Kidney Stones: A Global Picture of Prevalence,

Incidence, and Associated Risk Factors

Victoriano Romero, MD, Haluk Akpinar, MD, and Dean G Assimos, MD
Additional article information
Abstract
The prevalence and incidence of nephrolithiasis is reported to be increasing across the world Herein,
we review information regarding stone incidence and prevalence from a global perspective A literature
search using !ubMed and "vid was performed to identif# peer$reviewed %ournal articles containing
information on the incidence and prevalence of kidne# stones &e# words used included kidne# stone
prevalence, incidence, and epidemiolog# Data were collected from the identified literature and sorted
b# demographic factors and time period A total of '( articles were identified containing kidne# stone$
related incidence or prevalence data from )* countries+ ,- provided suitable information for review
Data regarding overall prevalence or incidence for more than a single time period were found for '
countries .incidence data for - countries+ prevalence data for ( countries/ These included ( 0uropean
countries .1tal#, German#, 2cotland, 2pain, and 2weden/, 3apan, and the 4nited 2tates The bod# of
evidence suggests that the incidence and prevalence of kidne# stones is increasing globall# These
increases are seen across se5, race, and age 6hanges in dietar# practices ma# be a ke# driving force 1n
addition, global warming ma# influence these trends
Key words: 7ephrolithiasis, &idne# stones, 2tone incidence, 0pidemiolog#
The prevalence and incidence of nephrolithiasis is reported to be increasing across the world This
article reviews information regarding stone incidence and prevalence from a global perspective
Methods
A literature search using !ubMed and "vid was performed to identif# peerreviewed %ournal articles
containing information on the incidence and prevalence of kidne# stones &e# words used included
kidne# stone prevalence incidence, and epidemiolog# Data were collected from the identified literature
and then sorted b# demographic factors and time period
Results
A total of '( articles were identified containing kidne# stone$related incidence or prevalence data from
)* countries+ ,- articles provided suitable information for review Data regarding overall prevalence or
incidence for more than a single time period were found for ' countries .incidence data for - countries+
prevalence data for ( countries/ These included ( 0uropean countries .1tal#, German#, 2cotland, 2pain,
and 2weden/, 3apan, and the 4nited 2tates
Prevalence
1n the 4nited 2tates, overall stone prevalence has doubled since the 89:-;89') time period, and
appears to have stabili<ed since the earl# 89=*s
8;,
"ther countries with documented increases in
prevalence include German#, 2pain, and 1tal#
-;'
Regional reports from Milan, 1tal#, also document an
increased prevalence
=
"nl# 2cotland had a slight decrease in prevalence from ,=,> in 89'' to ,(>
in 89='
9,8*
.Table 8 and Table )/
Table 8
Reported &idne# 2tone !revalence b# 6ountr# and ?ear
Table )
Reported &idne# 2tone 1ncidence b# 6ountr# and ?ear
6ountries or regions reporting prevalence rates for 8 #ear onl# included 1celand+ @uenos Aires,
Argentina+ Thebes, Greece+ 7ortheast Thailand+ 2eoul, &orea+ @alearic 1slands, 2pain+ Hellin, 2pain+
Taiwan, 6hina+ and 0astern Tennessee .Table ,/
-,88;89
Table ,
Reported Regional &idne# 2tone !revalence Rates per 6ountr# and ?ear
1n countries reporting prevalence rates in the 89=*s and 899*s, the nonweighted, average global
prevalence was ,)(> in the 89=*s and (:-> in the 899*s
,;',9,8*
The highest prevalence rates across
all reports were for uranium workers in eastern Tennessee .8=(>/ and adults in 7ortheast Thailand
.8:9>/ .Table ,/
8(,89
Incidence
1n the 4nited 2tates, overall incidence increased during 89'8 to 89'=
8,)*
1n the #ear )***, an
incidence of 888: per 8**,*** was reported for 8=$ to :-$#ear$old emplo#ees covered b# ) large
insurance carriers
)8
This incidence is significantl# higher than those from the aforementioned periods
2tudies performed in Rochester, M7, showed a stead# incidence increase from the 89(*s through 899*,
with a drop somewhat in )***
)),),
1n 3apan, the incidence of nephrolithiasis has doubled over a -*$#ear time period, both in men and
women These increases were most prominent in the last 8* to )* #ears, with rates among men
