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