Year : 2010 | Volume
: 21 | Issue : 3 | Page : 417--420
Ramadan fasting and transplantation: Current knowledge and what we still need to know
Hossein Khedmat1, Saeed Taheri2,
1 Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Dr. Taheri Medical Research Group, Tehran, Iran
Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah Hospital, Mullasadra St, P.O. Box 14155-6437 Postal code: 1435915371, Tehran
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;21:417-420
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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 2021 Dec 5 ];21:417-420
Available from: https://www.sjkdt.org/text.asp?2010/21/3/417/62693
Ramadan and its Significance in the Islamic Culture
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.  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
In healthy persons, fasting Ramadan does not induce abnormalities of urinary volume, osmolality, pH, and solute and electrolyte excretion.  Changes in serum urea and creatinine are usually insignificant, , and the alterations in serum sodium and potassium are negligible.  However, in chronic kidney disease (CKD) patients, Ramadan fasting is shown to induce adverse impact on renal function.
Previous studies have reported that carbohydrate metabolism is slowed down by Ramadan fasting in human subjects while fat oxidation is significantly increased.  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.  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. , Whole blood lactate and pyruvate levels also fell during Ramadan fasting in human subjects. , 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. 
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,  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  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. 
Ramadan Fasting and Allograft Recipients
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.  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  in the normal population, and another reported a decrease in complement C3 levels and an increase in C4 levels in renal transplant recipients. 
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  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  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  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  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  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  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  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 , 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. 
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.
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