The Relationship Between Fasting During The Ramadan Month and Acute Renal Colic Admissions Rate to The Emergency Department

Objectives: Dehydration is a risk factor for the development of urinary stones. Ramadan fasting restricts from consuming food and fluids for over 15 hours a day for 28 consecutive days. Our study aim was to assess whether fasting during Ramadan increases the number of Renal Colic (RC) Emergency Department (ED) visits. Methods: We reviewed the medical records of patients who applied to the ED with RC during the Ramadan period between years 2016 to 2018. We divided the population into Muslim and non-Muslim patients and compared them with patients who applied to the ED two weeks before and after the Ramadan period (control). Results: women separately. Conclusion: Fasting during the month of Ramadan causes a statistically significant increase in the rate of visits to the ED due to renal colic. Muslim patients are at increased risk of developing clinically significant stone disease. Those with known stone disease should be informed about the increased risk for renal colic during fasting.


Introduction
Urinary stone disease is a common pathological condition affecting approximately 7-10% of the population [1]. About one third of those diagnosed with nephrolithiasis will have a recurrent symptomatic stone event within 10 years if no preventive measures will be taken [2]. One of the main leading etiologies of urolithiasis is inadequate hydration where low urine volumes increase the solutes concentration and promote urinary stasis, which allows supersaturation, crystallization and stone formation [3]. An acute renal colic event represents obstruction of the urinary tract which is manifested by severe flank pain and tenderness. Once diagnosed the initial management of an obstructing urinary stone is done by pain management, medical expulsive therapy and adequate hydration. If necessary, drainage of the obstructive renal unit can be performed who are fasting during the Ramadan month. During this period, religious Muslims are obligated to abstain from eating and drinking from dawn to dusk (during 12-18 hours) for 28 consecutive days [8,9]. The aim of our study was to assess whether fasting during the Ramadan month increases the incidence and severity of renal colic admissions to the Emergency Department (ED).

Study Design
This is a retrospective case control study carried out by the Emergency and Urology departments at Rambam Health Care Campus, Haifa, Israel between May 2016 to Jan 2019. Our hospital is the only tertiary hospital in the north of Israel and is considered a high-volume urolithiasis referral center. Following approval by the Institutional Research Board (IRB) (RMB-0254-16), data was gathered from computerized medical files using specific ICD-9 discharge codes: Calculus of ureter and Renal Colic.

A.
Acute renal colic event as indicated by the ICD-9 relevant code.

B. Proven ureteral calculus according to Computed
Tomography (CT) scan.

Exclusion criteria
A. Known metabolic stone disease.
C. Second admission to the ED during the Ramadan month because of a renal colic event.
We reviewed the medical records of 1034 renal colic events that occurred during the Ramadan month in 3 consecutive years (2016)(2017)(2018). Out of all these cases, 399 patients met the inclusion criteria. The study examined two populations:

1.
Muslim patients who admitted to the ED with an acute renal colic event during the Ramadan month in these years.

2.
The control population was composed of two subgroups: a. Muslim patients who admitted to the ED with an acute renal colic event during the two weeks before or after the Ramadan month in these years.
b. Non-Muslim patients who admitted to the ED during the study period.

Primary End Point
The incidence of renal colic event with an obstructing ureteral stone during the Ramadan month.

Secondary End Point
The severity of the renal colic event among the two groups.
Severity was measured according to one of the following: renal function deterioration, admission to the urology department and the need for an emergent intervention.

Statistical Analysis
Fisher's Exact test for discrete variables and Mann-Whitney test for ordinal and continuous variables were used for statistical analysis. p<0.05 was considered statistically significant. All statistical analyses were performed using SPSS software (SPSS 25.0; SPSS Inc. Chicago, IL, USA).

ED Visits and Demographics
As described in Table 1  In order to verify the causative relationship between the Ramadan period and the occurrence of stone events a separate analysis of non-Muslim patients who were not subjected to dehydration was also studied. No differences were noted in the admission rate to the ED due to acute renal colic event during the studied periods (48.6% during the Ramadan vs 51.4% in the non-Ramadan periods), this is significantly different from the Muslim population whose rate of admission to the ED during the Ramadan period was 1.79, higher than their rate of admission at the non-Ramadan period (Figure 1).

Renal Colic (RC) is one of the most frequent urologic reasons
for Emergency Department (ED) referral, leading to a major burden on the health care system [1]. The most significant risk factors for urinary stone development include high salt and low fluid intake.
The major finding of the current study is that Ramadan fasting is have demonstrated a linear relationship between the rise in mean daily temperature and the ED visits due to renal colic: every increase in 1°C in the mean preceding week is associated with an increase of 2-4% in ED visits [11][12][13][14]. Our study protocol methodically overcame seasonal temperature changes bias by comparing the fasting population with a control group two weeks before and after Ramadan, logically with almost the same mean temperature. In our study we did not find any significant differences among ED visits during the first or last two weeks of the Ramadan month. However, other studies reported that the increase in RC events is most prominent during the first two weeks [11,15]. is an adaptive response to the fasting stress that results in increase of some regulatory hormones in order to maintain homeostasis: ADH which alters urine output and ACTH that enhances hypercalciuria [16]. One point to consider is that during the Ramadan month, Muslims are exposed to dietary changes as a result of high meat consumption during the post-fasting meals. These changes may also contribute to stone formation by altering the biochemical composition of the urine. Zghal et al. [17] studied 90 patients who were divided into three groups: healthy fasting patients (G1), healthy non-fasting patients (G2), and non-fasting patients with calcium lithiasis (G3). They found that supersaturation of urine with oxalate, uric acid and brushite were increased in healthy fasting individuals, similar to non-fasting stone formers [17].   [11].
Second, the nature of research conducted in Israel known for its diverse population has allowed the appointment of a non-Muslim control population, and increases the reliability of our findings. Which except for one study [11], has not been possible in previous studies [18][19][20][21][22]. Our study carries several limitations.

Conclusion
In the current study we were able to demonstrate that during the month of the Ramadan, the likelihood of Muslim patients to admit to the ED with an acute RC event is nearly two-fold higher than in the non-Ramadan period. Dehydration seems to be the main risk factor for the occurrence of acute RC event during this fasting period. Once a renal colic event occurred there was no difference in severity whether there was prior fasting or not.