increasing sharpl# since the 899*s, and rates among women increasing more graduall# since the
89=*s
)-;):
6ountries or regions reporting incidence rates for onl# 8 #ear include 2eoul, &orea, and - 2panish
cities .Granada, Tudela, Marina Alta, 2aragossa/
-,8:
.Table -/
Table -
Reported Regional &idne# 2tone 1ncidence Rates per 6ountr# and ?ear
Se and A!e
1ran, 3apan, and the 4nited 2tates had stone incidence reports stratified b# age
));)-,)'
.Aigures 8;
,
/
1ncidence rates reported b# age group consistentl# show a rise$and$fall pattern as a population ages
Age at peak incidence was similar among these , countriesB Age at peak incidence was similar among
these , countries, ranging from -* to -9 #ears, e5cept for 3apanese women for whom the peak
incidence occurred between ages (* to (9 #ears The actual incidence rate was similar for men age -*
to -9 #ears in the 4nited 2tates and 3apan but lower in 1ran
Aigure 8
)**( 1ran kidne# stone incidence b# age group A rise$and$fall pattern is observed for reported
incidence rates in 1ran during )**( !eak incidence is observed in the -*$ to -9$#ear$old age group
2tone prevalence increased with increasing age in German#, 1celand, 1ran, 1tal#, Greece, Turke#, and
the 4nited 2tates .Aigures -;8*/, although there is a sharp decrease in prevalence in 1talians, age C :*
#ears, living in Milan
),(,',88,8),8-,)'
.Aigure 88/ 1n &orea, prevalence rates decreased as men aged, but
increased in women and peaked at age :* to :9 #ears
8:
.Aigure 8)/ 1n the 4nited 2tates, a stud# during
the 89': through 89=* time period showed that prevalence rates decreased in women over age (9 and
men over age :9, but b# 8998 prevalence rates continued increasing as the population got older among
all age groups
)
.Aigure 8*/
Aigure -
German# kidne# stone prevalence b# age group An increasing prevalence is observed for Germans as
the# age This trend is observed in both 89'9 and )**8
Aigure 8*
42 kidne# stone prevalence b# age group 1n 89'=, prevalence in 42 men and women demonstrates a
rise$and$fall pattern as the population ages, with peak prevalence occurring between age :* and :9
#ears in men, and between age (* and (9 in women 1n 8998, """
Aigure 88
Milan, 1tal#, kidne# stone prevalence b# age group An increasing prevalence is observed with
increasing age among those living in Milan, but a prevalence decrease occurs after age C :* #ears
Aigure 8)
899= &orea kidne# stone prevalence b# age group &orean men demonstrated a decrease in stone
prevalence with increasing age &orean women demonstrated a rise$and$fall pattern, with peak
incidence occurring between age :* and :9 #ears
More men form stones than women The se5 ratios range from )(B8 in 3apan to 88(B8 in 1ran
)',)=

However, there are age ranges in some countries where this ratio is reversed This occurrence was
reported for 8-$ to )-$#ear$olds in German#, )8$ to ,*$#ear$olds in Milan, 1tal#, :*$ to '9$#ear$olds in
&orea, )*$ to )9$#ear$olds in the 4nited 2tates, and , age groups in Greece .age D )*, age ,* to ,9
#ears, and age (* to (9 #ears/
),',=,8-,8:
Although women demonstrated higher prevalence rates in these
instances, the difference between men and women was minimal
Race
Data comparing stone disease differences between races within one countr# were available onl# for the
4nited 2tates
)
!revalence and incidence rates were highest for whites, followed b# Hispanics, blacks,
and Asians .Aigure 8,/ "f interest, stone disease rates have nearl# doubled in 42 blacks in the :*$ to
'-$#ear old age group when comparing the 89': through 89=* and 89== through 899- time periods
.Aigure 8-/ Ehite men have the highest kidne# stone incidence rate whereas Asian women have the
lowest rate .Aigure 8,/ Eithin individual races, men still have a higher disease burden when compared
with women from the same race
Aigure 8,
42 kidne# stone prevalence rates b# race Data for kidne# stone prevalence rates show rates being
lowest in Asian women .A/ and highest in white men .@/ 6!2, 6ancer !revention 2tud#+ 7HA702,
7ational Health and 7utrition 05amination 2urve#
Aigure 8-
42 kidne# stone prevalence b# race and age group An increasing prevalence with increasing age is
observed in 42 white and black men for both reporting periods !revalence has nearl# doubled for
black men in the :*$ to '-$#ear$old age group between the """
