Our prospective study showed that fasting Ramadan in HD patients may be well tolerated by most of patients with no significant adverse effects, in addition to favorable effect on dry weight.

Limited data are available about the safety of fasting in Ramadan in patients with different renal diseases. Although some studies advice against fasting in this special population as patients with different degrees of renal disease, as they carry a higher risk for either dehydration during fasting hours or fluid overload due to increased fluid intake when breaking fast, some patients choose to overlook these recommendations, and still, they do fast Ramadan for its spiritual spirits and religious reasons [4].

Previously held studies showed different percentages of their patients allocated among either the complete or partial fasting state compared to the results of the current study. One study by Megahed and colleagues stated that among the 2055 included Muslim HD population, 965 (46.96%) succeeded to fast, of those who fasted, 39.5% admitted that they could fast the whole month [2]. In a previous report, 282 Pakistani HD patients were assessed by Imtiaz et al., and the frequency of fasting in Ramadan was 13.5% [5]. In another study conducted in Saudi Arabia, 64.1% out of the included 635 HD patients fasted [6]. The variation in the results of these studies and the current one could generally be ascribed to different personal, social, and environmental influences.

Body weight changes during Ramadan has always been a debate, between weight loss, gain, or even no change, particularly in special patients’ groups. In the current study, we noticed a significant reduction in the body weight among the fasting groups of patients after the holy month of Ramadan: 1.8 kg in the CF group (P-value: ˂ 0.001), 1.23 kg in the PF group (P-value: ˂ 0.001), unlike patients who did not fast, where they did not show a significant change in their weight during the holy month (P-value: 0.75).

This result is further supported by the results by Wan Md Adnan and colleagues, where they stated a significant decrease in the weight of patients who voluntary fasted during Ramadan [7]. Moreover, Bernish et al. confirmed the same finding stating that the main positive clinical finding, in their study, was the tendency towards weight reduction (1.4) kg and the decrease in systolic and diastolic blood pressure [4].

Conversely, other studies that investigated the same matter showed either no change in the patients’ body weight as noted by Megahed et al. and Elshamsi et al. [2, 8] or even reported weight gain during the holy month for the fasting dialysis patients as in the study by Khazneh et al. who reported a slightly higher mean IDWG by 0.6 kg and 0.4 kg in the complete and partial fasting groups compared to the non-fasting, respectively [9].

Those mixed findings might be attributed to the different cultural and festive traditions in different nations during the holy months in which, of course, food represents a big part.

With regard to safety of Ramadan fasting in hemodialysis population, in the current study, fasting Ramadan whether complete or partial was safe and tolerated by 96.6% of the patients (112/116). Reported untoward events occurred in 3.4% of patients, mostly hypotension along with muscle cramps. Wan Md Adnan et al. results agreed with ours in their previously mentioned study, stating that all patients who participated in this study tolerated Ramadan fasting quite well [7].

However, conflicting with this result was the results by Rashed, who noted that patients on long-term HD who fasted during Ramadan may experience an increase in body weight and fluid overload between dialysis sessions due to their tendency to increase food consumption at nights of Ramadan [10].

Moreover, in the results of Khazneh et al., in their previously mentioned study, although they stated that Ramadan fasting was not associated with significant complications, they highlighted that these patients are at higher risk of hyperkalemia and volume overload and mandated that hemodialysis patients intending to fast should be aware of the consequences of hyperkalemia and volume overload and should strictly adhere to their allowance of fluid intake and potassium rich diets [9].

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