Does Circadian rhythm influence timing of renal colic

Report By: Alexander Stewart - 4th Year Medical Student
Institution: Manchester University
Date Submitted: 11th July 2012
Last Modified: 11th July 2012
Status: Blue (submitted but not checked)

Three Part Question

[in adults] [does Circadian rhythm] [influence timing of renal colic]

Clinical Scenario

After working on the A&E department for 4 months, you are presented with your umpteenth patient with renal colic. You notice that this is the third patient in a row who has presented in the morning and consider if there is a link between the Circadian rhythm and renal stones.

Search Strategy

Ovid MEDLINE 1946 to June week 3 2012
Embase 1974 to 2012 July
Cochrane Database of Systematic Reviews 2005 to June 2012
Pubmed

[exp Circadian Rhythm/] OR [exp Circadian Clocks/] OR [circadian.mp.] AND [exp Kidney Calculi/] OR [exp Ureteral Calculi/] OR [exp Urolithiasis/] OR [exp Nephrolithiasis/]

Search Outcome

108 papers found Medline
116 papers found EMBase
6 relevant papers found, excluding duplicates and poor quality studies; 3 papers used.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Manfredini R, Gallerani M, Cecilia O et al 2002 Italy	All patients with renal colic between 1/1/90 and 31/12/96	Retrospective case series: 3410 colic episodes, of which time of pain starting could be determined in 3360.	If renal colic occurs in a Circadian pattern.	Highly significant Circadian rhythm found (p < 0.001), with morning peak and low in the afternoon.	Retrospective.
Robert M, Roux J, Bourelly F et al 1994 France	Patients with recurring calcium oxalate stones or control patients with no history/xray evidence of stones	Case control study: 50 patients. 25 (50%) with recurrent stones, 25 (50%) no history stones.	Concentrations of urinary lithogenic substances eg Oxalate, calcium, citrate, magnesium and calcium oxalate molar product.	Urine crystallisation potential, and therefore lithogenic risk, is maximum at end of night or during day in both groups.	Small sample size. Supported by weak theories concerning causes of stones.
Vahlensieck E, Bach D, Hesse A 1982 Germany	Patients with calcium oxalate stones vs healthy patients	Case control study: 20 patients (53%) with stones, 18 (47%)	Concentrations of lithogenic substances throughout day.	Evidence of Circadian rhythm in lithogenic substances; maximum in early hours and lowest	Small sample size. Supported by weak theories concerning causes of stones.

Comment(s)

One large retrospective case series indicates a strong link between renal colic/renal stones and Circadian rhythm, with two poor quality studies giving weak supportive evidence that substances linked to the creation of renal stones follow Circadian rhythms. Further large scale retrospective analyses would shed more light on the subject.

Clinical Bottom Line

Renal calculi, and therefore colic, are slightly more likely to present in the morning than at any other time of day.

References

Manfredini R, Gallerani M, Cecilia O et al. Circadian pattern in occurrence of renal colic in an emergency department: analysis of patients' notes. BMJ 2002; 324(7340):767
Robert M, Roux J, Bourelly F et al. Circadian variations in the risk of urinary calcium oxalate stone formation. Br J Urol 1994; 74(3):294-7
Vahlensieck E, Bach D, Hesse A. Circadian rhythm of lithogenic substances in the urine. Urol Res 1982; 10(4):195-203