Table 2 Recommendations for CKD patients planning to fast

Pre- Ramadan Assessment:

Schedule clinic visit: at 1 to 3 months before Ramadan

- Review previous fasting experience

- Evaluate for frailty [113]

- Evaluate clinical and other comorbid conditions

- Assess wellness for fasting and evaluate potential risk factors

- Measure of BP, weight / BMI

- Check basic laboratory investigations: creatinine and electrolytes, eGFR, CBC, blood glucose, calcium, phosphorus levels, protein-to-creatinine ratio, drug levels in patients on tacrolimus or cyclosporine (whenever indicated)

- Adjust medications to suit fasting hours, detailing the dosing schedule for Ramadan

- Substitute short-acting medications with long-acting formulations (e.g., tacrolimus) or patch-based options (eg clonidine), if available

- Gradually taper off medications prone to rebound effects (e.g., oral clonidine) if patches aren't an available

- Inform the patient about the need to adjust the timing for measuring calcineurin inhibitor (tacrolimus or cyclosporine) trough levels to align with their revised schedule

- Dietary adjustment and water / fluid intake during Ramadan:

- To eat balanced diet that fits patient’s health

- To avoid potassium rich food (dried fruits, banana, fruit juice,..) if hyperkalemia is a concern

- To break the fast gradually: Begin with a cup of water, followed by light meal, then to have the main meal post Taraweeh prayer

- Should not skip Sahoor “pre-dawn meal”

- To stay hydrated: to drink at least 1.5 to 2.5 L of water throughout the night, avoiding excessive intake at once. Space out your consumption

- Discuss physical (type and timing) activity during Ramadan

- Refer to other subspecialty clinics for the evaluation of relevant fasting risk factors (nephrology, cardiology, endocrinology, and others), whenever indicated

- Classify patient risk and recommend accordingly. (see Fig. 1)

- Monitoring during Ramadan fasting is advised for all patients

- Discuss the rules for early termination of the fast (Table 3)

During- Ramadan Assessment:

Schedule clinic visit: 1st week of Ramadan for moderate and high-risk patients who opted to fast

- Ask about tolerating fasting and any issues encountered

- Check BP, weight / BMI, blood glucose

- Basic laboratory investigations: Creatinine and electrolytes, eGFR, CBC, and drug trough levels in patients on tacrolimus or cyclosporine (be careful about the time of the test)

- Review medications and if patient is following the recommended adjustments

- Advise about dietary adjustment, water / fluid intake

- Review type and timing of physical activity during Ramadan

- Review the rules for early termination of the fast

Post- Ramadan Assessment:

Schedule clinic visit: at 1 then 3 months after Ramadan

- Evaluate the fasting experience and any issues encountered

- Measurement of BP, weight / BMI, blood glucose

- Basic laboratory investigations: HbA1c, creatinine, and electrolytes, eGFR, CBC, lipid panel, drug levels in patients on tacrolimus or cyclosporine

- Medications dose adjustment and schedule (resume pre-Ramadan)

- Evaluate the comorbid conditions post Ramadan