Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease

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Abstract

Background

Patients with diabetic mellitus (DM) and chronic kidney disease (CKD) are at an increased risk of urinary tract infection (UTI) due to their altered immunological integrity. These patients are similarly prone to developing frailty, a state of cumulative health deficits involving multiple domains and leading to adverse outcomes. Whether frailty predisposes affected individuals to UTI among patients with DM and CKD remains unclear.

Methods

A population-based cohort of patients with DM and CKD ( n = 79,887) were assembled from the Longitudinal Cohort of Diabetes Patients, with their baseline frailty status measured by a modified FRAIL scale. We analyzed their risk of developing UTI depending on their severity of frailty, after accounting demographic profiles, lifestyle factors, comorbidities, concurrent medications, and major interventions. A secondary analysis focused on the risk of urosepsis related to frailty.

Results

Among all participants, 36.1 %, 50.3 %, 12.8 %, and 0.8 % did not have or had 1, 2, and ≥ 3 FRAIL items, respectively, at baseline. After 3.51 years, 11,175 UTI events occurred. Kaplan-Meier analysis showed that participants with DM, CKD and an increasing number of FRAIL items had successively higher incidence of UTI than those without any FRAIL items (log rank p < 0.001). Cox proportional hazard modeling revealed that after accounting for all confounders, those with more severe frailty exhibited a significantly higher risk of incident UTI (for groups of 1, 2, and ≥ 3 FRAIL items, hazard ratio 1.19, 1.24, and 1.43, respectively; all p < 0.001) than those without. An 11 % risk elevation for UTI could be observed for every FRAIL item increase. Participants with more severe frailty exhibited a trend of having higher risk of urosepsis as well.

Conclusions

Having frailty predicted a higher risk of developing UTI in the future in patients with DM and CKD. It would be prudent to screen for frailty in these patients and provide optimal frailty-directed management to attenuate their risk of UTI and improve their outcomes.

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Most cited references 49

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Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Sylvia Ley, Yan Zheng, Frank Hu (2017)

Globally, the number of people with diabetes mellitus has quadrupled in the past three decades, and diabetes mellitus is the ninth major cause of death. About 1 in 11 adults worldwide now have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Asia is a major area of the rapidly emerging T2DM global epidemic, with China and India the top two epicentres. Although genetic predisposition partly determines individual susceptibility to T2DM, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic; early developmental factors (such as intrauterine exposures) also have a role in susceptibility to T2DM later in life. Many cases of T2DM could be prevented with lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation. Most patients with T2DM have at least one complication, and cardiovascular complications are the leading cause of morbidity and mortality in these patients. This Review provides an updated view of the global epidemiology of T2DM, as well as dietary, lifestyle and other risk factors for T2DM and its complications.

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A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.

John E. Morley, T Malmstrom, D Miller (2012)

To validate the FRAIL scale. Longitudinal study. Community. Representative sample of African Americans age 49 to 65 years at onset of study. The 5-item FRAIL scale (fatigue, resistance, ambulation, illnesses, and loss of weight), at baseline and activities of daily living (ADLs), instrumental activities of daily living (IADLs), mortality, short physical performance battery (SPPB), gait speed, one-leg stand, grip strength and injurious falls at baseline and 9 years. Blood tests for CRP, SIL6R, STNFR1, STNFR2 and 25 (OH) vitamin D at baseline. Cross-sectionally the FRAIL scale correlated significantly with IADL difficulties, SPPB, grip strength and one-leg stand among participants with no baseline ADL difficulties (N=703) and those outcomes plus gait speed in those with no baseline ADL dependencies (N=883). TNFR1 was increased in pre-frail and frail subjects and CRP in some subgroups. Longitudinally (N=423 with no baseline ADL difficulties or N=528 with no baseline ADL dependencies), and adjusted for the baseline value for each outcome, being pre-frail at baseline significantly predicted future ADL difficulties, worse one-leg stand scores, and mortality in both groups, plus IADL difficulties in the dependence-excluded group. Being frail at baseline significantly predicted future ADL difficulties, IADL difficulties, and mortality in both groups, plus worse SPPB in the dependence-excluded group. This study has validated the FRAIL scale in a late middle-aged African American population. This simple 5-question scale is an excellent screening test for clinicians to identify frail persons at risk of developing disability as well as decline in health functioning and mortality.

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Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

E. Dent, J E Morley, A. Cruz-Jentoft … (2019)

Objective The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. Methods These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty. Electronic Supplementary Material Supplementary material is available for this article at 10.1007/s12603-019-1273-z and is accessible for authorized users.

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Author and article information

Contributors

Jenq-Wen Huang: 007378@ntuh.gov.tw

Journal

Journal ID (nlm-ta): BMC Geriatr

Journal ID (iso-abbrev): BMC Geriatr

Title: BMC Geriatrics

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2318

Publication date (Electronic): 7 June 2021

Publication date PMC-release: 7 June 2021

Publication date Collection: 2021

Volume: 21

Electronic Location Identifier: 349

Affiliations

[1 ]GRID grid.412094.a, ISNI 0000 0004 0572 7815, Nephrology division, Department of Internal Medicine, , National Taiwan University Hospital BeiHu Branch, ; Taipei, Taiwan

[2 ]GRID grid.412094.a, ISNI 0000 0004 0572 7815, Geriatric and Community Medicine Research Center, , National Taiwan University Hospital BeiHu Branch, ; Taipei, Taiwan

[3 ]GRID grid.19188.39, ISNI 0000 0004 0546 0241, Graduate Institute of Toxicology, , National Taiwan University College of Medicine, ; Taipei, Taiwan

[4 ]GRID grid.412094.a, ISNI 0000 0004 0572 7815, Nephrology division, Department of Internal Medicine, , National Taiwan University Hospital Yunlin branch, ; Yunlin county, Taiwan

[5 ]GRID grid.19188.39, ISNI 0000 0004 0546 0241, Institute of Epidemiology and Preventive Medicine, College of Public Health, , National Taiwan University, ; Taipei, Taiwan

Article

Publisher ID: 2299

DOI: 10.1186/s12877-021-02299-3

PMC ID: 8186134

PubMed ID: 34098883

SO-VID: 81a79b14-3f9f-4bba-a22c-de04088152c2

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 18 January 2021

Date accepted : 4 May 2021

Funding

Funded by: National Taiwan University Hospital BeiHu Branch

Funded by: FundRef http://dx.doi.org/10.13039/501100004663, Ministry of Science and Technology, Taiwan;

Award ID: MOST 109-2314-B-002-193-MY3

Custom metadata

ScienceOpen disciplines: Geriatric medicine

Keywords: chronic kidney disease,diabetic kidney disease,diabetes mellitus,frail phenotype,frailty,sepsis,urinary tract infection

Data availability:

ScienceOpen disciplines: Geriatric medicine

Keywords: chronic kidney disease, diabetic kidney disease, diabetes mellitus, frail phenotype, frailty, sepsis, urinary tract infection

Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease

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Most cited references 49

Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

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