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

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 <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.