Fasting during Ramadan with CKD: your questions answered

We spoke to Dr Shafi Malik, Consultant Nephrologist at the Queen Elizabeth Hospital, Birmingham, about what to consider when it comes to fasting during Ramadan if you are living with chronic kidney disease (CKD).

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“Our role as healthcare professionals is not only to help patients with kidney disease who wish to fast fulfil their religious duty during Ramadan, but also to give advice that is appropriate and inform them of any potential risks they may experience while fasting," says Dr Malik. "I would always encourage you to meet with your primary care physician, or kidney team, four to six weeks prior to Ramadan so you can discuss feasibility of fasting safely.”

Dr Malik's 3 key tips for observing Ramadan as someone living with kidney disease

  1. Discuss your suitability to fast with your kidney team, and make any medication or lifestyle changes you can, or need to, make to safely fast during Ramadan.
  2. If it is safe for you to fast, try to put together a monitoring plan with your kidney team such as blood pressure, blood sugar or blood tests monitoring during Ramadan.
  3. When you break your fast, be sure to eat a balanced and healthy diet and stick to your normal food and fluid intake to ensure that you have adequate nutrition.

Is it safe for me to fast if I have kidney disease?

“When it comes to Ramadan and fasting, I tend to refer to patients living with kidney disease as low or moderate risk, high risk, and very high risk. My advice is that those who are low or moderate risk are safe to fast under the correct conditions, and those who are high risk should not fast and those in the very high group must not fast, due to complications that may occur.

Low or moderate risk patients are those who have stable kidney disease and stable kidney function. Generally, these people are stages 1-3 CKD. If your kidney function is stable, you should be able to fast without major complications. It is worth discussing with your healthcare professionals and GP about previous experiences with fasting if you have done so before.

High risk and very high risk patients are those with an unstable kidney function, those with CKD stages 4-5 or have other associated health conditions. If your kidney function is declining, you would be considered high or very high risk and my advice is that you should avoid fasting. The reason is because you have to abstain food/drink for up to 14 hours, and during that period there is an increased risk of dehydration and your kidney function being affected. Additionally, some patients in these categories may have strict fluid balance and salt restrictions, it would be tricky meeting these requirements while at the same time keeping themselves adequately nourished and hydrated to fast safely.”

What should I consider before and during fasting if I decide to do so?

“I would recommend asking your kidney team to put together a monitoring plan throughout Ramadan. This plan can monitor key information such as kidney function, phosphate and potassium levels, blood pressure, fluid retention, weight, and blood sugar levels.

“Your plan can be daily, weekly, or fortnightly depending on your level of risk and plans will be different from person to person. For example, if you also have diabetes, I recommend checking your blood sugar levels on a daily basis. If you are low risk with no other underlying health conditions, you may only need to check these parameters on a weekly basis.”

Why is it important to chat with my kidney team and ask for advice before fasting?

“Even if you are in the low or moderate risk category and have good underlying health, there may be things that you need to consider or change prior to fasting. Other health conditions may affect your ability to fast, and you may need changes to your medication.

“Also be sure to discuss ‘sick day rules’ and when to break the fast with your kidney team. If you are ever feeling unwell, discuss this immediately with your kidney team. You may be dehydrated, have elevated potassium, or have low sugar, and your team may need to know so they can advise you if you need to break your fast for medical reasons.”

Can I fast if I have other health conditions?

“There is plenty of information in the British Islamic Medical Association (BIMA) Ramadan compendium. If you have other health conditions, the key is to not treat your kidney disease section in isolation, as risks associated with fasting may be compounded. For example, you may be classed as low risk in terms of your kidney disease which means you can safely fast, but your diabetes may mean that it is not safe to fast.

“The best thing to do is chat with your kidney team about the risks that may be associated with fasting and other health conditions.”

Do I need to change my medication?

“Fasting may require medication changes, even if you are in the low or moderate risk categories. For example, blood pressure medication may need to be altered, as abstaining from water during your fast may alter your blood pressure. The timing, frequency and type of medications might also have to be changed, or example if you are taking a water tablet, instead of taking it during the day you might have to take it in the evening after breaking your fast.

“Be sure to discuss these medication changes four to six weeks prior to Ramadan, so your healthcare team can monitor any changes to medication before you start your fast.”

Are there religious alternatives to fasting?

“For patients who are high and very high risk, I would recommend researching alternatives to fasting and having a conversation with your local religious community or religious authority (Imam). For example, a person may want to give to charity if they cannot safely fast due to health conditions.

“There are also alternative methods of fasting, but always discuss these alternatives with your kidney team, as there may be other considerations.

