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. Author manuscript; available in PMC: 2026 Jan 1.
Published in final edited form as: Diabetes Obes Metab. 2024 Sep 30;27(1):40–53. doi: 10.1111/dom.15981

Analyzing the Influence of Dapagliflozin on Urinary Tract Infection Vulnerability and Kidney Injury in Mice Infected with Uropathogenic Escherichia coli

Kristin Salamon 1,*, Sarah Linn-Peirano 1,2,3,*, Aaron Simoni 1, Juan de Dios Ruiz-Rosado 1,4, Brian Becknell 1,4, Preeti John 1, Laura Schwartz 1,4, John David Spencer 1,4
PMCID: PMC11620950  NIHMSID: NIHMS2023494  PMID: 39344841

Abstract

Aim:

Sodium glucose co-transporter-2 (SGLT2) inhibitors have revolutionized clinical medicine, but their association with urinary tract infection (UTI) risk remains debated. This study investigates the influence of dapagliflozin on UTI outcomes, focusing on kidney injury.

Methods:

Female non-diabetic C57BL/6J and C3H/HeOuJ mice, along with diabetic db/db mice, were orally administered dapagliflozin (1 mg/kg or 10 mg/kg) for seven days before transurethral uropathogenic Escherichia coli (UPEC) infection. Mice were sacrificed either twenty-four hours after UTI or after six additional days of dapagliflozin treatment. UPEC titers were enumerated and kidney histopathology, injury, fibrosis, and function were assessed.

Results:

Vehicle and dapagliflozin-treated C57BL/6J mice exhibited similar urine and bladder UPEC titers, with minimal kidney burden twenty-four hours after UTI. In C3H/HeOuJ mice, UPEC burden was comparable in vehicle and 1 mg/kg dapagliflozin-treated groups both twenty-four hours and seven days after UTI. However, C3H/HeOuJ mice receiving 10 mg/kg dapagliflozin had increased UPEC titers in the urine, bladder, and kidneys at both endpoints. Kidney injury and fibrosis markers, as well as kidney function, were similar in vehicle and dapagliflozin groups. In diabetic db/db mice receiving dapagliflozin, UPEC strain UTI89 titers were reduced seven days after UTI compared to vehicle-treated mice, but no difference in UPEC titers were observed when mice were infected with UPEC strain CFT073. Kidney injury and fibrosis markers and kidney function remained similar across treatment groups.

Conclusion:

Dapagliflozin does not consistently influence UTI susceptibility and shows limited impact on kidney injury or fibrosis, suggesting SGLT2 inhibitors have minimal effects on UTI-related kidney complications.

Keywords: Urinary tract infection, pyelonephritis, sodium glucose co-transporter-2 inhibitors, dapagliflozin, histopathology

INTRODUCTION

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have emerged as valuable therapeutic drugs for managing both type 2 diabetes and chronic kidney disease (CKD). These medications work by inhibiting glucose reabsorption in the kidneys, leading to lower blood glucose concentrations and increased glucose excretion in the urine. Beyond their glycemic control benefits in diabetes, SGLT2 inhibitors have shown benefit in slowing the progression of CKD by decreasing renal hyperfiltration, reducing proteinuria, and lowering the risk of adverse cardiovascular events, making them a valuable treatment option for people with diabetes or CKD.1,2

Initial clinical studies suggested that SGLT2 inhibitors increase the frequency of genital and urinary tract infections (UTI).3–6 By promoting glucosuria, SGLT2 inhibitors create a favorable environment for microbial growth. In response, regulatory authorities issued warnings and label changes to acknowledge these drug-related risks.7–11 More recent meta-analyses, large population-based cohort studies, and insurance based-claims data indicate that SGLT2 inhibitors may not increase UTI susceptibility.12–16 These regulatory warnings are noteworthy because UTI are both common and a significant cause of morbidity in individuals with diabetes and CKD.17–20

In the general population, UTI can cause pain and discomfort. If left untreated, UTI can lead to more severe symptoms, especially if bacteria ascend from the bladder into the kidneys and cause pyelonephritis.21 In people with diabetes, UTI are more likely to cause complications such as pyelonephritis, acute kidney injury, or a kidney abscess.22–24 Severe or repeated episodes of pyelonephritis can eventually lead to kidney scarring, contributing to a decline in kidney function. UTI can also be more severe in people with diabetes. Urosepsis is more common and UTI-associated mortality rates are greater.25,26 People with CKD also have increased UTI risk and UTI-associated complications. Urinary stasis, compromised immune responses, and changes in urine composition or tonicity linked to CKD can heighten UTI susceptibility.19,20,27,28 Because millions of people with diabetes and/or CKD receive SGLT2 inhibitor therapy, a deeper appreciation of the relationship between these medications and UTI outcomes is warranted. Recent clinical studies suggest that when individuals receiving SGLT2 inhibitors develop UTI, the infections are often mild-to-moderate and resolve with conventional antibiotic therapy.29

To interrogate this possible connection, we administered the SGLT2 inhibitor, dapagliflozin, to non-diabetic C57BL/6J and C3H/HeOuJ mice as well as diabetic db/db mice via oral gavage. Mice were transurethrally infected with uropathogenic Escherichia coli (UPEC) and bacterial burden, kidney pathology, and markers of kidney injury and function were assessed. We hypothesized that dapagliflozin would uniformly increase UPEC burden, promote kidney pathology, and impair kidney function. However, our results reveal varying patterns of UPEC susceptibility. Dapagliflozin did not heighten UTI susceptibility in C57BL/6J mice. Conversely, C3H/HeOuJ mice exhibited increased UPEC burden when treated with dapagliflozin. Diabetic mice treated with dapagliflozin showed reduced UPEC burden when infected with strain UTI89 but had similar UPEC vulnerability as vehicle-treated mice when infected with UPEC strain CFT073. Importantly, dapagliflozin did not exacerbate kidney injury or worsen kidney function following UTI.

MATERIALS & METHODS

Mice:

Mouse experiments were performed in accordance with Nationwide Children’s Institutional Animal Care and Use Committee rules and regulations. Four- to six-week-old C57BL/6J (strain #000664, Jackson Laboratory, Bar Harbor, ME, USA), C3H/HeOuJ (strain #000635, Jackson), and db/db mice (strain #000642, Jackson) were purchased. Mice were housed in controlled temperature and humidity, with twelve-hour light and dark cycles. Mice were provided unrestricted access to standard rodent chow and water.

Dapagliflozin treatment and glucose measurements:

Mice were administered vehicle (0.5% carboxymethyl cellulose) or dapagliflozin at 1 mg/kg or 10 mg/kg (Cayman Chemical, Ann Arbor, MI, USA) by oral gavage. Dapagliflozin dosing was based on prior publications11,30 Blood glucose concentrations were obtained using the AlphaTrak glucose monitoring system (Abbott Point of Care, Abbott Park, IL, USA). Urinary glucose measurements were assessed by dipstick urinalysis (Chemstrip 2 GP, Roche, Basel, Switzerland). Serum blood urea nitrogen (BUN) concentrations were measured using the Vet Axcel Chemistry Analyzer (Alfa Wassermann Diagnostic Technologies, West Caldwell, NJ, USA) at the Ohio State University College of Veterinary Medicine Comparative Pathology and Mouse Phenotyping Resource.

Experimental UTI:

Female mice aged 6–10 weeks were infected by transurethral catheterization with 107 colony forming units (CFU) UPEC or sham infected with sterile phosphate buffered saline as published.31,32 UPEC is the most common UTI inciting pathogen in people with and without diabetes.33–35 As indicated, mice were infected with either UPEC strain UTI89 or CFT073. UTI89 is a type I-piliated UPEC strain isolated from a person with cystitis while CFT073 was isolated from the blood and urine of a woman with pyelonephritis.36,37 At the indicated time points after inoculation, mice were anesthetized and sacrificed via cervical dislocation. Organs were aseptically harvested and UPEC colonies were enumerated.31,32

Histopathology:

Kidneys were fixed in 4% paraformaldehyde at 4°C at least 48 hours prior to routine processing and sectioning. Four representative 5 μm thick sections were obtained from one kidney and stained with hematoxylin and eosin. Kidney histopathology was scored by a veterinary pathologist as outlined in Table 1 and Supplemental Figure 1.

