title: CKD and the risk of acute, community-acquired infections among older people with diabetes mellitus: a retrospective cohort study using electronic health records.
abstract: BACKGROUND
  Hospital admissions for community-acquired infection are increasing rapidly in the United Kingdom, particularly among older individuals, possibly reflecting an increasing prevalence of comorbid conditions such as chronic kidney disease (CKD). This study describes associations between CKD (excluding patients treated by dialysis or transplantation) and community-acquired infection incidence among older people with diabetes mellitus.
  
  
  METHODS
  Retrospective cohort study using primary care records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics admissions data.
  
  
  METHODS
  191,709 patients 65 years or older with diabetes mellitus and no history of renal replacement therapy, United Kingdom, 1997 to 2011.
  
  
  METHODS
  Estimated glomerular filtration rate (eGFR) and history of proteinuria.
  
  
  RESULTS
  Incidence of community-acquired lower respiratory tract infections (LRTIs, with pneumonia as a subset) and sepsis, diagnosed in primary or secondary care, excluding hospital admissions from time at risk.
  
  
  METHODS
  Poisson regression was used to calculate incidence rate ratios (IRRs) adjusted for age, sex, smoking status, comorbid conditions, and characteristics of diabetes. Estimates for associations of eGFR with infection were adjusted for proteinuria, and vice versa.
  
  
  RESULTS
  Strong graded associations between lower eGFRs and infection were observed. Compared with patients with eGFRs≥60mL/min/1.73m(2), fully adjusted IRRs for pneumonia among those with eGFRs<15, 15 to 29, 30 to 44, and 45 to 59mL/min/1.73m(2) were 3.04 (95% CI, 2.42-3.83), 1.73 (95% CI, 1.57-1.92), 1.19 (95% CI, 1.11-1.28), and 0.95 (95% CI, 0.89-1.01), respectively. Associations between lower eGFRs and sepsis were stronger, with fully adjusted IRRs up to 5.56 (95% CI, 3.90-7.94). Those associations with LRTI were weaker but still clinically relevant at up to 1.47 (95% CI, 1.34-1.62). In fully adjusted models, a history of proteinuria remained an independent marker of increased infection risk for LRTI, pneumonia, and sepsis (IRRs of 1.07 [95% CI, 1.05-1.09], 1.26 [95% CI, 1.19-1.33], and 1.33 [95% CI, 1.20-1.47]).
  
  
  CONCLUSIONS
  Patients without creatinine results were excluded.
  
  
  CONCLUSIONS
  Strategies to prevent infection among people with CKD are needed.
authors: Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom. Electronic address: helen.mcdonald@lshtm.ac.uk.
authors: Helen I
authors: HI
authors: McDonald
authors: Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors: Sara L
authors: SL
authors: Thomas
authors: Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors: Elizabeth R C
authors: ER
authors: Millett
authors: Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors: Dorothea
authors: D
authors: Nitsch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000453:epidemiology; D017714:Community-Acquired Infections / Q000453:epidemiology*; D015897:Comorbidity; D003704:Dementia / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000453:epidemiology*; D057286:Electronic Health Records; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D015994:Incidence; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data; D011014:Pneumonia / Q000453:epidemiology; D011507:Proteinuria / Q000453:epidemiology; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology* / Q000503:physiopathology; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000209:etiology; D012907:Smoking / Q000453:epidemiology; D006113:United Kingdom / Q000453:epidemiology
keywords: Community-acquired infections; aged; decreased renal function; diabetes mellitus; elderly; electronic health records; estimated glomerular filtration rate (eGFR); lower respiratory tract infections (LRTIs); non–dialysis-dependent chronic kidney disease (CKD); pneumonia; proteinuria; sepsis
references: Lancet. 1997 Oct 11;350(9084):1097-9
references: 10213569
references: Diabet Med. 2007 Apr;24(4):364-9
references: 17335468
references: J Public Health (Oxf). 2014 Dec;36(4):684-92
references: 24323951
references: Am J Kidney Dis. 2009 Jul;54(1):24-32
references: 19447535
references: Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266
references: 11904577
references: Am J Kidney Dis. 2011 Jan;57(1 Suppl 1):A8, e1-526
references: 21184928
references: Diabet Med. 2014 May;31(5):606-14
references: 24341529
references: Nephron Clin Pract. 2011;117(3):c213-24
references: 20805694
references: Diabetologia. 2005 Jul;48(7):1288-91
references: 15918016
references: Arch Intern Med. 2008 Nov 24;168(21):2333-9
references: 19029498
references: Emerg Infect Dis. 2008 May;14(5):727-33
references: 18439353
references: JAMA. 2012 May 9;307(18):1941-51
references: 22570462
references: BMJ Open. 2013 Jan 02;3(1):null
references: 23288268
references: Am J Kidney Dis. 2012 Jan;59(1 Suppl 1):A7, e1-420
references: 22177944
references: Nephrol Dial Transplant. 2009 Nov;24(11):3411-9
references: 19535434
references: Ann Intern Med. 2009 May 5;150(9):604-12
references: 19414839
references: Clin Med. 2013 Jun;13(3):233-8
references: 23760694
references: PLoS One. 2013;8(3):e60502
references: 23536910
references: Adv Chronic Kidney Dis. 2006 Jul;13(3):209-14
references: 16815227
references: Diabet Med. 2011 May;28(5):575-82
references: 21480968
references: Br J Gen Pract. 2009 Oct;59(567):e329-38
references: 19843413
references: N Engl J Med. 2009 Jul 23;361(4):368-78
references: 19625717
references: N Engl J Med. 2004 Sep 23;351(13):1296-305
references: 15385656
references: Br J Clin Pharmacol. 2010 Jan;69(1):4-14
references: 20078607
references: Am J Kidney Dis. 2012 Mar;59(3):356-63
references: 21906862
references: Addiction. 2005 Apr;100 Suppl 2:59-69
references: 15755262
references: Nephrol Dial Transplant. 2011 Sep;26(9):2899-906
references: 21273232
references: Nephrol Dial Transplant. 2005 Oct;20(10):2089-96
references: 16030033
references: PLoS One. 2013;8(9):e75131
references: 24040394