“For example, you could explore trial fasting, where you observe one or two days fasting prior to Ramadan and see whether you can safely fast.

“You can try intermittently fasting, where you fast every other day, or every few days. Or, instead of fasting for the full 30 days, you only fast for the last 10 days (generally considered to be the most holy period).

“Fasting during the winter months, when days are shorter, is another option.”

What should I consider during Ramadan regarding food and drink?

“It is vital to fast safely and in a healthy manner. A few things I would recommend:

  • Keep your food portions similar to what you would eat prior to Ramadan. However, it may be better to have smaller, more regular portions rather than large meals.
  • Include all food groups in your diet. Your diet should mirror a normal, balanced diet so you have adequate nutrition for the following day.
  • When starting fast (at dawn period), it may be best to incorporate complex carbohydrates into your last meal. This is because the release of energy is slower and can sustain.
  • Do not drink a large amount immediately after breaking the fast. This is because you may fill up with fluid. Instead, space your fluid intake across the iftar and suhoor period.
  • Avoid fizzy and caffeinated drinks where possible.
  • In many cultures, it may be traditional to eat fried foods at iftar. If you have kidney disease, consider baking or grilling rather than frying.
  • Exercise is important, especially if you are fasting with kidney disease. Try walking to your local place of worship for prayers or getting out during the day for a while.”

Can I eat foods like dates and apricots?

“During the breaking of the fast, it can be traditional to eat dates and apricots. These can be high in potassium and can increase phosphate and calcium, all of which can be a risk if you have kidney disease.

“While you can eat these foods in smaller quantities, pay close attention to your dietary requirements and chat with your kidney team, or dietitian if you have one.”

Fasting if you are receiving kidney replacement therapy

“It can be tricky to observe Ramadan while on dialysis. While there have been a few studies of successful fasting, these patients are motivated, stick to fluid and nutrition requirements, and are generally younger and healthier. Patients on all forms of dialysis would fall in to the very high risk category due to the strict fluid restrictions in addition to potassium, calcium, and phosphate restrictions. However, some patients may have a strong urge to fulfil their religious duty and do so against medical advice. It would be imperative that patients intending to do so, speak with their kidney teams ideally 4-6 weeks prior to put together an individualised monitoring plan. Always speak with your dialysis team before making any decisions to fast.”

Can I fast while receiving haemodialysis (HD)?

“If you are receiving in-centre HD and wish to fast, ask to change your dialysis shift to one later in the day, or even nocturnal. This means that you are closer to sundown when you start dialysing.

“If you are on home HD, try switching your dialysis after breaking the fast so you are able to eat and drink during your treatment. If you cannot do this, I recommend changing your dialysis to be as close to sundown as possible. Fasting on non-dialysis days might be a safer option.”

Can I fast while receiving peritoneal dialysis (PD)?

“If you are receiving PD, I suggest automated peritoneal dialysis (APD) treatment. If you receive continuous ambulatory peritoneal dialysis (CAPD) treatment, the recommendation is switching to APD if it is possible to do so. Always check with your kidney team first.

“If you are on APD, expert advice is to fast for a maximum of 16 hours. This means that you can have 8 hours of APD after breaking your fast. This Clinical Kidney Journal article has more information, and a flow chart, about how to make those changes if you are on peritoneal dialysis.”

Can I fast after a kidney transplant?

“As long as there isn’t any rejection, and transplantation function is stable, you can safely fast after one year post-transplantation.

“The reason I don’t recommend fasting before a year has passed since your transplant is:

  1. function can fluctuate in the first 6-12 months
  2. there is a higher risk of rejection in the first 3-6 months.

“Allowing a year after transplant before fasting gives us good time period to ensure that your kidney function and trajectory is smooth and stable.

“You may need to change your transplant immunosuppressive medication which are usually taken twice a day to those that can be taken once a day ahead of time to ensure stability prior to fasting, so I recommend chatting with your team and changing medication at least four to six weeks before Ramadan.”

More information about fasting during Ramadan if you are living with CKD

  • Diet and nutrition, Living with kidney disease

    "I enjoy the many other blessings this month brings"

    Kidney patients Sumaya and Rehana share their experience of Ramadan while living with chronic kidney disease (CKD).

  • Creamy fruit chaat

    An iftar table is not complete without fruit chaat. For people with kidney disease who are unable to fast during Ramadan, enjoying a safe, yet delicious fruit chaat recipe will make you feel part of the celebration.

  • Living with kidney disease: fasting during Ramadan

    People with chronic kidney disease are exempt from fasting during the month of Ramadan, but it can be a difficult decision for Muslims.