Table 1.

Kidney histopathological grading scale

Category Definition Score Max Score
Total Kidney
Percentage Affected Percent of the kidney affected with pathology 0 Normal 4
1 <20%
2 20–50%
3 50–75%
4 75–100%
Pelvis and Hilus
Number of urothelial cell layers Maximum number of urothelial cells lining pelvis (1–2 normal) 0 1–2 cell layers 2
1 3 cell layers
2 4+ cell layers
Ballooning Degeneration Urothelial cell cytoplasmic swelling and clearing 0 Absent 1
1 Present
Necrosis/ Apoptosis Urothelial cell necrosis/apoptosis and sloughing into lumen 0 Absent 1
1 Present
Mitoses Within urothelial cells 0 Absent 1
1 Present
Neutrophil Transmigration Migration through the urothelium 0 Absent 1
1 Present
Inflammatory Localization Location of leukocytes, mostly neutrophils but can be lymphocytes and plasma cells (Sum of each location – within pelvic lumen or hilar adipose) 0 Absent 2
1 Present
Bacteria Bacteria within lumen and/or attached to urothelium 0 Absent 1
1 Present
Intracellular Bacterial Communities Bacteria within urothelium forming discrete colonies 0 Absent 1
1 Present
Pelvic Inflammation Inflammatory cells present in the suburothelial pelvis - neutrophils, lymphocytes, and/or macrophages 0 Absent 4
1 Rare
2 Small clusters of leukocytes
3 Regions of leukocytes up to 3 cell layers thick
4 Regions of leukocytes more than 3 cell layers thick
Pelvic Edema Increased separation of lamina propria 0 Absent 1
1 Present
Pelvic Fibrosis Increased fibroblasts and/or increased collagen deposition 0 Absent 1
1 Present
Papilla
Papilla Inflammatory localization Location of leukocytes, mostly neutrophils but can be lymphocytes and plasma cells (Sum of each location - intratubular/intraductal or interstitial) 0 Absent 2
1 Present
Papilla Bacteria Bacilli noted within tubules 0 Absent 1
1 Present
Papilla Tubular Necrosis Necrosis of tubular epithelium with or without attenuation 0 Absent 1
1 Present
Papilla Mineralization Mineral deposition within tubules or interstitium 0 Absent 1
1 Present
Medulla and Cortex
Medulla and Cortex Inflammatory Localization Location of leukocytes - mostly neutrophils, but can be lymphocytes and plasma cells (Sum of each location - intratubular/intraductal or interstitial; inner medulla or outer medulla or cortex or all 3) 0 Absent 6
1 Present
Medulla & Cortex Bacteria Bacteria noted within tubules 0 Absent 1
1 Present
Medulla & Cortex Tubular Necrosis Necrosis of tubular epithelium with or without attenuation 0 Absent 1
1 Present
Medulla & Cortex Mineralization Mineral deposition within tubules or interstitium 0 Absent 1
1 Present
Medulla & Cortex Fibrosis Interstitial fibrosis 0 Absent 1
1 Present
Lymphoid Nodule Formation Clusters of lymphocytes within the interstitium 0 Absent 1
1 Present
Abscess/ Microabscess Formation Collection of degenerate neutrophils and cellular debris (+/− bacteria) surrounded by nondegenerate/degenerate neutrophils and fibrous connective tissue 0 Absent 1
1 Present
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RNA isolation and real-time PCR:

Kidney RNA was isolated using the RNeasy Plus Mini Kit (Qiagen, Hilden, Germany) and cDNA was generated using the Verso cDNA synthesis kit (Thermo-Fisher, Waltham, MA, USA). Quantitative RT-PCR reactions were performed with the 7500 Real-Time PCR System as previously described (Applied Biosystems, Carlsbad, CA, USA).38 Each reaction included cDNA, Absolute Blue QPCR SYBR Mix (Thermo-Fisher), and the following target specific primers: fibronectin 1 (Fn1) forward 5’-ATGTGGACCCCTCCTGATAGT-3’ and reverse 5’-GCCCAGTGATTTCAGCAAAGG-3’; hepatitis A virus cellular receptor 1 (Havcr1) forward 5’-CTATGTTGGCATCTGCATCG-3’ and reverse 5’-AAGGCAACCACGCTTAGAGA-3’; lipocalin-2 (Lcn2) forward 5’-CCCATCTCTGCTCACTGTCC-3’ and reverse 5’-TACCTGAGGATACCTGTGCAT-3’; transforming growth factor beta 1 (Tgfb1) forward 5’-GCAACAATTCCTGGCGTTACC-3’ and reverse 5’-CGAAAGCCCTGTATTCCGTCT-3’; and glyceraldehyde-3-phosphate dehydrogenase (Gapdh) forward 5’- CTGGAGAAACCTGCCAAGTA-3’ and reverse 5’-TGTTGCTGTAGCCGTATTCA-3.’

Enzyme Linked Immunosorbent Assay (ELISA):

Commercial ELISA assays quantified kidney injury and fibrosis markers including kidney injury molecule-1 (Kim-1, Abcam, catalog number ab213477, Cambridge, United Kingdom), lipocalin 2 (Lcn 2, Abcam, catalog number ab199083), fibronectin (Lifespan Biosciences, catalog number LS-F3999–1, Lynnwood, WA, USA), and transforming growth factor beta (TGFβ, Abcam, catalog number ab119557). Kidney cytokines, including granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon gamma (IFN-γ), interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-10, and tumor necrosis factor alpha (TNFα) were measured using a mouse cytokine 8-plex immunoassay (Bio-Rad Laboratories, catalog number M60000007A, Hercules, CA, USA). Kidney homogenates (0.3 μg) were diluted 1:100 for the Kim-1 assay, 1:10,000 for the Lcn 2 and fibronectin assays, 1:40 TGFβ assay, and 1:40 for the mouse cytokine platform. Values were normalized to kidney protein input concentrations. ELISA assays were performed following the manufacturer’s instructions.

Statistics:

Continuous differences between groups were evaluated for a normal distribution with the D’Agostino-Pearson Omnibus test. Significant differences between 2 groups were evaluated using the Student’s t-test or Mann-Whitney test for parametric and nonparametric data, respectively. Differences between >2 groups were evaluated using one-way ANOVA or Kruskal-Wallis test for parametric and nonparametric data, respectively. Analyses were performed and figures were generated using GraphPad Prism software (Boston, MA, USA). Data with P-values less than 0.05 were considered statistically significant.

RESULTS

C3H/HeOuJ mice demonstrate greater susceptibility to UPEC compared to C57BL/6J mice.

Because different mouse strains can demonstrate varying susceptibility patterns to UPEC, we assessed UPEC burden and kidney histopathology in non-diabetic C57BL/6J and C3H/HeOuJ mice. Female mice were transurethrally infected with UPEC and urine, bladder, and kidney bacterial titers were enumerated twenty-four hours and seven days after infection. To quantify how UPEC infection impacts kidney histopathology, kidney inflammation and injury was quantified using the histopathologic features defined in Table 1. Representative images highlighting key histopathologic features and their associated scores are shown in Supplemental Figure 1.