Radio!ra#hic Studies
Three studies published between 8998 and )**, e5amined as#mptomatic stone prevalence rates b#
performing ultrasonograph# on randoml# selected sub%ects
)9;,8
The stone rates in as#mptomatic
sub%ects were ,*>, )8>, and )*> in !akistan, Denmark, and 3apan, respectivel#
$iscussion and %onclusions
"ur review demonstrates that there has been an increase in the prevalence and incidence of kidne#
stones in the 4nited 2tates and other parts of the world The cause of these changes is unclear &idne#
stone formation is usuall# due to genetic and environmental factors Although genetic factors influence
stone risk, changes in the gene pool occur at a slow rate Therefore, it is unlikel# to be the driving force
for these trends 0nvironmental factors are also varied and comple5, but their influence is more
apparent as changes in these factors occur over much shorter intervals Ee believe that changes in ) of
the most important environmental factors$diet and climate$have the most significant impact on these
trends
There is historical evidence of the influence of diet on stone formation The first documented increase
in stone disease occurred during the 8:th centur# when 0uropean 2tein$2chneiders .stone cutters/
found that their services were more in demand
,)
During this period, there were improvements in food
production and corn became a popular food staple
,,
The increased consumption of starch# foods
derived from corn promoted obesit#, currentl# a known risk factor for stone formation
,,(,,-
The impact of agricultural moderni<ation remains toda#, and is reflected b# the epidemic in obesit#
seen in man# countries, especiall# the 4nited 2tates The prevalence of obesit# has been tracked in the
4nited 2tates since 89:* "besit# in adults has risen from 8-:> in the 89'8 through 89'- time period
to ,()> in the )**( through )**: time period
,(
Moreover, a similar trend is present for children,
with 88> to 8'=> being in the overweight categor# in the )**( through )**: time period
,(
The
consumption of fast foods and high fructose corn s#rup preparations has been thought to promote this
epidemic 1n the 4nited 2tates alone, the percentage of meals coming from fast$food eateries or
restaurants rose from 9:> to ),(> during the timeframe of 89'' to 899:
,:
These dietar# changes
have also been reported in man# other countries including 6hina, 1ndia, 0g#pt, Russia, and the
!hilippines
,:;,9
High fructose consumption has been demonstrated to be a risk factor for stone
formation
-*
"ther dietar# risk factors for stone formation have been identified There is strong evidence that
diminished fluid and calcium consumption are risk factors
8-,-8;--
1ncreased o5alate consumption has
also been demonstrated to promote stone formation
-(,-:
0pidemiologic studies have demonstrated that
increased sodium and animal protein intake have an eFuivocal impact on stone risk However, a
randomi<ed prospective dietar# intervention stud# demonstrated that reduction of sodium and animal
protein and maintenance of normal dietar# calcium intake attenuates stone activit# in recurrent
h#percalciuric stone formers
-8
There is evidence that the consumption of animal protein has increased
in a number of countries, paralleling the acceleration of stone disease
,:;,9
There are also studies that
demonstrate an increased intake of sodium and sodium$rich foods in certain cohorts
-'
Global climate change is another environmental factor that affects stone disease rates Aor man# #ears
the concept of global warming has been debated, and toda# it is more accepted as a legitimate
phenomenon The general consensus is that average global temperatures have increased
-=
1n addition,
studies have documented the association between increased environmental temperatures and increased
kidne# stone rates
-9
Two recent studies have shown the temporal relationship between e5posure to
high temperatures and the subseFuent development of kidne# stones 0vans and 6ostabile
(*
compared
the time of arrival of 42 soldiers to &uwait and the time to development of acute renal colic at a 42
militar# hospital Doumerc and colleagues
(8
recorded temperature and number of renal colic
admissions at a Arench tertiar# care center between )**) and )**- These ) studies reported time
dela#s between e5posure to higher temperatures and clinical manifestation of s#mptoms of 9, da#s and
