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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 371-376
Seasonal variation in the incidence of acute renal colic

1 Division of Urology, King Abdulaziz Medical City; Department of Surgery, College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
2 Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia

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Date of Web Publication11-Jan-2022


Urolithiasis is a prevalent medical disease affecting the general population. Many epidemiological studies reported an association between a geographic area with a high mean daily temperature and urolithiasis disease. However, it is unclear if the seasonal variation in a high temperature geographical area will affect the acute presentation of renal colic to the emergency department. The aim of this study was to identify the effect of the seasonal variation on the presentation with acute urolithiasis disease. The design was a retrospective chart review, using the database in King Abdulaziz Medical City that was retrieved by the data management office in King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia. The study period was from January 26, 2016, to the end of December 2019. All patients who presented with renal colic, and diagnosed with urolithiasis using a noncontrast-enhanced computed tomography scan, have been included. A total of 1057 patients were included in this study. The majority (71.24%, n = 753) were male, and the mean age was 42.33 ± 16.12 years. The highest proportion presented in summer (31.22%), followed by spring (26.87%), fall (24.12%), and winter (17.79%). The majority of the sample (84.77%) presented with ureteral stones, and 15.23%with kidney stones. Most of the sample (78.33%) had no history of previous stone formation, with 21.67% being current stone former. The acute presentation with urolithiasis is higher during summer, followed by spring, fall, and winter. A public educational program is highly recommended to increase awareness about stone formation and the appropriate avoidance methods. To this end, additional research is required to understand the stone composition and appropriate methods to avoid developing urolithiasis.

How to cite this article:
Alkhayal A, Alfraidi O, Almudlaj T, Nazer A, Albogami N, Alrabeeah K, Alathel A. Seasonal variation in the incidence of acute renal colic. Saudi J Kidney Dis Transpl 2021;32:371-6

How to cite this URL:
Alkhayal A, Alfraidi O, Almudlaj T, Nazer A, Albogami N, Alrabeeah K, Alathel A. Seasonal variation in the incidence of acute renal colic. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jul 6];32:371-6. Available from: https://www.sjkdt.org/text.asp?2021/32/2/371/335449

   Introduction Top

Urolithiasis is a prevalent medical disease affecting the general population. The calculi can occur in the kidney, ureter, or bladder, and they vary in shape and size.[1] A study done with stone formers, attending four hospitals in Riyadh, indicated that urolithiasis is a highly prevalent disorder in Saudi Arabia.[1] The presenting complaints of urolithiasis are flank pain, urinary tract infection, and decreased urinary output; however, it may also be asymptomatic.[2] Medical imaging is required to diagnose nephrolithiasis. Using noncontrast computed tomography (NCCT) to identify urolithiasis was first reported in 1995 by Fulgham et al with a sensitivity ranging from 96% to 100% and specificity from 92% to 100%, it has become the standard diagnostic tool to evaluate urolithiasis.[3]

Many studies provided evidence of an association between a high mean daily temperature and urolithiasis disease.[4] However, it is still unclear if the seasonal variation will affect the presentation of urolithiasis disease to the emergency department (ED). The aim of this study is to identify the influence of seasonal variation in the acute presentation with urolithiasis disease at the ED. Data from the ED in King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, have been reviewed retrospectively from January 26, 2016, to the end of December 2019.

   Methods Top

Study design and participants After obtaining Institutional Review Board approval from King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia, the ED data from January 2016 to December 2019 were retrieved by the Data Management Office in KAIMRC. All patients presenting to the ED at KAMC are classified in the system according to their chief complaint, with pre-set codes based on the ICD-10 coding system. These codes are renal stone, renal pelvis stone, right flank pain, left flank pain, and bilateral flank pain. All patients presenting with the identified codes and diagnosed with urolithiasis via NNCT were included in the study.

Each year was divided into four seasons: spring, from March 1 to May 31; summer, from June 1 to August 31; fall (autumn), from September 1 to November 30; and winter from December 1 to February 28.

Data collection and analysis

Patient charts have been reviewed retrospectively as the tool for data collection. Data were entered into an Excel spreadsheet, and analyzed using a statistical program, SAS (version 9.4). The Kruskal–Wallis test was used for continuous variables, and a Chi-square test to identify an association between the categorical variables. All statistical tests were considered significant at P <0.05.

   Results Top

In total, 1057 participants were included in the study. The majority (71.24%, n = 753) were male, and the mean age was 42.33 ± 16.12 years. The majority (94.72%, n = 950) presented in the morning (12 AM–12PM). A small proportion (5.28%, n = 53) presented in the afternoon and during the night [Figure 1].
Figure 1: Presentation of the patient by seasons.