Compared to C57BL/6J mice, C3H/HeOuJ mice showed heightened UPEC susceptibility, evidenced by higher urine and bladder UPEC titers twenty-four hours and seven days after infection. In the kidneys, UPEC were not routinely detected in C57BL/6J mice but were routinely enumerated in C3H/HeOuJ mice (Figure 1A/B). Similarly, the kidneys from C57BL/6J mice exhibited minimal pathology while the kidneys from C3H/HeOuJ mice had higher and persistent histopathology scores (Figure 1C). Within C3H/HeOuJ kidneys, there was mild to moderate neutrophilic to suppurative inflammation centered on the renal urothelium that extended into the renal pelvis (pyelitis) and distal papilla twenty-four hours post infection (Figure 1D). Seven days post infection, there was a persistent suppurative pyelitis with moderate to marked neutrophilic and lymphoplasmacytic inflammation expanding into the pelvic lamina propria (Figure 1D). Occasionally, neutrophils extended into the renal medulla but were not present within the renal cortex. These findings illustrate distinct UPEC susceptibility patterns between C57BL/6J and C3H/HeOuJ mice, with C57BL/6J mice demonstrating greater UPEC resistance compared to C3H/HeOuJ mice.

Figure 1. C3H/HeOuJ mice exhibit increased UPEC susceptibility and develop more severe kidney pathology than C57BL/6J mice.

Figure 1.

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(A-C) Female C57BL/6J (closed circles) and C3H/HeOuJ mice (open circles) were transurethrally infected with UPEC. Bacterial burden was enumerated in the urine, bladders, and kidneys twenty-four hours (A) and (B) seven days after infection. Each data point depicts UPEC burden per mL urine or per organ from a unique mouse (n=10–14 mice/time point). The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. (C) Kidney histopathology scores in female C57BL/6J and C3H/HeOuJ mice at twenty-four hours (24 HPI) and seven days post infection (7 DPI). Each data point represents the average kidney score in a unique mouse determined from four representative serial sections (n=5 mice/group). Graphs show the mean score and standard deviation. (A-C) Asterisks identify significant P-values for the indicated pairwise comparisons (Mann-Whitney U test). *P <0.05 and ****P <0.0001. (D) Representative hematoxylin and eosin-stained kidney images obtained from sham-infected and UPEC-infected C57BL/6J and C3H/HeOuJ mice. The numbers in the bottom left of each photomicrograph list the histopathology score for the presented kidney. (D, top row) Low power (inset) and higher power images show minimal to mild changes in kidney histopathology were observed in C57BL/6J mice at 24 HPI or 7 DPI. Mild inflammation was occasionally observed seven days after infection in the suburothelial connective tissue (lamina propria) (asterisk) and there were occasional neutrophils migrating through the urothelium (pyelitis). P = papilla and PL = pelvic lumen. (D, bottom row) There was moderate neutrophilic inflammation present in C3H/HeOuJ kidneys 24 HPI which persisted to 7 DPI. Inflammation was centered on the renal pelvis and urothelium (pyelitis) with rare extension into the distal papilla. There was a moderate to marked expansion of the suburothelial lamina propria by neutrophils and fewer lymphocytes (asterisks) and rare inflammation affecting the papilla and medulla (pyelonephritis) 7 DPI. Scale bars denote 50μm. Insets mark 40x magnification focused on the kidney pelvis and papilla. See Table 1 for scoring quantification.

Dapagliflozin therapy does not affect UPEC susceptibility in C57BL/6J mice.

To begin to assess the effects of dapagliflozin on UPEC susceptibility, C57BL/6J female mice were treated with vehicle or dapagliflozin (1 mg/kg or 10 mg/kg) for seven days. On the seventh day of treatment, mice were infected with UPEC and sacrificed twenty-four hours later (Figure 2A). A single administration of dapagliflozin augmented urinary glucose excretion, and the extent of glucosuria exhibited a dose-dependent relationship (Figure 2B). Dapagliflozin therapy did not impact blood glucose concentrations or body weight (Figure 2C/D). Twenty-four hours after infection, vehicle and dapagliflozin treated mice had comparable bladder UPEC titers, minimal kidney UPEC titers, and limited kidney histopathology changes (Figure 2E–G). Compared to vehicle treated mice, urine UPEC burden was greater in mice receiving 10 mg/kg dapagliflozin, but this did not reach statistical significance (Figure 2E). These data indicate that dapagliflozin therapy does not significantly potentiate UTI in C57BL/6J mice.

Figure 2. Dapagliflozin does not sizably impact UPEC susceptibility in C57BL/6J mice.

Figure 2.

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(A) Schematic showing how C57BL/6J female mice were enterally treated with dapagliflozin or vehicle before transurethral infection with 107 CFU UPEC (strain UTI89). (B) Effect of a single dose of dapagliflozin on urinary glucose excretion. Closed circles depict mice treated with vehicle, black and white circles depict mice treated with 1 mg/kg dapagliflozin, and open circles depict mice treated with 10 mg/kg dapagliflozin. (C/D) Blood glucose concentrations (C) and changes in body weight (D) seven days after vehicle or dapagliflozin treatment. Graphs show the mean values and SEM. (E) UPEC titers enumerated in the urine (left), bladder (center), and kidney (right) twenty-four hours after infection. Each data point depicts UPEC burden in a unique mouse (n=14–15 mice/cohort). The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. (F) Kidney histopathology scores in vehicle and dapagliflozin treated mice twenty-four hours after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections (n=4 mice/cohort). Graphs show the mean score and SEM. (G) Low power (top) and higher power (bottom) representative images of hematoxylin and eosin-stained kidney tissue obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the histopathology score for the represented kidney. Kidneys rarely had histopathological changes that included increased urothelial thickening and mild inflammation in the suburothelial pelvis (black arrow). The blue scale bar marks 500μm and the black scale bar marks 50μm. P = papilla, PL = pelvic lumen, and ISOM = inner stripe of the outer medulla.

C3H/HeOuJ mice receiving dapagliflozin demonstrate increased UPEC susceptibility but have minimal changes in kidney histopathology.

Next, we assessed UTI outcomes in female C3H/HeOuJ mice treated seven days with dapagliflozin (1 mg/kg or 10 mg/kg) or vehicle. On the seventh day of treatment, C3H/HeOuJ mice were infected with UPEC strain UTI89 and sacrificed twenty-four hours later (Figure 3A). Dapagliflozin augmented urinary glucose excretion but did not impact blood glucose concentrations or body weight (Figure 3B–3D). UPEC burden was similar between vehicle and 1 mg/kg dapagliflozin treated mice twenty-four hours after infection. In contrast, UPEC burden was significantly greater in mice receiving 10 mg/kg dapagliflozin (Figure 3E) and UPEC titers were more routinely enumerated in the liver and spleen (Supplemental Figure 2). Kidney histopathology scores did not differ between dapagliflozin (1 mg/kg or 10 mg/kg) and vehicle treated mice (Figure 3F). In all groups, pathology was limited to the renal pelvis, showing differing degrees of neutrophilic inflammation (pyelitis). Rarely, inflammation extended into the papilla (Figure 3G). These findings suggest dapagliflozin may increase UPEC susceptibility in C3H/HeOuJ mice, but it does not acutely alter kidney histopathology.

Figure 3. Dapagliflozin acutely augments UPEC susceptibility but does not affect kidney pathology in C3H/HeOuJ mice.

Figure 3.

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(A) Schematic showing how C3H/HeOuJ female mice were treated with dapagliflozin or vehicle before transurethral infection with 107 CFU UPEC (strain UTI89). (B-D) Urine glucose concentrations (B), blood glucose (C) and changes in body weight (D) seven days after vehicle or dapagliflozin treatment. Graphs show the mean values and SEM. (E) UPEC titers enumerated in the urine (left), bladder (center), and kidney (right) twenty-four hours after infection. Each data point depicts UPEC burden in a unique mouse (n=13 mice/cohort). The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. Asterisks show statistical significance determined by Kruskal-Wallis. *P <0.05 and **P <0.01. (F) Kidney histopathology scores in vehicle and dapagliflozin treated mice twenty-four hours after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections (n=13 mice/cohort). Graphs show the mean score and SEM. (G) Low power (top) and higher power (bottom) representative images of hematoxylin and eosin-stained kidney tissue obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the histopathology score for the represented kidney. Inflammation was limited to the pelvis with varying degrees of neutrophilic inflammation. Rarely, inflammation extended into the papilla (dashed circle) in the more severely infected mice. The blue scale bar marks 500μm and the black scale bar marks 50μm. P = papilla, PL = pelvic lumen, and ISOM = inner stripe of the outer medulla.