) months, respectivel# 1maging studies to identif# stones prior to e5posure to warmer temperatures
were not done in these studies Aurthermore, epidemiologic studies in the 4nited 2tates have shown
that regions with higher average temperatures have the highest stone rates
),,,()
The correlation
between increased environmental temperature and increased number of stone events supports the
conclusion that global warming has an impact on the development of stones This has been recentl#
addressed in a stud# b# @rikowski and associates
-9
The# e5amined how global warming alters
regional distribution of kidne# stones using a modeling techniFue The# predicted that, based on the
effects of global warming, the percentage of people living in areas designated as high risk for kidne#
stone formation would increase from -*> in )*** to (:> b# )*(*, and up to '*> b# )*9( This
would result in a significant Gclimate$relatedH increase in kidne# stone events
"ur review demonstrated that there were decreases in stone prevalence among older age groups This
could be due to differences in sampling methods or sub%ects with stones d#ing at a #ounger age The
latter is certainl# plausible as kidne# stone formation has been linked to a number of medical
comorbidities including obesit#, diabetes mellitus, h#pertension, chronic kidne# disease, and
cardiovascular problems
(,,-,(,;(:
The bod# of evidence suggests that the incidence and prevalence of kidne# stones is increasing
globall# These increases are seen across se5, race, and age 6hanges in dietar# practices ma# be a ke#
driving force 1n addition, global warming ma# influence these trends
"verall stone prevalence has doubled in the 4nited 2tates since the 89:- through 89') time
period, although it appears to have stabili<ed since the earl# 89=*s "ther countries with
documented increases in prevalence include German#, 2pain, and 1tal# "nl# 2cotland had a
slight decrease in prevalence from ,=,> in 89'' to ,(> in 89='
1ran, 3apan, and the 4nited 2tates had stone incidence reports stratified b# age 1ncidence rates
reported b# age group consistentl# show a rise$and$fall pattern as a population ages !eak
incidence was age -* to -9 #ears for all , countries, but for 3apanese women, peak incidence
occurred at age (* to (9 #ears The actual incidence rate was similar for men age -* to -9 #ears
in the 4nited 2tates and 3apan but lower in 1ran
The incidence and prevalence of kidne# stones is increasing globall# and is seen across se5,
race, and age 6hanges in dietar# practices ma# be a ke# driving force influencing these trends
as well as the effects of global warming

Aigure )
3apan kidne# stone incidence b# age group 1ncidence data reported for 3apanese men .A/ and women
.@/ show a consistent rise$and$fall pattern in ever# #ear of reporting Male peak incidence occurs
between ages -* and -9 #ears, whereas female peak incidence """
Aigure ,
89=: 4nited 2tates kidne# stone incidence b# age group A rise$and$fall pattern is observed for reported
incidence rates in the 4nited 2tates during 89=: !eak incidence is observed between ages -( and -9
#ears
Aigure (
899: 1celand kidne# stone prevalence b# age group An increasing prevalence is observed in 1celand as
the population ages This trend is observed in both men and women
Aigure :
)**( 1ran kidne# stone prevalence b# age group !revalence increases with increasing age among
1ranIs population up until age (* to (9 #ears, after which it remains stable
Aigure '
899, 1talian kidne# stone prevalence b# age group An increasing prevalence with increasing age is
observed in 1tal# for both men and women
Aigure =
)**: Thebes, Greece, kidne# stone prevalence b# age group An increasing prevalence is observed with
increasing age among those living in Thebes for both men and women
Aigure 9
89=9 Turke# kidne# stone prevalence b# age group An increasing prevalence of kidne# stones is
observed as the population ages
Article infor&ation
Rev 4rol )*8* 2pring$2ummer+ 8).)$,/B e=:;e9:
!M61DB !M6)9,8)=:
Victoriano Romero, MD, Haluk Akpinar, MD, and Dean G Assimos, MD
Eake Aorest 4niversit# 2chool of Medicine, Einston$2alem, 76
6op#right J )*8* MedReviews, KK6
This article has been cited b# other articles in !M6
Articles from Reviews in 4rolog# are provided here courtes# of MedReviews, ''%
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