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Presenting to the ED with renal colic was higher during summer and spring compared with the other seasons. The highest proportion (31.22%) presented during the summer and 26.87% during spring. The winter and fall proportions were 17.79% and 24.12% respectively [Figure 2]. The majority of the sample (84.77%) was diagnosed with ureteral stones, and 15.23% with kidney stones [Table 1]. Notably, the majority (78.33%) had no prior history of stone formation, and 21.67% were known stone formers. Gender was significantly associated with the location of the stone (P = 0.001), with males forming more kidney stones (61.8%), ureteropelvic junction (UPJ) stones (70.3%), ureteral stone (78.0%), and ureterovesical junction (UVJ) stones (70.4%) than females. A younger age group (40.67 ± 15.1) was significantly associated with a distal ureteral stone presentation, specifically UVJ stones, while kidney stones affected an older age group (48.04 ± 18.2) (P <0.0001).
Figure 2: Age distribution.

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Table 1: Association between the location of the stone and age.

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   Discussion Top

Upper urinary tract stones in Saudi Arabia are a very prevalent pathology, with a lifetime incidence of 20% and the country has one of the highest incidence rates globally.[1] Multiple factors are associated with contributing to the formation of urolithiasis, including gender, diet, geographical location, and climate condition.[5],[6],[7] Various studies, including regional studies in Saudi Arabia, Iraq, and Iran, reported a positive association between the presentation with urolithiasis and increased mean temperature.[8],[9],[10],[11],[12],[13],[14],[15] Few studies, however, including studies from Kuwait and United Arab Emirates, failed to establish any seasonal correlation.[16],[17],[18],[19] Most of the studies in the region were reported from 1970 to 2000, and there have been no studies establishing an association between seasonal variation and urolithiasis presentation in the Central Region of Saudi Arabia. The Central Region has an average annual humidity of 29% and the temperature reaches 50°C in summer, and as low as 0°C in winter.

The aim of this study was to evaluate the influence of this seasonal variation in the presentation of urolithiasis in one of the largest hospitals in Riyadh, Saudi Arabia. According to the Saudi Arabian General Authority of Meteorology and Environmental Protection, the average annual temperature in Riyadh is 25.4°C and the average seasonal temperature for spring is 25°C, summer: 40°C, fall: 30°C, and winter 20°C. The current study reported a positive correlation of urolithiasis-related ED visits and the mean seasonal temperature. The highest incidence of urolithiasis occurs in summer and spring, with the lowest in winter and fall. The increased incidence of presenting with urolithiasis and increased temperature is well-documented globally. Chen et al investigated the association of urinary stone attacks in 270,302 patients in relation to meteorological data over five years. The authors reported that the ambient temperature was the major sole factor with a positive significant association.[8] They also reported that the urinary stone attacks peaked in July–September. Sirohi et al reported a similar result in New York City and highlighted that temperature and relative humidity have a positive effect on presenting with urolithiasis.[20]

Regarding other meteorological parameters, studies from New Zealand,[11] United States[21],[22] and Iran[23] indicated a significant association between sunlight exposure and the risk of urolithiasis. Other studies suggested a negative association between atmospheric pressure and renal colic.[8],[9],[10],[11],[12],[13]

When interpreting these results, it should be noted that the studies were conducted at different times, with different methodologies and selection criteria. Our study only reported patients with an ICD-10 code related to urolithiasis, which was confirmed by NCCT, the standard diagnostic tool for urolithiasis.[24] The characteristics of urolithiasis were also reported in our study, with 84.77% of the sample presenting with an ureteric stone. A significant association between gender and the location of the stone, with males forming more kidney stones, as well as proximal and distal ureteral stones, compared to females, was also reported.

Another interesting finding is that the majority (94.72%) of the cases presented in the AM time (00:00–12:00). Koopman et al noted that renal colic attacks follow a significant circadian pattern, with a peak in the morning and a nadir in the afternoon. This finding may be explained by hyperconcentrated urine at night, which promotes urinary saturation of stone-forming salts.[25]

The month of Ramadan, based on the Islamic lunar calendar, was in summer during the 4- year period of the study. As Ramadan requires all Muslims to fast (abstain from food and drink) during the daytime (from sunrise to sunset) for the entire month, it may have affected the outcome of the current study by increasing the risk of presenting with urolithiasis. However, multiple studies, including at least two prospective studies, have shown that Ramadan does not independently increase the incidence of urinary tract stones.[13],[15],[26],[27]

   Acknowledgments Top

We want to express our appreciation for the support of KAIMRC during the collection and analysis of the study.

Conflict of interest: None declared.