To test if dapagliflozin impacts UPEC susceptibility and kidney histopathology after prolonged infection, female C3H/HeOuJ mice were treated with vehicle or dapagliflozin for seven days, transurethrally infected with UPEC, and sacrificed seven days later after receiving daily dapagliflozin (Figure 4A). At the time of sacrifice, urinary glucose was elevated in dapagliflozin treated mice, while blood glucose concentrations and body weight were comparable between treatment groups (Figure 4B–4D). Compared to vehicle treated mice, mice receiving 1 mg/kg dapagliflozin had comparable UPEC burden. Mice treated with 10 mg/kg dapagliflozin had greater UPEC burden in the urine, bladder, kidneys, liver, and spleen, but this did not reach statistical significance (Figure 4E and Supplemental Figure 3). Kidney histopathology scores did not significantly differ between dapagliflozin (1 mg/kg or 10 mg/kg) and vehicle treated mice (Figure 4F/G). In all groups, there was evidence of chronic-active infection with neutrophils present within urothelium, scattered necrotic urothelial cells, and bacteria present within the pelvic lumen. All groups had increased urothelial cell layers with mitotic figures, indicating increased urothelial cell proliferation (Figure 4G).

Figure 4. Extended dapagliflozin therapy does not affect kidney pathology in C3H/HeOuJ mice.

Figure 4.

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(A) Schematic showing how C3H/HeOuJ female mice were treated with dapagliflozin or vehicle before transurethral infection with 107 CFU UPEC (strain UTI89). (B-D) Urine glucose concentrations (B), blood glucose (C) and changes in body weight (D) fourteen days after vehicle or dapagliflozin treatment. Graphs show the mean values and SEM. (E) UPEC titers enumerated in the urine (left), bladder (center), and kidney (right) seven days after infection. Each data point depicts UPEC burden in a unique mouse (n=10 mice/cohort). The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. (F) Kidney histopathology scores in vehicle and dapagliflozin treated mice seven days after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections (n=10 mice/cohort). Graphs show the mean score and SEM. (G) Low power (top) and higher power (bottom) representative images of hematoxylin and eosin-stained kidney tissue obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the histopathology score for the represented kidney. Histopathologic changes were limited to the pelvis. All groups showed increased urothelial thickness (dotted double-edged arrow) with occasional mitotic figures (arrowhead). Neutrophil transmigration and urothelial cell necrosis (dashed circle) were present in all groups. The black scale bar marks 50μm and the red scale bar marks 20μm. Insets mark 40x magnification focused on the kidney pelvis and papilla. P = papilla, PL = pelvic lumen, and U = urothelium. (H) Serum BUN concentrations seven days after infection. (I/J) Relative mRNA transcript expression (left) and protein concentrations of kidney injury (I) and fibrosis (J) markers measured by qRT-PCR or ELISA in UPEC infected kidneys from vehicle and dapagliflozin treated mice. Graphs show the mean expression and SEM. Each data point shows marker expression in a unique mouse (n=6–9 mice/cohort).

Following infection, we assessed kidney function by measuring serum BUN, a marker that reflects the kidney’s ability to filter and excrete waste products from the blood. Serum BUN concentrations were comparable between dapagliflozin and vehicle treated mice (Figure 4H). We also profiled the transcript expression and tissue concentrations of kidney tubular injury markers that can increase before detectable changes in kidney filtration (i.e. BUN).39,40 After UTI, the expression of the proximal tubule injury marker Havcr1, which encodes the Kim-1 protein, as well as the nephron and collecting duct marker Lcn2, which encodes the Lcn 2 protein (also known as neutrophil gelatinase-associated lipocalin (NGAL)) were comparable between the dapagliflozin and vehicle groups (Figure 4I). Additionally, we measured both the transcript and protein expression of kidney fibrosis markers fibronectin 1 and TGFβ which showed comparable expression in vehicle and dapagliflozin treated mice (Figure 4J). Lastly, we measured the expression of proinflammatory cytokines, which had similar concentrations in kidneys from vehicle and dapagliflozin treated mice (Supplemental Figure 4). Collectively, these findings suggest that dapagliflozin therapy during extended infections has no notable impact on UPEC burden, kidney histopathology, immune responses, or markers of renal injury.

Dapagliflozin does not augment UTI susceptibility or impact kidney injury in diabetic mice.

To assess the impact of dapagliflozin on UTI susceptibility and kidney outcomes in the context of diabetes, female db/db mice were administered either vehicle or dapagliflozin for seven days, transurethrally infected with UPEC, and sacrificed seven days later after receiving daily dapagliflozin (Figure 5A). Diabetic db/db mice had glucosuria, hyperglycemia, and obesity, which persisted despite dapagliflozin administration. Dapagliflozin caused a mild reduction in blood glucose concentrations and body weight, but these changes did not reach statistical significance (Figure 5B–D).

Figure 5. Dapagliflozin therapy does not impact kidney pathology in diabetic mice.

Figure 5.

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(A) Schematic showing how diabetic db/db female mice were treated with dapagliflozin or vehicle before transurethral infection with 107 CFU UPEC (strain UTI89). (B-D) Urine glucose concentrations (B), blood glucose (C) and changes in body weight (D) fourteen days after vehicle or dapagliflozin treatment. Graphs show the mean values and SEM. (E) UPEC titers enumerated in the urine (left), bladder (center), and kidney (right) seven days after infection. Each data point depicts UPEC burden in a unique mouse (n=11–12 mice/cohort). The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. (F) Kidney histopathology scores in vehicle and dapagliflozin treated mice seven days after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections. Graphs show the mean score and SEM. (G) Low power (top) and higher power (bottom) representative hematoxylin and eosin-stained kidney images obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the histopathology score for the represented kidney (n=11–12 mice/cohort). Histopathologic changes were limited to the pelvis. Vehicle treated mice often had increased urothelial thickening and inflammation within the renal pelvis. Dapagliflozin treated mice were less affected with only minimal inflammation in most cases. The blue scale bar marks 500μm and the black scale bar marks 50μm. P = papilla, and PL = pelvic lumen. (H) Serum BUN concentrations seven days after infection. (I/J) Relative mRNA transcript expression (left) and protein concentrations of kidney injury (I) and fibrosis (J) markers measured by qRT-PCR or ELISA in UPEC infected kidneys from vehicle and dapagliflozin treated mice. Graphs show the mean expression and SEM. Each data point shows marker expression in a unique mouse (n=6–9 mice/cohort).

Following transurethral infection with UPEC strain UTI89, dapagliflozin treated db/db mice demonstrated a dose-dependent reduction in urine, bladder, and kidney UPEC titers one week after infection, with a statistically significant reduction observed with 10 mg/kg dose (Figure 5E). Similar results were observed in the liver and spleen (Supplemental Figure 5). Kidney histopathology scores were also significantly lower between dapagliflozin and vehicle treated mice (Figure 5F/G). Vehicle treated diabetic mice demonstrated a bimodal distribution of histopathologic changes with some mice having minimal histopathology (n=4) and others were more moderately affected (n=8). This latter group had mild to moderate pyelitis with increased pelvic urothelial thickening, neutrophil transmigration, and varying degrees of neutrophilic inflammation, edema, and fibrosis within the suburothelial pelvis. Some mice (n=3) had papillary and inner medullary intratubular neutrophilic inflammation. Dapagliflozin treated mice (n=12) only demonstrated minimal to mild pyelitis (Figure 5G). This improvement in UPEC clearance was not observed when db/db mice were challenged with UPEC strain CFT073, as both UPEC burden and kidney histopathology scores were comparable between vehicle and dapagliflozin groups (Supplemental Figure 6).

