{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T11:23:34Z","timestamp":1787829814426,"version":"build-2784847793"},"reference-count":30,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>Background: Patients with end-stage kidney disease (ESKD) and diabetes undergoing maintenance hemodialysis (HD) may be at increased risk of metabolic disturbances and intradialytic complications during Ramadan fasting. However, evidence regarding the safety of fasting in this population remains limited. This study evaluated the association between Ramadan fasting and intradialytic hypoglycemia and other clinical outcomes. Methods: This multicenter prospective cohort study included 153 patients with ESKD and diabetes undergoing maintenance HD at four centers in Thailand during the pre-Ramadan and Ramadan periods in 2024. Participants were categorized as non-fasting, partial fasting, or full fasting. All underwent HD using glucose-containing dialysate (100 mg\/dL) and received standardized pre-Ramadan medication adjustments, including insulin dose reduction and oral glucose-lowering medication modification. The primary outcome was intradialytic hypoglycemia, defined as a blood glucose level &lt;70 mg\/dL. Secondary outcomes included HD-related complications, blood pressure, interdialytic weight gain (IDWG), dialysis adequacy, and laboratory parameters. Results: Among 153 participants, 73 were non-fasting, 44 were partial fasting, and 36 were full fasting. No intradialytic hypoglycemia occurred in the full- or non-fasting groups, whereas one episode (0.2%) occurred in the partial-fasting group. HD-related complications, blood pressure, IDWG, and dialysis adequacy (Kt\/V) were comparable across groups. Serum potassium and parathyroid hormone levels increased during Ramadan in the full- and non-fasting groups without reported clinical events. Overall, participants remained clinically stable under the standardized protocol. Conclusions: In this cohort, Ramadan fasting was not associated with an observed increase in major intradialytic hypoglycemic events and hemodialysis-related complications, indicating that the practice is clinically feasible and well-tolerated under strictly supervised protocols. Therefore, fasting may be considered for carefully selected patients with ESKD and diabetes receiving maintenance hemodialysis, provided it is accompanied by individualized medication adjustments, meticulous monitoring, and shared decision-making.<\/jats:p>","DOI":"10.3390\/medsci14050522","type":"journal-article","created":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T10:58:21Z","timestamp":1787828301000},"page":"522","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of Ramadan Fasting on Intradialytic Hypoglycemia and Clinical Outcomes in Patients with Diabetes on Maintenance Hemodialysis: A Multicenter Prospective Cohort Study in Southern Thailand"],"prefix":"10.3390","volume":"14","author":[{"given":"Ashari","family":"Saman","sequence":"first","affiliation":[{"name":"Department of Medicine, Pattani Hospital, Pattani 94000, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8977-2995","authenticated-orcid":false,"given":"Jayanton","family":"Patumanond","sequence":"additional","affiliation":[{"name":"Division of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Naresuan University, Phitsanulok 65000, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3264-1155","authenticated-orcid":false,"given":"Moragot","family":"Chatatikun","sequence":"additional","affiliation":[{"name":"Department of Medical Technology, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8422-2644","authenticated-orcid":false,"given":"Atthaphong","family":"Phongphithakchai","sequence":"additional","affiliation":[{"name":"Nephrology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla 90110, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1524","DOI":"10.1093\/ckj\/sfab032","article-title":"Effects of fasting on patients with chronic kidney disease during Ramadan and practical guidance for healthcare professionals","volume":"14","author":"Malik","year":"2021","journal-title":"Clin. Kidney J."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Boobes, Y., Afandi, B., AlKindi, F., Tarakji, A., Al Ghamdi, S.M., Alrukhaimi, M., Hassanein, M., AlSahow, A., Said, R., and Alsaid, J. (2024). Consensus recommendations on fasting during Ramadan for patients with kidney disease: Review of available evidence and a call for action (RaK Initiative). BMC Nephrol., 25.","DOI":"10.1186\/s12882-024-03516-y"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2042018819889019","DOI":"10.1177\/2042018819889019","article-title":"Fasting during Ramadan in people with chronic kidney disease: A review of the literature","volume":"10","author":"Ahmad","year":"2019","journal-title":"Ther. Adv. Endocrinol. Metab."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e001248","DOI":"10.1136\/bmjdrc-2020-001248","article-title":"Recommendations for management of diabetes during Ramadan: Update 2020, applying the principles of the ADA\/EASD consensus","volume":"8","author":"Ibrahim","year":"2020","journal-title":"BMJ Open Diabetes Res. Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"506","DOI":"10.47391\/JPMA.25-21","article-title":"Optimizing kidney disease management during Ramadan: Evidence-based risk stratification and tailored strategies","volume":"75","author":"Sharma","year":"2025","journal-title":"J. Pak. Med. Assoc."},{"key":"ref_6","first-page":"189","article-title":"Mortality trend among hemodialysis patients during the Islamic month of Ramadan: A 24 years retrospective study","volume":"25","author":"Imtiaz","year":"2015","journal-title":"J. Coll. Physicians Surg. Pak."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Wan Md Adnan, W.A.H., Zaharan, N.L., Wong, M.H., and Lim, S.K. (2014). The effects of intermittent fasting during the month of Ramadan in chronic haemodialysis patients in a tropical climate country. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0114262"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"339","DOI":"10.4103\/1319-2442.256841","article-title":"Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study","volume":"30","author":"Megahed","year":"2019","journal-title":"Saudi J. Kidney Dis. Transplant."