The impact of Ramadan fasting on Glycemic Control and Kidney Function in Patients with Diabetes and Chronic Kidney Disease stage 3.

Fatheya Alawadi , Fauzia Rashid, Alaaeldin  Basheir, Elamin Abdelgadir, Maryam Al Saeed, Sona AbuAlkheir, Fatima Alsayyah,  Azza Khalifa, Fawzi El tayeb, Mohammed Abdellatif, Khadija AbdAllah ,  Mohamed  Hassanein

Background
Global prevalence of chronic kidney disease (CKD) in patients with diabetes is rising over the last two decades. Wild et. al. estimated this increment from 2.8% to 4.4% of total diabetes population by the year 2030 (1). Unfortunately, diabetes and its complications are more endemic in the under-developed and developing countries; the areas where the Muslims are majority, therefore, fasting Ramadan will be an important religious/health issue. 
The patients with diabetes and renal impairment are considered high risk for fasting due to the relative increased risk of hypoglycemia and the possible worsening of renal functions due to prolonged dehydration hours, however, many usually prefer to fast despite advice against it (2,3). There are few studies that assessed the impact of fasting on the kidney function at different stages of renal jeopardy with very variable results (4,5,6). 
 To our best research and knowledge, there is no study available till date that used continuous glucose monitoring in patients with diabetes and renal impairment aiming for objective stratification of hypoglycemia risk in this group of patients. 

Aim of the study
To understand the risk of hypoglycaemia during Ramadan fasting as well as the renal and other metabolic changes after Ramadan in patients with diabetes and chronic kidney disease stage 3. We aimed to conduct this prospective study in a tertiary care hospital in Dubai during Ramadan 2016 that from June 6th till July 5th. 
METHODS
Adult patient aged between 18 to 70 years with type 2 diabetes (T2DM) and stable CKD stage-3 (estimated glomerular filtration rate 30-60 ml/min), who insisted on fasting, were randomly selected from endocrine and nephrology clinic 1 to 2 months before Ramadan, counseled, and asked to sign an informed consent. Patients with any recent hospitalisation or with known cardiovascular disease were excluded. All the patients received a 60 minutes’ session of Ramadan-focused diabetes education. After the education, a Libre free style sensor was inserted for continuous glucose monitoring. Their biophysical and biochemical profile was recorded 2-4 weeks before and after Ramadan. 
We recorded the change in weight, Body mass index, systolic and diastolic blood pressure, HBA1c, lipids profile, renal functions, and frequency and pattern of hypoglycemia during Ramadan fasting and non -fasting period. 

RESULTS and discussion
 Total of 25 patients were recruited. Out of which, one patient did not manage to fast in Ramadan due to ill-health feeling. Another five patients dropped out during the study. 19 patients completed the study, 11 were males, and 8 were females with the mean age of 62 (±14 years). 95% (n=18) of patients fast for more than 15 days and average days of fasting were 27. During Ramadan 42% (n=8) patients experienced symptomatic hypoglycemia, however, none of them reported severe hypoglycemia, emergency room visit or hospitalisation due to any cause during the study period.
Most patients had three sensors during the study, covering an average three weeks during Ramadan and three weeks outside Ramadan (Sha'ban and shawal). The captured data from the sensors showed peak glucose of 333mg/dl during Ramadan and 295mg/dl outside Ramadan while the lowest mean glucose was 70mg/dl (Ranged 40-110) and 94mg/dl (Ranged 43-258) respectively. Total 42 events of hypoglycemic episodes were recorded during the non-Ramadan period with a mean duration of 44 minutes (range 15-120), and that increased to 80 events during fasting with an average length of 100 minutes (range30—500) during Ramadan. The glucose level below 60mg/dl in CGMS was seen in 50% of patients in Ramadan and 45% during non–Ramadan period. This increased frequency and duration of low glucose levels was later reflected as improvement in their HBA1c from 7.9% to 7.6% pre-and post-Ramadan. 
No significant difference was observed in weight, blood pressure and renal functions measured as serum urea, creatinine, e-GFR, electrolytes before and after Ramadan fasting.
Conclusion: This study is unique by providing CGMS with high quality medical care in such a high-risk group of patients. Patients with DM and moderate renal impairment experienced prolonged and more frequent hypoglycemia during Ramadan compared to non- Ramadan period. However, no severe hypoglycemia or hospitalisation or deterioration in renal functions was observed.
To anchor these findings, and to further confirm the risk stratification of diabetes patients during Ramadan; larger multicenter studies are necessary.


References:
1.	Wild S., Roglic G., Green A., Sicree R., King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047–1053. doi: 10.2337/diacare.27.5.1047.
2.	Salti I, Bénard E, Detournay B, Bianchi-Biscay M, Le Brigand C, The EPIDIAR Study Group, et al. A population-based study of diabetes and its characteristics during the fasting month of Ramadan in 13 countries: results of the Epidemiology of Diabetes and Ramadan 1422/2001 (EPIDIAR) study. Diabetes Care. 2004;27:2306–11.
3.	IDF. & DAR International Alliance2016. Diabetes and Ramadan : Practical Guidelines,
4.	Al Wakeel J, Mitwalli AH, Alsuwaida A, Al Ghonaim M, Usama S, Hayat A, et al. Recommendations for fasting in Ramadan for patients on peritoneal dialysis. Perit Dial Int. 33(1):86–91. 
5.	Kara E, Sahin OZ, Kizilkaya B, Ozturk B, Pusuroglu G, Yildirim S, et al. Fasting in Ramadan is not associated with deterioration of chronic kidney disease: A prospective observational study. Saudi J Kidney Dis Transpl. 28(1):68–75. 
6.	NasrAllah MM, Osman NA. Fasting during the month of Ramadan among patients with chronic kidney disease: renal and cardiovascular outcomes. Clin Kidney J. 2014 Aug 1;7(4):348–53.

The impact of ramadan fasting on glycemic control and kidney function in patients with diabetes and chronic CKD stage 3