Ramadan Fasting with Diabetes and Kidney Disease

Section 8

Ramadan

Directly relevant to this clinic's population, and the one topic where the risk assessment must happen weeks before the diet advice.

The IDF-DAR risk score is the tool. What matters for our patients is that renal function alone can decide the category before anything else is counted.

IDF-DAR points for renal complications, and the score bands
eGFR	Points	Effect
Above 60	0	No contribution
45 to 60	2	Pushes toward moderate risk
30 to 45	4	Moderate risk on its own. Basal-bolus, pump or multiple daily mixed insulin (2.5 to 3 points) takes it to high; lesser regimens leave it moderate.
Below 30	6.5	High risk on its own, before diabetes type, HbA1c or treatment are counted.

Bands: 0 to 3 low risk, fasting probably safe. 3.5 to 6 moderate risk, safe with supervision but the patient may reasonably choose not to fast. Above 6 high risk, advise not to fast.

The kidney-specific tiering published in 2021 goes further. CKD G4 to G5 without dialysis, and all forms of haemodialysis and peritoneal dialysis, are classed very high risk, with the explicit advice that these patients must not fast. CKD G1 to G3 with unstable function, known electrolyte abnormality, or on diuretics or ACE inhibitors and ARBs, is high risk and should not fast. Only stable CKD G1 to G3 may fast at the physician's discretion.

Acute kidney injury during Ramadan has been reported in 11 to 34 percent of patients across cohorts from CKD stage 2 to 3 upward, rising with severity. In haemodialysis, interdialytic weight gain rises and hyperkalaemia has been reported in up to 16 percent, though the studies conflict.

If a low or moderate risk patient elects to fast

Pre-Ramadan visit six to eight weeks ahead. Bloods within four weeks before, and again one week after starting.
Withhold the SGLT2 inhibitor for the duration in older patients, those on diuretics, or those with CKD. This is the clearest published statement on the question.
Move antihypertensives and diuretics to once-daily preparations taken at iftar. Shift the larger sulfonylurea or insulin dose to iftar and halve or omit the suhoor dose. Metformin two-thirds at iftar, one-third at suhoor.
Fluid 1.5 to 2 L across the night hours, front-loaded at iftar and suhoor. Avoid caffeine and very sweet drinks.
Dates. The traditional iftar opener runs about 800 mg potassium per 100 g, roughly 240 mg for four dates (30 g). Limit the number and pair with low-potassium items rather than banning them outright.
Suhoor as late as possible, with slowly absorbed carbohydrate and protein. Iftar should not be one large high-glycaemic-load meal.
Break the fast immediately if glucose falls below 70 mg/dL or rises above 300 mg/dL, or on symptoms of dehydration or hypotension. Blood glucose testing does not invalidate the fast.
Haemodialysis patients who fast should do so on non-dialysis days only.

For patients: Fasting in Ramzan with diabetes, and the Ramzan fasting risk calculator.

Medically reviewed by Dr. Khizer Hussain Junaidy, Diabetologist & Bariatric Physician, Telangana State Medical Council 04937. Reference material for clinicians at Caspian Healthcare.