Effects of Diabetes Mellitus and HbA1c on Treatment Prognosis in Uncomplicated Acute Pyelonephritis

Min Ho Bae; Chang Hoo Park; oung Sam Cho; Kwan Joong Joo; Chil Hun Kwon; Heung Jae Park

doi:10.14777/kjutii.2015.10.1.41

Journal List > Korean J Urogenit Tract Infect Inflamm > v.10(1) > 1059909

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Bae, Park, Cho, Joo, Kwon, and Park: Effects of Diabetes Mellitus and HbA1c on Treatment Prognosis in Uncomplicated Acute Pyelonephritis

Original Article

Korean J Urogenit Tract Infect Inflamm 2015;10(1):41-48.

Published online: 17 April 2015

DOI: https://doi.org/10.14777/kjutii.2015.10.1.41

Effects of Diabetes Mellitus and HbA1c on Treatment Prognosis in Uncomplicated Acute Pyelonephritis

Min Ho Bae, Chang Hoo Park, oung Sam Cho, Kwan Joong Joo, Chil Hun Kwon, Heung Jae Park

Department of Urology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Heung Jae Park, http://orcid.org/0000-0003-4000-2636, Department of Urology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 110-746, Korea Tel: +82-2-2001-2237, Fax: +82-2-2001-2247 E-mail: tigerhj@dreamwiz.com

Received 18 April 2015 Revised 23 April 2015 Accepted 24 April 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

We investigated potential difference in the clinical features of hospitalized female acute pyelonephritis (APN) patients with and without diabetes mellitus (DM). The additional purpose of the study was to determine whether HbA1c has a role in predicting clinical outcome in terms of morbidity compared with those considered to have normal glycemic control in female APN patients with DM.

Materials and Methods

Among the female patients who received inpatients care due to APN from January 2011 to December 2013, 282 patients (86 with DM and 196 without DM) were selected and their medical records were analyzed. Laboratory results (white blood cell, blood urea nitrogen, serum creatinine, fasting plasma glucose, HbA1c) were dichotomized. Primary outcomes for comparison between the groups of patients with or without DM were early clinical response rate and length of in-hospital stay. Subgroup analysis was also performed in DM patients according to HbA1c status (<6.5%, ≥6.5%).

Results

In multivariate logistic regression analysis, DM was not found to show independent association with poor early clinical response or longer hospital stay. HbA1c was the common risk factor of poor early clinical response (odds ratio [OR] 4.88, 95% confidence interval [CI] 1.61-14.8) and longer hospital stay (OR 4.20 95% CI 1.52-11.60) in APN patients with DM.

Conclusions

Strict glucose control may be more important prognostic factor than presence or absence of DM in APN patients. As a marker of prolonged hospitalization and poor early clinical response, HbA1c can complement the present clinical and laboratory parameters used as guide in the proper treatment of DM patients with APN.

Keywords: Pyelonephritis, Diabetes mellitus, Hemoglobin A, glycosylated, Prognosis

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Table 1.

Demographic and clinical characteristics in all APN patients

Characteristic	Without DM (n=196)	With DM (n=86)	p-value
Age (y)	39.5±13.5	56.6±14.2	<0.01
Older age (≥65 y)	11 (5.6)	34 (39.5)	<0.01
Recurrent APN	23 (11.7)	24 (27.9)	<0.01
WBC (/mm³)	9,678.2±4,075.4	11,560.8±3,257.4	<0.01
BUN (mg/dl)	11.4±4.0	18.6±8.0	<0.01
Serum creatinine (mg/dl)	0.9±0.2	1.1±0.2	<0.01
FPG (mg/dl)	104.2±17.4	161.0±68.6	<0.01
WBC >12,000/mm³	56 (28.6)	35 (40.7)	>0.05
BUN >20.0 mg/dl	8 (4.1)	24 (27.9)	<0.01
Creatinine >1.2 mg/dl	7 (3.6)	37 (43.0)	<0.01
FPG >125 mg/dl	7 (3.6)	43 (50.0)	<0.01
Bacteremia(+)	19 (9.7)	28 (32.6)	<0.01
Urine culture(+)	119 (60.7)	63 (73.3)	0.04
Abnormal findings on kidney US	97 (49.5)	47 (54.7)	0.44
Fever duration (d)	2.0±1.6	2.7±1.4	<0.01
In-hospital duration (d)	6.3±1.7	7.4±2.3	<0.01
Early clinical response	137 (69.9)	49 (57.0)	0.04
Longer hospital stay	66 (33.7)	40 (46.5)	<0.01

Values are presented as mean±standard deviation or number (%). APN: acute pyelonephritis, DM: diabetes mellitus, WBC: white blood cell, BUN: blood urea nitrogen, FPG: fasting plasma glucose, US: ultrasonography.

Table 2.

Microorganisms from urine cultures of APN patients

Microorganism	Urine culture(+) in non-DM (119/196)	Urine culture(+) in DM (63/86)
Escherichia coli	108 (90.8)	58 (92.1)
Enterococcus faecium Enterococcus faecalis	2 (1.7) 1 (0.8)	1 (1.6) 2 (3.2)
Klebsiella pneumoniae	1 (0.8)	-
Streptococcus agalactiae	3 (2.5)	-
Streptococcus salivarius	1 (0.8)	-
Staphylococcus saprophyticus	3 (2.5)	-
Proteus mirabilis	-	2 (3.2)

Values are presented as number (%). APN: acute pyelonephritis, DM: diabetes mellitus.