Despite the improved kidney histopathology in UTI89 infected mice, there were no significant differences in BUN concentrations, acute kidney injury or fibrosis markers, or kidney cytokines between groups (Figure 5H–J and Supplemental Figure 7). These findings suggest that while dapagliflozin may have some beneficial effects in reducing UPEC burden in specific UPEC infections, it does not significantly impact overall kidney function or injury in diabetic mice.

DISCUSSION

The impact of SGLT2 inhibitors on urinary tract infection (UTI) susceptibility and severity has been a subject of debate.4,7,8,12–14 Given the pivotal role SGLT2 inhibitors have in the management of both type 2 diabetes and CKD, it is imperative to conduct thorough investigations that examine their effects on common infections like UTI in diabetic and non-diabetic model systems. For this project, we aimed to delineate the effects of dapagliflozin on UTI outcomes, particularly focusing on bacterial burden, kidney injury, and fibrosis in both non-diabetic and diabetic mice. Our findings provide nuanced insights into how dapagliflozin influences UTI severity and kidney pathology.

In non-diabetic C57BL/6J mice, our results demonstrate that dapagliflozin does not significantly alter UTI susceptibility, as evidenced by comparable bacterial burden in the urine and bladder between treated and vehicle groups. This suggests that in a non-diabetic context, dapagliflozin does not exacerbate UTI severity or kidney injury, aligning with clinical data suggesting a minimal impact of SGLT2 inhibitors on UTI severity.29 These outcomes also highlight a complex relationship between SGLT2 inhibitors, glucosuria and UPEC UTI, especially since glucose enhances bacterial replication in vitro.41

Conversely, in non-diabetic C3H/HeOuJ mice, a strain known for its heightened UTI susceptibility, dapagliflozin administration at the higher dose of 10 mg/kg resulted in an increased UPEC burden in the urinary tract and kidneys.42 Despite this heightened bacterial load, we did not observe a significant progression of kidney histopathology, augmented expression of markers of kidney injury, or changes in kidney function – indicating that dapagliflozin may increase bacterial colonization without necessarily translating to more severe kidney injury or dysfunction. These findings underscore the importance of genetic background in modulating UTI susceptibility and response to SGLT2 inhibitor therapy.

Our results complement three published studies that have assessed the effect of SGLT2 inhibition on UTI risk in non-diabetic rodents. The first study showed that Sglt2 knock-out mice, on a C57BL/6 background, do not spontaneously develop ascending UTI.43 The second study showed female C57BL/6 treated with dapagliflozin or canagliflozin had increased susceptibility to transurethral Candida albicans infection, whereas this result was not observed when mice were treated with tofoglifozin.11 More recent data show that female CBA/J mice treated with dapagliflozin or canagliflozin had increased susceptibility to UPEC strain CFT073, evidenced by higher UPEC titers in urinary tract tissues as well as evidence of disseminated infection.30 Similar results were observed when CBA/J mice were infected with Klebsiella pneumoniae.30 These findings underscore the complex interplay between SGLT2 inhibition and UTI susceptibility, which may be influenced by factors such as the infecting pathogen and bacterial strain-specific variations.44 Additionally, they emphasize how the genetic background of a mouse can influence UTI susceptibility. Prior studies show mice on the C57BL/6 background develop less severe UTI and are resistant to kidney infection compared to C3H/OuJ mice. This disparity may partly stem from C3H/OuJ mice having urinary reflux, expediting an ascending UTI.42,45 However, added host characteristics that contribute to this phenotype remain undefined. The merits and drawbacks of different mouse models have been examined in previous reviews.42,45–48 Taken together, both host and pathogen factors should be considered when exploring UTI pathogenesis.

In this project, we provide the initial published data evaluating how dapagliflozin impacts UTI outcomes in diabetic rodents. In db/db mice, dapagliflozin had differential effects depending on the infecting UPEC strain. Dapagliflozin reduced UPEC burden when mice were infected with strain UTI89 but not with strain CFT073. This strain-dependent response may reflect differences in the pathogenic mechanisms of these UPEC strains and suggests that dapagliflozin’s impact on UTI outcomes in diabetes may be more complex and dependent on specific bacterial factors.37,44 Importantly, despite these differences in UPEC burden, dapagliflozin did not significantly worsen kidney injury or fibrosis, suggesting that SGLT2 inhibition does not amplify kidney complications of UTI in a diabetic context. This finding is particularly intriguing given the clinical relevance of UTI in diabetic populations, where infections are often more severe and challenging to manage.22–26

This study has limitations. First, it focused exclusively on female UTI. Given established influences of sex and mouse genetic backgrounds on UTI susceptibility, additional research is needed to explore the potential impact of SGLT2 inhibitors on male UTI susceptibility.42,49 Further, we did not control for the effects of the estrous cycle and mice required additional handling for the longer observational periods after UTI, both of which could impact UTI outcomes. Also, our experiments were restricted to db/db diabetic mice so added experiments using other diabetic mouse models could provide value. Moreover, our investigation centered on one SGLT2 inhibitor, dapagliflozin, at two different doses. Considering there are four other FDA-approved SGLT2 inhibitors for diabetes and kidney disease, including bexagliflozin, canagliflozin, empagliflozin, and ertugliflozin, it is plausible that these may yield different outcomes in terms of bacterial burden and histopathologic responses in experimental UTI. Also, alternative dosing regimens could impact experimental outcomes.50,51 Long-term studies are also necessary to assess renal injury and fibrosis progression over time or with repeated infections and alternative uropathogens – including those that are more prevalent with diabetes.25 Lastly, our studies did not assess the potential impact of SGLT2 inhibitors on diuresis or natriuresis, both of which could influence UTI outcomes.52,53

Collectively, our results suggest that while dapagliflozin may influence UTI susceptibility in a UPEC strain- and mouse genetic background-dependent manner, it does not consistently exacerbate kidney injury or fibrosis. These findings support the notion that SGLT2 inhibitors, such as dapagliflozin, may have a limited impact on UTI outcomes, particularly in terms of kidney pathology, across different populations. Translating these findings into clinical practice could pave the way for personalized management strategies for individuals prescribed SGLT2 inhibitor therapy. Before implementation, research is needed to thoroughly evaluate the therapeutic value and potential UTI risks associated with SGLT2 inhibitors, especially across multiple different models of CKD and diabetes.

Supplementary Material

Supinfo2

Supplemental Figure 2. UPEC burden in liver and spleen of C3H/HeOuJ mice treated with vehicle or dapagliflozin for seven doses. UPEC titers enumerated in the liver (left) and spleen (right) twenty-four hours after infection in vechile and dapagliflozin treated mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 3.

Supinfo3

Supplemental Figure 3. UPEC burden in liver and spleen of C3H/HeOuJ mice treated with vehicle or dapagliflozin for thirteen doses. UPEC titers enumerated in the liver (left) and spleen (right) seven days after infection in vechile and dapagliflozin treated mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 4.

Supinfo4

Supplemental Figure 4. Kidney cytokine expression in UPEC infected C3H/HeOuJ mice treated with vehicle or dapagliflozin for thirteen doses. Kidney cytokine concentrations measured by multiplex ELISA in C3H/HeOuJ treated with vehicle or dapagloflozin. Cytokine concentrations were measured seven days after UTI. Graphs show mean cytokine concentrations and SEM. Each data point depicts cytokine expression in a unique mouse kidney. These data supplement Figure 4.

Supinfo5

Supplemental Figure 5. UPEC burden in liver and spleen of diabetic mice infected with UPEC strain UTI89. UPEC titers enumerated in the liver (left) and spleen (right) seven days after infection in vechile and dapagliflozin treated db/db mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 5.