   References Top

Robertson WG, Hughes H. Epidemiology of urinary stone disease in Saudi Arabia. In: Ryall R, Bais R, Marshall VR, Rofe AM, Smith LH, Walker VR, editors. Urolithiasis 2. Boston, MA: Springer; 1994.  Back to cited text no. 1
Lorenz EC, Lieske JC, Vrtiska TJ, et al. Clinical characteristics of potential kidney donors with asymptomatic kidney stones. Nephrol Dial Transplant 2011;26:2695-700.  Back to cited text no. 2
Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol 2013;189:1203-13.  Back to cited text no. 3
Lee S, Kim MS, Kim JH, et al. Daily mean temperature affects urolithiasis presentation in seoul: A time-series analysis. J Korean Med Sci 2016;31:750-6.  Back to cited text no. 4
Wickham JE, Buck AC. Renal Tract Stone: Metabolic Basis and Clinical Practice. Edinburgh [England]; New York: Churchill Livingstone; 1990.  Back to cited text no. 5
Elliott JP Jr., Gordon JO, Evans JW, Platt L. A stone season. A 10-year retrospective study of 768 surgical stone cases with respect to seasonal variation. J Urol 1975;114:574-7.  Back to cited text no. 6
Borghi L, Guerra A, Meschi T, et al. Relationship between supersaturation and calcium oxalate crystallization in normals and idiopathic calcium oxalate stone formers. Kidney Int 1999;55:1041-50.  Back to cited text no. 7
Chen YK, Lin HC, Chen CS, Yeh SD. Seasonal variations in urinary calculi attacks and their association with climate: A population based study. J Urol 2008;179:564-9.  Back to cited text no. 8
Cervellin G, Comelli I, Comelli D, Meschi T, Lippi G, Borghi L. Mean temperature and humidity variations, along with patient age, predict the number of visits for renal colic in a large urban Emergency Department: Results of a 9-year survey. J Epidemiol Glob Health 2012;2:31-8.  Back to cited text no. 9
Condemi V, Gestro M, Dozio E, et al. Association with meteo-climatological factors and daily emergency visits for renal colic and urinary calculi in Cuneo, Italy. A retrospective observational study, 2007-2010. Int J Biometeorol 2015;59:249-63.  Back to cited text no. 10
Lo SS, Johnston R, Al Sameraaii A, Metcalf PA, Rice ML, Masters JG. Seasonal variation in the acute presentation of urinary calculi over 8 years in Auckland, New Zealand. BJU Int 2010;106:96-101.  Back to cited text no. 11
Park HK, Bae SR, Kim SE, et al. The effect of climate variability on urinary stone attacks: Increased incidence associated with temperature over 18°C: A population-based study. Urolithiasis 2015;43:89-94.  Back to cited text no. 12
Al-Hadramy MS. Seasonal variations of urinary stone colic in Arabia. J Pak Med Assoc 1997;47:281-4.  Back to cited text no. 13
Al-Dabbagh TQ, Fahadi K. Seasonal variations in the incidence of ureteric colic. Br J Urol 1977;49:269-75.  Back to cited text no. 14
Basiri A, Moghaddam SM, Khoddam R, Nejad ST, Hakimi A. Monthly variations of urinary stone colic in Iran and its relationship to the fasting month of Ramadan. J Pak Med Assoc 2004;54:6-8.  Back to cited text no. 15
Hussain F, Billimoria FR, Singh PP. Urolithiasis in northeast Bombay: Seasonal prevalence and chemical composition of stones. Int Urol Nephrol 1990;22:119-24.  Back to cited text no. 16
Baker PW, Coyle P, Bais R, Rofe AM. Influence of season, age, and sex on renal stone formation in South Australia. Med J Aust 1993;159:390-2.  Back to cited text no. 17
El-Reshaid K, Mughal H, Kapoor M. Epidemiological profile, mineral metabolic pattern and crystallographic analysis of urolithiasis in Kuwait. Eur J Epidemiol 1997; 13:229-34.  Back to cited text no. 18
Freeg MA, Sreedharan J, Muttappallymyalil J, et al. A retrospective study of the seasonal pattern of urolithiasis. Saudi J Kidney Dis Transpl 2012;23:1232-7.  Back to cited text no. 19
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Sirohi M, Katz BF, Moreira DM, Dinlenc C. Monthly variations in urolithiasis presentations and their association with meteorologic factors in New York City. J Endourol 2014;28:599- 604.  Back to cited text no. 20
Soucie JM, Coates RJ, McClellan W, Austin H, Thun M. Relation between geographic variability in kidney stones prevalence and risk factors for stones. Am J Epidemiol 1996;143: 487-95.  Back to cited text no. 21
Robertson WG, Peacock M, Marshall RW, Speed R, Nordin BE. Seasonal variations in the composition of urine in relation to calcium stone-formation. Clin Sci Mol Med 1975;49: 597-602.  Back to cited text no. 22
Safarinejad MR. Adult urolithiasis in a population-based study in Iran: Prevalence, incidence, and associated risk factors. Urol Res 2007;35:73-82.  Back to cited text no. 23
Ha M, MacDonald RD. Impact of CT scan in patients with first episode of suspected nephrolithiasis. J Emerg Med 2004;27:225-31.  Back to cited text no. 24
Koopman MG, Koomen GC, Krediet RT, de Moor EA, Hoek FJ, Arisz L. Circadian rhythm of glomerular filtration rate in normal individuals. Clin Sci (Lond) 1989;77:105-11.  Back to cited text no. 25
Bragazzi NL. Ramadan fasting and chronic kidney disease: A systematic review. J Res Med Sci 2014;19:665-76.  Back to cited text no. 26
Cevik Y, Corbacioglu SK, Cikrikci G, Oncul V, Emektar E. The effects of Ramadan fasting on the number of renal colic visits to the emergency department. Pak J Med Sci 2016; 32:18-21.  Back to cited text no. 27

Correspondence Address:
Abdullah Alkhayal
Division of Urology, King Abdulaziz Medical City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.335449

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