Ramadan fasting and adverse outcomes in cirrhosis: primary risk estimates with associated independent predictors

Ramadan fasting is observed annually by millions of Muslims worldwide. Although generally considered safe, its clinical impact on patients with cirrhosis remains insufficiently defined. To evaluate the impact of Ramadan fasting on hospitalization, hypoglycaemia, upper gastrointestinal bleeding, Child-Pugh score, and quality-of-life in patients with cirrhosis. This prospective cohort study was conducted at Cipto-Mangunkusumo Hospital and included adult patients with liver cirrhosis without hepatocellular carcinoma who intended to fast during Ramadan. Patients were evaluated during non-fasting and Ramadan periods for hospitalization, hypoglycaemia, upper gastrointestinal bleeding, Child-Pugh score, and quality of life using the Chronic Liver Disease Questionnaire. Hypoglycaemia was assessed in a subgroup using continuous glucose monitoring. Of 156 participants (35.9% decompensated; 52 with continuous glucose monitoring), Ramadan fasting was associated with higher rates of hospitalization (12.2% vs. 3.2%; p = 0.003), upper gastrointestinal bleeding (10.9% vs. 1.3%; p < 0.001), and hypoglycaemia (13.5% vs. 0%; p = 0.013), but not with deterioration of Child-Pugh category (14.1% vs. 9.0%; p = 0.156) or quality-of-life scores (9.0% vs. 6.4%; p = 0.395). Ramadan fasting in cirrhosis increases the risk of hospitalization, upper gastrointestinal bleeding, and hypoglycaemia. Careful monitoring and individualized fasting guidance are recommended.