Supinfo1

Supplemental Figure 1. Features of the UTI histopathologic murine kidney scoring system. (A) Kidney sections were cut in transverse section to ensure adequate and repeatable assessment of all components. The black arrow indicates the pelvic urothelium evaluated in the renal pelvis and hilus. The cortex was identified by the presence of glomeruli. In between the two black dashed lines is the renal outer medulla with a white dotted line separating the outer stripe of the outer medulla (OSOM) and inner stripe of the outer medulla (ISOM). IM = inner medulla; H = hilar adipose; P = papilla. Blue scale bar = 500μm. (B) High magnification image of the renal pelvis and pelvic urothelium (black arrow). Within the pelvic connective tissue (lamina propria), the asterisk (*) indicates expansion and increased clear space separating the lamina propria (pelvic edema score of 1). There are numerous leukocytes within the lamina propria more than 4 cell layers thick (pelvic inflammation score of 4). Within the pelvic urothelium (black arrow), there are mitotic figures present (score of 1) and neutrophil transmigration present (score of 1). The red arrows indicate the urothelium lining the renal papilla (P). Within the papilla, there are numerous interstitial neutrophils (black circle) (papillary inflammatory localization score of 1). PL = pelvic lumen; Black scale bar = 50μm. (C) High magnification image of the pelvic lumen (PL). The dotted black circle indicates clusters of free bacteria (pelvic bacteria within lumen score of 1) within the PL surrounded by large numbers of neutrophils (pelvic inflammatory localization score of 1 (within pelvic lumen). There is urothelial cell sloughing into the PL (urothelial cell necrosis score of 1) and neutrophils transmigrating through the urothelium (score of 1) (black arrow). The red arrow indicates the papilla urothelium. Black scale bar = 50μm. (D) High magnification image of the papilla (P) and pelvic lumen (PL). The pelvic urothelium (black arrow) is markedly thickened (>3 cell layers thick) (urothelial cell layer score of 2) (white double arrows). There are intratubular neutrophils (papilla inflammatory localization score of 1) and tubular epithelial cell necrosis within the papillary ducts (score of 1) (black circle). Red arrows = papilla urothelium; Scale bar = 50μm. (E) High magnification of renal cortex with chronic-active infection. Within the cortical tubules, there are cellular casts composed of intratubular neutrophils (black dotted line) filling the tubular lumen and fewer interstitial neutrophils adjacent to the circle (cortical intratubular and interstitial inflammatory localization score of 2). G = glomerulus; Scale bar = 50μm. (F) High magnification of renal cortex with chronic-active infection. The cortex is expanded by large numbers of lymphocytes and plasma cells often surrounding vasculature (V) (white dotted circle) (lymphoid nodule formation score of 1). There are fewer neutrophils at this stage but often still present. Scale bar = 50μm. Panels A-D depict histopathological changes observed between one- and seven-days after infection. Panels E-F show changes only observed four weeks after infection. This information supplements Table 1 and applies to Figures 1–5.

Supinfo7

Supplemental Figure 7. Kidney cytokine concentrations in UPEC infected diabetic mice treated with vehicle or dapagliflozin. Kidney cytokine concentrations measured by multiplex ELISA in db/db treated with vehicle or dapagloflozin. Cytokine concentrations were measured seven days after infection with UPEC (strain UTI89). Graphs show mean cytokine concentrations and SEM. Each data point depicts cytokine expression in a unique mouse kidney. These data supplement Figure 5.

Supinfo6

Supplemental Figure 6. Dapagliflozin therapy does not impact kidney pathology in diabetic mice infected with UPEC strain CFT073. (A/B) UPEC titers enumerated in the urine, bladder, kidney, liver, and spleen seven days after infection with UPEC (strain CFT073). Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group (n=13 mice/cohort). The dashed horizontal line indicates the lower limit of UPEC detection. (C) Kidney histopathology scores in vehicle and dapagliflozin treated mice at seven days after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections. Graphs show the mean score and SEM. (D) Low power (top) and higher power (bottom) representative images of hematoxylin and eosin-stained kidney obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the overall histopathology score for the represented kidney. Histopathologic changes were limited to the pelvis. Occasionally, there were mild to moderate inflammatory cells within the suburothelial pelvis (black arrow). The blue scale bar marks 500μm and the black scale bar marks 50μm. P = papilla and PL = pelvic lumen. These data supplement Figure 5.

ACKNOWLEDGMENTS:

We would like to thank Dr. Krista La Perle for assistance in developing the kidney histopathology scoring system and Rollin Li for performing the mouse infections. We would like to recognize the Comparative Pathology & Digital Imaging Shared Resource, Department of Veterinary Biosciences and the Comprehensive Cancer Center, The Ohio State University, Columbus, OH, supported in part by the National Cancer Institute (NCI) P30 CA016058. S.L-P. was supported by The Ohio State University Genentech Veterinary Pathology Fellowship. This work is supported by the National Institutes of Health (NIDDK) R01 DK128088 and R01 DK115737 (J.D.S.).

Footnotes

CONFLICT OF INTEREST: The authors declare no competing interests and no conflicts of interest to disclose.