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Khazneh, E., Qaddumi, J., Hamdan, Z., Qudaimat, F., Sbitany, A., Jebrin, K., Sawalmeh, O., Abuiram, Y., and Shraim, M. (2019). The effects of Ramadan fasting on clinical and biochemical markers among hemodialysis patients: A prospective cohort study. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0218745"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1111\/hdi.12369","article-title":"Changes in biochemical, hemodynamic, and dialysis adherence parameters in hemodialysis patients during Ramadan","volume":"20","author":"Alshamsi","year":"2016","journal-title":"Hemodial. Int."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"176","DOI":"10.4103\/1947-489X.210236","article-title":"Glucose homeostasis during Ramadan fasting: First case series illustrated by flash glucose monitoring and ambulatory glucose profiling","volume":"8","author":"Beshyah","year":"2016","journal-title":"Ibnosina J. Med. Biomed. Sci."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1177\/1932296817747620","article-title":"Hypoglycemia in hospitalized hemodialysis patients with diabetes: An observational study","volume":"12","author":"Gianchandani","year":"2018","journal-title":"J. Diabetes Sci. Technol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1647","DOI":"10.2337\/dc21-0269","article-title":"Hemodialysis-related glycemic disarray proven by continuous glucose monitoring; glycemic markers and hypoglycemia","volume":"44","author":"Hayashi","year":"2021","journal-title":"Diabetes Care"},{"key":"ref_14","first-page":"1541","article-title":"Blood glucose fluctuations in diabetic and non diabetic hemodialysis patients","volume":"3","author":"Sakla","year":"2015","journal-title":"Int. J. Adv. Res."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"National Kidney Foundation (2005). K\/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am. J. Kidney Dis., 45, 16\u2013153.","DOI":"10.1053\/j.ajkd.2005.01.019"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e112","DOI":"10.1161\/HYP.0000000000000230","article-title":"Hypertension in patients treated with in-center maintenance hemodialysis: A scientific statement from the American Heart Association","volume":"80","author":"Bansal","year":"2023","journal-title":"Hypertension"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"(2024). Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int., 105, S117\u2013S314.","DOI":"10.1016\/j.kint.2023.10.018"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"(2017). Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease\u2013Mineral and Bone Disorder (CKD-MBD). Kidney Int. Suppl., 7, 1\u201359.","DOI":"10.1016\/j.kisu.2017.04.001"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1053\/j.ajkd.2020.05.006","article-title":"KDOQI clinical practice guideline for nutrition in CKD: 2020 update","volume":"76","author":"Ikizler","year":"2020","journal-title":"Am. J. Kidney Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e15","DOI":"10.1053\/j.jrn.2019.06.003","article-title":"Investigating physical and nutritional changes during prolonged intermittent fasting in hemodialysis patients","volume":"30","author":"Adanan","year":"2020","journal-title":"J. Ren. Nutr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1186\/s43162-022-00150-8","article-title":"Ramadan fasting in hemodialysis population: Single-center study","volume":"34","author":"Emara","year":"2022","journal-title":"Egypt J. Intern Med."},{"key":"ref_22","first-page":"75","article-title":"Clinical and biochemical parameters of hemodialysis patients before and during Islamic month of Ramadan","volume":"10","author":"Imtiaz","year":"2016","journal-title":"Iran. J. Kidney Dis."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Tashkandi, B., Kaur, D., Latifi, E., Tallman, D.A., Chinna, K., Daud, Z.A.M., Karupaiah, T., Alhozali, H., and Khosla, P. (2019). Lipids, lipoprotein distribution and nutritional parameters over the Ramadan period in hemodialysis patients. Nutrients, 11.","DOI":"10.3390\/nu11092225"},{"key":"ref_24","first-page":"131","article-title":"Clinical and biochemical parameters among hemodialysis patients before and during the month of Ramadan","volume":"6","author":"Qureshi","year":"2025","journal-title":"Pak. J. Health Sci."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Adanan, N.I.H., Adnan, W.A.H.W.M., Khosla, P., Karupaiah, T., and Daud, Z.A.M. (2021). Exploring the experiences and perceptions of haemodialysis patients observing Ramadan fasting: A qualitative study. BMC Nephrol., 22.","DOI":"10.1186\/s12882-021-02255-8"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1177\/2374373519831706","article-title":"Relation between health-care medical provider opinion and hemodialysis patient attitude toward fasting in Ramadan","volume":"7","author":"Elsawaf","year":"2020","journal-title":"J. Patient Exp."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"86","DOI":"10.3747\/pdi.2010.00095","article-title":"Recommendations for fasting in Ramadan for patients on peritoneal dialysis","volume":"33","author":"Wakeel","year":"2013","journal-title":"Perit. Dial. Int."},{"key":"ref_28","first-page":"665","article-title":"Ramadan fasting and chronic kidney disease: A systematic review","volume":"19","author":"Bragazzi","year":"2014","journal-title":"J. Res. Med. Sci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e201023222409","DOI":"10.2174\/0115733998249793231005105724","article-title":"Risk stratification in people with diabetes for fasting during Ramadan","volume":"20","author":"Shaltout","year":"2024","journal-title":"Curr. Diabetes Rev."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1055\/s-0045-1809319","article-title":"Diabetes and Ramadan fasting (2024): A thematic overview","volume":"8","author":"Beshyah","year":"2025","journal-title":"J. Diabetes Endocr. Pract."}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/5\/522\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T11:12:15Z","timestamp":1787829135000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/5\/522"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,27]]},"references-count":30,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["medsci14050522"],"URL":"https:\/\/doi.org\/10.3390\/medsci14050522","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,27]]}}}