (age 18 to 64 years); 71 patients fasted during Ramadan while 74 did not. The serum creatinine and blood urea did not show any significant change between the two groups be­fore and after fasting. There was a tendency for higher blood sugar in patients with type I diabetes mellitus. Cyclosporine toxicity was observed in two fasters, and acute rejection episodes occurred in other two, urinary tract infection occurred in two more. No graft or patient loss occurred in any of the groups. Authors finally concluded that fasting Rama­dan by kidney transplant recipients with nor­mal kidney function is safe, but diabetic pa­tients should exercise more caution during fasting.

Finally Boobes et al [17] studied 22 (12 women) kidney transplant patients with stable kidney functions and voluntarily chose to fast Ramadan. Body weight, blood pressure, kidney function tests, blood sugar, lipid profile, and cyclospo­rine levels remained stable after Ramadan fas­ting, and the authors concluded that it is safe for kidney transplant recipients of more than one year and stable graft function to fast Ra­madan. However, they cautioned about possi­ble adverse impact of fasting on the patients with moderate to severe impaired renal func­tion despite nonspecific findings.

Based on this literature review, the general belief among medical professionals in trans­plantation is to allow fasting when the trans­planted kidney graft is functioning well for at least one year. The overall number of trans­plant patients fasting during Ramadan studied in all the reviewed articles was 213 patients, which may not be large enough to have a final conclusion. However, none of the studies found any significant adverse effects related to Ra­madan type fasting. Although two studies [13],[17] suggested preserving Ramadan fasting to pa­tients without impaired allograft function, no evidence was presented in any of them.

Defining specific allograft function values as safe levels for Ramadan fasting is also of ex­treme relevance, since none of the studies defi­ned renal function level for safe fasting; GFR level ≥ 60 mL/min was not based on scientific findings, but a mere prediction. [13]

All the existing literature was on kidney trans­plant recipients and we did not find any study in other transplant patients. This may be due to the better quality of life and larger patient po­pulation in kidney transplant group than other organ recipients.

One of the major limitations of the current studies is that they do not mention the com­pliance of the patients for all the 30 days of fas­ting and this may impose an obstacle in discussing the results.

We conclude that Ramadan fasting represents no major adverse impact on kidney allografts in kidney transplant recipients. However, lar­ger studies targeting distinct groups of patients (for example diabetic patients) and describing more precisely the fasting process of patients are required to better evaluate the impact of Ramadan fasting on this population.

 
   References Top

1.Islam RN. A concise introduction. New Jersey; Curzon Press, 1999.  Back to cited text no. 1      
2.Malhotra A, Scott PH, Scott J, Gee H, Wharton BA. Metabolic changes in Asian Muslim pregnant mothers observing the Ramadan fast in Britain. Br J Nutr 1989;61:663-72.  Back to cited text no. 2      
3.Nomani MZ, Hallack MH, Nomani S, Siddiqui IP. Changes in blood urea and glucose and their association with energy containing nutrients in men on hypocaloric diets during Ramadan fasting. Am J Clin Nutr 1989;49:1141-5.  Back to cited text no. 3      
4.Cheah SH, Chng SL, Husain R, Duncan MT. Effects of fasting during Ramadan on urinary excretion in Malaysian Muslims. Br J Nutr 1990;63:329-37.  Back to cited text no. 4      
5.El-Wakil HS, Desoky I, Lotfy N, Adam AG. Fasting the month of Ramadan by Muslims: could it be injurious to their kidneys? Saudi J Kidney Dis Transpl 2007;18(3):349-54.  Back to cited text no. 5      
6.El Ati J, Beji C, Danguir J. Increased fat oxi­dation during Ramadan fasting in healthy wo­men: an adaptative mechanism for body weight maintenance. Am J Clin Nutr 1995;62:302-7.  Back to cited text no. 6      
7.Farooq N, Priyamvada S, Arivarasu NA, Salim S, Khan F, Yusufi AN. Influence of Ramadan type fasting on enzymes of carbohydrate metabolism and brush border membrane in small intestine of rat used as a model. Br J Nutr 2006;96:1087-94.  Back to cited text no. 7      
8.Salim S, Farooq N, Priyamvada S, et al. In­fluence of Ramadan-type fasting on carbo­hydrate metabolism, brush border membrane enzymes and phosphate transport in rat kidney used as a model. Br J Nutr 2007;98(5):984-90.  Back to cited text no. 8      
9.Al-Khader AA. The Iranian transplant pro­gramme: Comment from an Islamic perspec­tive. Nephrol Dial Transplant 2002;17(2):213-5.  Back to cited text no. 9      
10.Latifynia A, Vojgani M, Abofazeli T, Jafarieh H. Circulating immune complex during Ramadan. J Ayub Med Coll Abbottabad 2007;19(2):15-8.  Back to cited text no. 10      
11.Argani H, Mozaffari S, Rahnama B, Rahbani M, Rejaie M, Ghafari A. Evaluation of bio­chemical and immunologic changes in renal transplant recipients during Ramadan fasting. Transplant Proc 2003;35(7):2725-6.  Back to cited text no. 11      
12.Einollahi B, Lessan-Pezeshki M, Simforoosh N, et al. Impact of Ramadan fasting on renal allo­graft function. Transplant Proc 2005;37(7): 3004-5.  Back to cited text no. 12      
13.Einollahi B, Lessan-Pezeshki M, Pourfarziani V, et al. Ramadan fasting in kidney transplant recipients with normal renal function and with mild-to-moderate renal dysfunction. Int Urol Nephrol 2009;41(2):417-22.  Back to cited text no. 13      
14.Abdualla AH, Shaheen FA, Rassoul Z, et al. Effect of Ramadan fasting on Moslem kidney transplant recipients. Am J Nephrol 1998;18 (2):101-4.  Back to cited text no. 14      
15.Ghalib M, Qureshi J, Tamim H, et al. Does repeated Ramadan fasting adversely affect kid­ney function in renal transplant patients? Trans­plantation 2008;85(1):141-4.  Back to cited text no. 15      
16.Said T, Nampoory MR, Haleem MA, et al. Ramadan fast in kidney transplant recipients: a prospective comparative study. Transplant Proc 2003;35(7):2614-6.  Back to cited text no. 16      
17.Boobes Y, Bernieh B, Al Hakim MR. Fasting Ramadan in kidney transplant patients is safe. Saudi J Kidney Dis Transpl 2009;20(2):198­-200.  Back to cited text no. 17      

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Correspondence Address:
Hossein Khedmat
Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah Hospital, Mullasadra St, P.O. Box 14155-6437 Postal code: 1435915371, Tehran
Iran
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