REFERENCES

  • 1.Heerspink HJL, Jongs N, Chertow GM, et al. Effect of dapagliflozin on the rate of decline in kidney function in patients with chronic kidney disease with and without type 2 diabetes: a prespecified analysis from the DAPA-CKD trial. Lancet Diabetes Endocrinol. 2021;9(11):743–754. [DOI] [PubMed] [Google Scholar]
  • 2.Xu B, Li S, Kang B, Zhou J. The current role of sodium-glucose cotransporter 2 inhibitors in type 2 diabetes mellitus management. Cardiovasc Diabetol. 2022;21(1):83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Liu J, Li L, Li S, et al. Effects of SGLT2 inhibitors on UTIs and genital infections in type 2 diabetes mellitus: a systematic review and meta-analysis. Sci Rep. 2017;7(1):2824. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Uitrakul S, Aksonnam K, Srivichai P, Wicheannarat S, Incomenoy S. The Incidence and Risk Factors of Urinary Tract Infection in Patients with Type 2 Diabetes Mellitus Using SGLT2 Inhibitors: A Real-World Observational Study. Medicines (Basel). 2022;9(12). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Puckrin R, Saltiel MP, Reynier P, Azoulay L, Yu OHY, Filion KB. SGLT-2 inhibitors and the risk of infections: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol. 2018;55(5):503–514. [DOI] [PubMed] [Google Scholar]
  • 6.Schneeberger C, Kazemier BM, Geerlings SE. Asymptomatic bacteriuria and urinary tract infections in special patient groups: women with diabetes mellitus and pregnant women. Curr Opin Infect Dis. 2014;27(1):108–114. [DOI] [PubMed] [Google Scholar]
  • 7.Musso G, Gambino R, Cassader M, Pagano G. A novel approach to control hyperglycemia in type 2 diabetes: sodium glucose co-transport (SGLT) inhibitors: systematic review and meta-analysis of randomized trials. Ann Med. 2012;44(4):375–393. [DOI] [PubMed] [Google Scholar]
  • 8.Nicolle LE, Capuano G, Ways K, Usiskin K. Effect of canagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, on bacteriuria and urinary tract infection in subjects with type 2 diabetes enrolled in a 12-week, phase 2 study. Curr Med Res Opin. 2012;28(7):1167–1171. [DOI] [PubMed] [Google Scholar]
  • 9.Nyirjesy P, Zhao Y, Ways K, Usiskin K. Evaluation of vulvovaginal symptoms and Candida colonization in women with type 2 diabetes mellitus treated with canagliflozin, a sodium glucose co-transporter 2 inhibitor. Curr Med Res Opin. 2012;28(7):1173–1178. [DOI] [PubMed] [Google Scholar]
  • 10.Unnikrishnan AG, Kalra S, Purandare V, Vasnawala H. Genital Infections with Sodium Glucose Cotransporter-2 Inhibitors: Occurrence and Management in Patients with Type 2 Diabetes Mellitus. Indian J Endocrinol Metab. 2018;22(6):837–842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Suzuki M, Hiramatsu M, Fukazawa M, et al. Effect of SGLT2 inhibitors in a murine model of urinary tract infection with Candida albicans. Diabetes Obes Metab. 2014;16(7):622–627. [DOI] [PubMed] [Google Scholar]
  • 12.Wilding J SGLT2 inhibitors and urinary tract infections. Nat Rev Endocrinol. 2019;15(12):687–688. [DOI] [PubMed] [Google Scholar]
  • 13.Dave CV, Schneeweiss S, Kim D, Fralick M, Patorno E. Sodium-Glucose Cotransporter-2 Inhibitors and Urinary Tract Infections. Ann Intern Med. 2019;171(12):944–945. [DOI] [PubMed] [Google Scholar]
  • 14.Dave CV, Schneeweiss S, Kim D, Fralick M, Tong A, Patorno E. Sodium-Glucose Cotransporter-2 Inhibitors and the Risk for Severe Urinary Tract Infections: A Population-Based Cohort Study. Ann Intern Med. 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. N Engl J Med. 2019;380(24):2295–2306. [DOI] [PubMed] [Google Scholar]
  • 16.Radholm K, Wu JH, Wong MG, et al. Effects of sodium-glucose cotransporter-2 inhibitors on cardiovascular disease, death and safety outcomes in type 2 diabetes - A systematic review. Diabetes Res Clin Pract. 2018;140:118–128. [DOI] [PubMed] [Google Scholar]
  • 17.Korbel L, Spencer JD. Diabetes mellitus and infection: an evaluation of hospital utilization and management costs in the United States. J Diabetes Complications. 2015;29(2):192–195. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Korbel L, Easterling RS, Punja N, Spencer JD. The burden of common infections in children and adolescents with diabetes mellitus: A Pediatric Health Information System study. Pediatr Diabetes. 2018;19(3):512–519. [DOI] [PubMed] [Google Scholar]
  • 19.Dimitrijevic Z, Paunovic G, Tasic D, Mitic B, Basic D. Risk factors for urosepsis in chronic kidney disease patients with urinary tract infections. Sci Rep. 2021;11(1):14414. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Chao CT, Lee SY, Wang J, Chien KL, Huang JW. Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease. BMC Geriatr. 2021;21(1):349. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Schwartz L, de Dios Ruiz-Rosado J, Stonebrook E, Becknell B, Spencer JD. Uropathogen and host responses in pyelonephritis. Nat Rev Nephrol. 2023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Thakar CV, Christianson A, Himmelfarb J, Leonard AC. Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus. Clin J Am Soc Nephrol. 2011;6(11):2567–2572. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Shah BR, Hux JE. Quantifying the risk of infectious diseases for people with diabetes. Diabetes Care. 2003;26(2):510–513. [DOI] [PubMed] [Google Scholar]
  • 24.Muller LM, Gorter KJ, Hak E, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41(3):281–288. [DOI] [PubMed] [Google Scholar]
  • 25.Geerlings SE. Urinary tract infections in patients with diabetes mellitus: epidemiology, pathogenesis and treatment. Int J Antimicrob Agents. 2008;31 Suppl 1:S54–57. [DOI] [PubMed] [Google Scholar]
  • 26.Nicolle LE, Friesen D, Harding GK, Roos LL. Hospitalization for acute pyelonephritis in Manitoba, Canada, during the period from 1989 to 1992; impact of diabetes, pregnancy, and aboriginal origin. Clin Infect Dis. 1996;22(6):1051–1056. [DOI] [PubMed] [Google Scholar]
  • 27.Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Rev Anti Infect Ther. 2015;13(1):81–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Gilbert DN. Urinary tract infections in patients with chronic renal insufficiency. Clin J Am Soc Nephrol. 2006;1(2):327–331. [DOI] [PubMed] [Google Scholar]
  • 29.Khan S, Hashmi MS, Rana MA, et al. Frequency of Urinary Tract Infections in Type 2 Diabetic Patients Taking Dapagliflozin. Cureus. 2022;14(1):e21720. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Saenkham P, Jennings-Gee J, Hanson B, Kock ND, Adams LG, Subashchandrabose S. Hyperglucosuria induced by dapagliflozin augments bacterial colonization in the murine urinary tract. Diabetes Obes Metab. 2020;22(9):1548–1555. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Murtha MJ, Eichler T, Bender K, et al. Insulin receptor signaling regulates renal collecting duct and intercalated cell antibacterial defenses. J Clin Invest. 2018;128(12):5634–5646. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Olson PD, McLellan LK, Hreha TN, et al. Androgen exposure potentiates formation of intratubular communities and renal abscesses by Escherichia coli. Kidney Int. 2018;94(3):502–513. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Ahmad S, Hussain A, Khan MSA, Shakireen N, Ali I. Diabetes mellitus and urinary tract infection: Causative uropathogens, their antibiotic susceptibility pattern and the effects of glycemic status. Pak J Med Sci. 2020;36(7):1550–1557. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Hoepelman AI, Meiland R, Geerlings SE. Pathogenesis and management of bacterial urinary tract infections in adult patients with diabetes mellitus. Int J Antimicrob Agents. 2003;22 Suppl 2:35–43. [DOI] [PubMed] [Google Scholar]
  • 35.Woldemariam HK, Geleta DA, Tulu KD, et al. Common uropathogens and their antibiotic susceptibility pattern among diabetic patients. BMC Infect Dis. 2019;19(1):43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Mulvey MA, Schilling JD, Hultgren SJ. Establishment of a persistent Escherichia coli reservoir during the acute phase of a bladder infection. Infect Immun. 2001;69(7):4572–4579. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Kao JS, Stucker DM, Warren JW, Mobley HL. Pathogenicity island sequences of pyelonephritogenic Escherichia coli CFT073 are associated with virulent uropathogenic strains. Infect Immun. 1997;65(7):2812–2820. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Spencer JD, Schwaderer AL, Dirosario JD, et al. Ribonuclease 7 is a potent antimicrobial peptide within the human urinary tract. Kidney Int. 2011;80(2):174–180. [DOI] [PubMed] [Google Scholar]
  • 39.Stanski NL, Rodrigues CE, Strader M, Murray PT, Endre ZH, Bagshaw SM. Precision management of acute kidney injury in the intensive care unit: current state of the art. Intensive Care Med. 2023;49(9):1049–1061. [DOI] [PubMed] [Google Scholar]
  • 40.Alge JL, Arthur JM. Biomarkers of AKI: a review of mechanistic relevance and potential therapeutic implications. Clin J Am Soc Nephrol. 2015;10(1):147–155. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Geerlings SE, Brouwer EC, Gaastra W, Verhoef J, Hoepelman AI. Effect of glucose and pH on uropathogenic and non-uropathogenic Escherichia coli: studies with urine from diabetic and non-diabetic individuals. J Med Microbiol. 1999;48(6):535–539. [DOI] [PubMed] [Google Scholar]
  • 42.Hopkins WJ, Gendron-Fitzpatrick A, Balish E, Uehling DT. Time course and host responses to Escherichia coli urinary tract infection in genetically distinct mouse strains. Infect Immun. 1998;66(6):2798–2802. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Vallon V, Rose M, Gerasimova M, et al. Knockout of Na-glucose transporter SGLT2 attenuates hyperglycemia and glomerular hyperfiltration but not kidney growth or injury in diabetes mellitus. Am J Physiol Renal Physiol. 2013;304(2):F156–167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Mobley HL, Donnenberg MS, Hagan EC. Uropathogenic Escherichia coli. EcoSal Plus. 2009;3(2). [DOI] [PubMed] [Google Scholar]
  • 45.Li B, Haridas B, Jackson AR, et al. Inflammation drives renal scarring in experimental pyelonephritis. Am J Physiol Renal Physiol. 2017;312(1):F43–F53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Hung CS, Dodson KW, Hultgren SJ. A murine model of urinary tract infection. Nat Protoc. 2009;4(8):1230–1243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Olson PD, McLellan LK, Liu A, et al. Renal scar formation and kidney function following antibiotic-treated murine pyelonephritis. Dis Model Mech. 2017;10(11):1371–1379. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Barber AE, Norton JP, Wiles TJ, Mulvey MA. Strengths and Limitations of Model Systems for the Study of Urinary Tract Infections and Related Pathologies. Microbiol Mol Biol Rev. 2016;80(2):351–367. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Deltourbe L, Lacerda Mariano L, Hreha TN, Hunstad DA, Ingersoll MA. The impact of biological sex on diseases of the urinary tract. Mucosal Immunol. 2022;15(5):857–866. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Martínez-Vizcaíno V, Díez-Fernández A, Álvarez-Bueno C, Martínez-Alfonso J, Cavero-Redondo I. Safety and Efficacy of SGLT2 Inhibitors: A Multiple-Treatment Meta-Analysis of Clinical Decision Indicators. Journal of Clinical Medicine. 2021;10(12):2713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Lin J, Wang S, Wen T, Zhang X. Renal protective effect and safety of sodium-glucose cotransporter-2 inhibitors in patients with chronic kidney disease and type 2 diabetes mellitus: a network meta-analysis and systematic review. Int Urol Nephrol. 2022;54(9):2305–2316. [DOI] [PubMed] [Google Scholar]
  • 52.Packer M, Wilcox CS, Testani JM. Critical Analysis of the Effects of SGLT2 Inhibitors on Renal Tubular Sodium, Water and Chloride Homeostasis and Their Role in Influencing Heart Failure Outcomes. Circulation. 2023;148(4):354–372. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Palmer BF, Clegg DJ. Kidney-Protective Effects of SGLT2 Inhibitors. Clin J Am Soc Nephrol. 2023;18(2):279–289. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supinfo2

