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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 215-216

Advising patient on peritoneal dialysis to fast Ramadan using 3As clinical decision support tool

Department of Medicine, Nephrology Unit, College of Medicine, King Saud University, and King Khalid University Hospital, Riyadh, Saudi Arabia

Date of Submission27-Aug-2020
Date of Decision09-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Ahmad Raed Tarakji
P. O. Box 300158, Riyadh, 11372
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_103_20

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How to cite this article:
Tarakji AR. Advising patient on peritoneal dialysis to fast Ramadan using 3As clinical decision support tool. J Nat Sci Med 2021;4:215-6

How to cite this URL:
Tarakji AR. Advising patient on peritoneal dialysis to fast Ramadan using 3As clinical decision support tool. J Nat Sci Med [serial online] 2021 [cited 2021 May 16];4:215-6. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/215/313636

Dear Sir,

Peritoneal dialysis (PD) is a life-saving procedure for patients with end-stage renal disease. In Saudi Arabia, there were 1389 patients on PD in 2017.[1] Fasting the month of Ramadan is one of the religious obligations for Muslim adults.[2],[3] Many PD patients are willing to fast Ramadan, and they seek the advice of their treating nephrologists. The majority of the religious scholars are in favor that PD violates the fasting rules since it involves injection of salts, sugar, and water into the body cavity as similar to eating and drinking during the fasting hours.[3],[4] However, draining PD fluid during fasting hours without installing a new fluid is considered as passing urine and it does not violate the fasting.

It is well known that Ramadan, the ninth month of the lunar Islamic calendar, moves backward every year in the Gregorian calendar (10–12 days) with varying daytime length, especially for the temperate countries (from around 11 h in the winter season to 22 h in the summer season).[5] Two major meals are consumed after complete sunset (Iftar) and before dawn (Sohoor). Dates, fruits, soups, juices, and sweets are common components of traditional Ramadan meals. Some of the social changes that happen in Ramadan are decreasing the number of working hours and the sleeping time shifts as being awake at night, especially in the last ten nights for extra worshiping acts.

Literature search revealed only one small study reporting the experience of one academic center, regarding PD patients fasting Ramadan from Saudi Arabia. They were required to adjust their PD regimen with few complications.[6] Based on this study and my personal experience, this Clinical Decision Support Tool was created to guide the treating nephrologists through a structured approach to reach their decision regarding the fasting recommendations (3As: Assess, Adjust, and Advise) [Figure 1]:
Figure 1: Peritoneal dialysis and fasting ramadan clinical decision support tool

Click here to view

  • Step 1: Assess the medical fitness to fast Ramadan.
  • Step 2: Adjust the PD prescription.
  • Step 3: Advise the PD patient.

Few important points are worth mentioning:

  1. PD with manual exchanges or by cycler can start right after Iftar till before Sohoor.
  2. Praying while sitting in the chair is advisable for the special night prayer (Taraweeh) with its frequent bowing and prostration due to the increased risk of leaks and hernias.
  3. Small frequent meals are advised to accommodate the full abdomen during the night, especially if higher PD fill volume is proposed.
  4. It is advisable to try the adjusted PD prescription while the patient is optionally fasting in the eighth lunar month preceding Ramadan (Shabaan) due to similar daytime length and temperature, besides it is easy to break the fast if needed during the day.
  5. Dietitian guidance is very important to recommend culturally specific Ramadan dishes with appropriate ingredients.
  6. Regarding medication dosing and schedules:

    1. Patients need to watch their blood pressure with the aim to decrease or hold some antihypertensive medications as needed. It is advisable to take their antihypertensive medications 2–3 h after Iftar meal and space them out, including moving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers toward the dawn time.
    2. For diabetic patients, the insulin regimen might need adjustment for the night glucose dwells, especially for continuous ambulatory peritoneal dialysis/intermittent peritoneal dialysis patients. Most patients are advised to decrease the dawn insulin dose by half and adjust the dose incrementally based on daytime glucose readings. GlucoCheck is recommended 6–8 h after the dawn and again 3–4 h before the sunset to avoid hypoglycemia, especially if the abdomen is empty, or icodextrin is used for the day dwell.
    3. Extra care toward avoiding constipation is crucial with appropriate laxatives regimen.
    4. Phosphorus binders are important to be taken with the main meals during the nighttime.

This report presents a practical tool with simple steps for nephrologists to use during their decision-making about recommending and supporting Muslim PD patients for fasting Ramadan. Further reports of experiences from PD centers in different Muslim countries are eagerly needed.


Special thanks to my colleague Dr. Saira Usama for her valuable comments for the early version of this article and to all PD nurses for their special care and support they always provide to our PD patients, especially during Ramadan.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Saudi Center for Organ Transplantation. Statistical Summary; 2017. Available from: http://www.scot.gov.sa/images/Report_En_F_Statistical%20Summary.pdf. [Last accessed on 2020 Aug 18].  Back to cited text no. 1
Alquran Alkareem, Sura Albaqara. Ch. 1. Aya 183-5. Available from: http://quran.ksu.edu.sa/translations. [Last accessed on 2020 Aug 18].  Back to cited text no. 2
Almushaikeeh KA. Aljamee Le'Ahkam Alsiyam. 1st ed. Riyadh: Alrush Bookstore; 2016.  Back to cited text no. 3
Alkindy AA. Almufatteerat Altibiyah Almua'Asirah (PhD Thesis). Riyadh: Dar Alhaqiqa; 2014.  Back to cited text no. 4
Bello AK, Kurzawa J, Osman MA, Olah ME, Lloyd A, Wiebe N, et al. Impact of Ramadan fasting on kidney function and related outcomes in patients with chronic kidney disease: A systematic review protocol. BMJ Open 2019;9:e022710.  Back to cited text no. 5
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 2013;33:86-91.  Back to cited text no. 6


  [Figure 1]


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