Table 3.

Risk factors for poor early clinical response in APN

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Age (≥65 y)	1.89 (0.99-3.60)	>0.05	-	-
Recurrent APN	0.61 (0.30-1.25)	0.18	-	-
DM	1.75 (1.03-2.96)	0.03	0.69 (0.33-1.46)	0.34
FPG >125 mg/dl	3.07 (1.64-5.74)	<0.01	2.01 (0.85-4.73)	0.11
BUN >20.0 mg/dl	2.45 (1.16-5.16)	<0.05	1.02 (0.37-2.78)	0.96
Creatinine >1.2 mg/dl	3.46 (1.78-6.72)	<0.01	2.57 (1.04-6.34)	0.03
Bacteremia(+)	2.91 (1.54-5.53)	<0.01	1.89 (0.92-3.88)	0.08
Urine culture(+)	1.91 (1.11-3.29)	<0.05	1.51 (0.84-2.69)	0.16

APN: acute pyelonephritis, OR: odds ratio, CI: confidence interval, DM: diabetes mellitus, FPG: fasting plasma glucose, BUN: blood urea nitrogen

Table 4.

Risk factors for longer hospital stay in APN

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Age (≥65 y)	3.76 (1.93-7.34)	<0.01	2.80 (1.26-6.24)	<0.05
Recurrent APN	0.93 (0.48-1.78)	0.82	-	-
DM	1.71 (1.02-2.87)	<0.05	0.77 (0.37-1.59)	0.48
FPG >125 mg/dl	3.07 (1.64-5.77)	<0.01	2.11 (0.91-4.89)	0.08
BUN >20.0 mg/dl	2.05 (0.97-4.30)	>0.05	-	-
Creatinine >1.2 mg/dl	2.04 (1.06-3.91)	0.03	0.84 (0.38-2.17)	0.84
Bacteremia(+)	2.16 (1.14-4.06)	0.01	1.26 (0.61-2.60)	0.53
Urine culture(+)	2.40 (1.40-4.12)	<0.01	2.02 (1.14-3.57)	<0.05

APN: acute pyelonephritis, OR: odds ratio, CI: confidence interval, DM: diabetes mellitus, FPG: fasting plasma glucose, BUN: blood urea nitrogen.

Table 5.

Clinical characteristics in APN patients with DM

Characteristic	Normal HbA1c (n=49)	Abnormal HbA1c (n=37)	p-value
Age (y)	55.6±14.6	57.9±13.7	0.31
Recurrent APN	13 (26.5)	11 (29.7)	0.81
HbA1c (%)	5.7±0.3	7.8±1.3	<0.01
WBC >12,000/mm³	15 (30.6)	20 (54.1)	<0.05
Creatinine >1.2 mg/dl	16 (32.7)	21 (56.8)	<0.05
FPG >125 mg/dl	19 (38.8)	24 (64.9)	<0.05
Bacteremia(+)	9 (18.4)	19 (51.4)	<0.01
Urine culture(+)	32 (65.3)	31 (83.8)	0.08
Abnormal findings on kidney US	25 (51.0)	22 (59.5)	0.51
Fever duration (d)	2.2±0.9	3.3±1.8	<0.01
In-hospital duration (d)	6.6±1.5	8.4±2.7	<0.01
Early clinical response	38 (77.6)	11 (29.7)	<0.01
Longer hospital stay	14 (28.6)	26 (70.3)	<0.01

Values are presented as mean±standard deviation or number (%). APN: acute pyelonephritis, DM: diabetes mellitus, WBC: white blood cell, FPG: fasting plasma glucose, US: ultrasonography.

Table 6.

Risk factors for poor early clinical response in APN patients with DM

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
HbA1c ≥6.5%	8.16 (3.08-21.60)	<0.01	4.88 (1.61-14.80)	<0.01
FPG >125 mg/dl	5.56 (2.17-14.20)	<0.01	2.69 (0.87-8.24)	0.08
WBC >12,000/mm³	2.66 (1.09-6.47)	<0.05	1.93 (0.61-6.11)	0.25
Creatinine >1.2 mg/dl	4.10 (1.65-10.10)	<0.01	2.19 (0.71-6.71)	0.16
Bacteremia(+)	7.87 (2.80-22.00)	<0.01	4.39 (1.25-15.40)	<0.05

APN: acute pyelonephritis, DM: diabetes mellitus, OR: odds ratio, CI: confidence interval, FPG: fasting plasma glucose, WBC: white blood cells.

Table 7.

Risk factors for longer hospital stay in APN patients with DM

Variable	Univariate analysis		Multivariate analysis
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
HbA1c ≥6.5%	5.90 (2.31-15.10)	<0.01	4.20 (1.52-11.60)	<0.01
FPG >125 mg/dl	4.82 (1.93-12.00)	<0.01	3.13 (1.12-8.71)	<0.05
WBC >12,000/mm³	1.39 (0.58-3.31)	0.44	-	-
Creatinine >1.2 mg/dl	1.40 (0.59-3.31)	0.43	-	-
Bacteremia(+)	4.75 (1.77-12.68)	<0.01	2.23 (0.70-7.03)	0.17

APN: acute pyelonephritis, DM: diabetes mellitus, OR: odds ratio, CI: confidence interval, FPG: fasting plasma glucose, WBC: white blood cells.

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