Supplemental Figure 2. UPEC burden in liver and spleen of C3H/HeOuJ mice treated with vehicle or dapagliflozin for seven doses. UPEC titers enumerated in the liver (left) and spleen (right) twenty-four hours after infection in vechile and dapagliflozin treated mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 3.

NIHMS2023494-supplement-Supinfo2.pdf (25.6KB, pdf)
Supinfo3

Supplemental Figure 3. UPEC burden in liver and spleen of C3H/HeOuJ mice treated with vehicle or dapagliflozin for thirteen doses. UPEC titers enumerated in the liver (left) and spleen (right) seven days after infection in vechile and dapagliflozin treated mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 4.

NIHMS2023494-supplement-Supinfo3.pdf (25.6KB, pdf)
Supinfo4

Supplemental Figure 4. Kidney cytokine expression in UPEC infected C3H/HeOuJ mice treated with vehicle or dapagliflozin for thirteen doses. Kidney cytokine concentrations measured by multiplex ELISA in C3H/HeOuJ treated with vehicle or dapagloflozin. Cytokine concentrations were measured seven days after UTI. Graphs show mean cytokine concentrations and SEM. Each data point depicts cytokine expression in a unique mouse kidney. These data supplement Figure 4.

NIHMS2023494-supplement-Supinfo4.pdf (221.4KB, pdf)
Supinfo5

Supplemental Figure 5. UPEC burden in liver and spleen of diabetic mice infected with UPEC strain UTI89. UPEC titers enumerated in the liver (left) and spleen (right) seven days after infection in vechile and dapagliflozin treated db/db mice. Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group. The dashed horizontal line indicates the lower limit of UPEC detection. These data supplement Figure 5.

NIHMS2023494-supplement-Supinfo5.pdf (64.9KB, pdf)
Supinfo1

Supplemental Figure 1. Features of the UTI histopathologic murine kidney scoring system. (A) Kidney sections were cut in transverse section to ensure adequate and repeatable assessment of all components. The black arrow indicates the pelvic urothelium evaluated in the renal pelvis and hilus. The cortex was identified by the presence of glomeruli. In between the two black dashed lines is the renal outer medulla with a white dotted line separating the outer stripe of the outer medulla (OSOM) and inner stripe of the outer medulla (ISOM). IM = inner medulla; H = hilar adipose; P = papilla. Blue scale bar = 500μm. (B) High magnification image of the renal pelvis and pelvic urothelium (black arrow). Within the pelvic connective tissue (lamina propria), the asterisk (*) indicates expansion and increased clear space separating the lamina propria (pelvic edema score of 1). There are numerous leukocytes within the lamina propria more than 4 cell layers thick (pelvic inflammation score of 4). Within the pelvic urothelium (black arrow), there are mitotic figures present (score of 1) and neutrophil transmigration present (score of 1). The red arrows indicate the urothelium lining the renal papilla (P). Within the papilla, there are numerous interstitial neutrophils (black circle) (papillary inflammatory localization score of 1). PL = pelvic lumen; Black scale bar = 50μm. (C) High magnification image of the pelvic lumen (PL). The dotted black circle indicates clusters of free bacteria (pelvic bacteria within lumen score of 1) within the PL surrounded by large numbers of neutrophils (pelvic inflammatory localization score of 1 (within pelvic lumen). There is urothelial cell sloughing into the PL (urothelial cell necrosis score of 1) and neutrophils transmigrating through the urothelium (score of 1) (black arrow). The red arrow indicates the papilla urothelium. Black scale bar = 50μm. (D) High magnification image of the papilla (P) and pelvic lumen (PL). The pelvic urothelium (black arrow) is markedly thickened (>3 cell layers thick) (urothelial cell layer score of 2) (white double arrows). There are intratubular neutrophils (papilla inflammatory localization score of 1) and tubular epithelial cell necrosis within the papillary ducts (score of 1) (black circle). Red arrows = papilla urothelium; Scale bar = 50μm. (E) High magnification of renal cortex with chronic-active infection. Within the cortical tubules, there are cellular casts composed of intratubular neutrophils (black dotted line) filling the tubular lumen and fewer interstitial neutrophils adjacent to the circle (cortical intratubular and interstitial inflammatory localization score of 2). G = glomerulus; Scale bar = 50μm. (F) High magnification of renal cortex with chronic-active infection. The cortex is expanded by large numbers of lymphocytes and plasma cells often surrounding vasculature (V) (white dotted circle) (lymphoid nodule formation score of 1). There are fewer neutrophils at this stage but often still present. Scale bar = 50μm. Panels A-D depict histopathological changes observed between one- and seven-days after infection. Panels E-F show changes only observed four weeks after infection. This information supplements Table 1 and applies to Figures 1–5.

NIHMS2023494-supplement-Supinfo1.pdf (3.9MB, pdf)
Supinfo7

Supplemental Figure 7. Kidney cytokine concentrations in UPEC infected diabetic mice treated with vehicle or dapagliflozin. Kidney cytokine concentrations measured by multiplex ELISA in db/db treated with vehicle or dapagloflozin. Cytokine concentrations were measured seven days after infection with UPEC (strain UTI89). Graphs show mean cytokine concentrations and SEM. Each data point depicts cytokine expression in a unique mouse kidney. These data supplement Figure 5.

NIHMS2023494-supplement-Supinfo7.pdf (254.7KB, pdf)
Supinfo6

Supplemental Figure 6. Dapagliflozin therapy does not impact kidney pathology in diabetic mice infected with UPEC strain CFT073. (A/B) UPEC titers enumerated in the urine, bladder, kidney, liver, and spleen seven days after infection with UPEC (strain CFT073). Each data point depicts UPEC burden in a unique mouse. The solid horizontal line shows the geometric mean of each group (n=13 mice/cohort). The dashed horizontal line indicates the lower limit of UPEC detection. (C) Kidney histopathology scores in vehicle and dapagliflozin treated mice at seven days after infection. Each data point represents the average kidney score in a unique mouse determined from four representative serial sections. Graphs show the mean score and SEM. (D) Low power (top) and higher power (bottom) representative images of hematoxylin and eosin-stained kidney obtained from vehicle and dapagliflozin treated mice after infection. The score above each column lists the overall histopathology score for the represented kidney. Histopathologic changes were limited to the pelvis. Occasionally, there were mild to moderate inflammatory cells within the suburothelial pelvis (black arrow). The blue scale bar marks 500μm and the black scale bar marks 50μm. P = papilla and PL = pelvic lumen. These data supplement Figure 5.

NIHMS2023494-supplement-Supinfo6.pdf (5.3MB, pdf)

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