Frailty outperforms conventional risk factors for predicting complications and death in type 1 diabetes

Aims: To examine whether frailty predicts cardiovascular and diabetes-related complications and mortality in adults with type 1 diabetes, to quantify its impact on event timing, and to compare its predictive performance with conventional risk factors. Methods: We studied 4,819 adults with type 1 diabetes from the nationwide FinnDiane cohort. Frailty at baseline was measured using a frailty index and classified as non-frail, pre-frail, or frail. Participants were followed for a median of 19 years via national registries for major cardiovascular events, kidney replacement therapy, severe retinopathy, and all-cause and cause-specific mortality. Associations were assessed with Cox and Fine-Gray models; Weibull models estimated earlier onset of events; discrimination was evaluated with 10-year time-dependent AUC. Results: At baseline (age 18-81 years), 33 % were non-frail, 54 % pre-frail, and 13 % frail. Frail versus non-frail participants had 3-to 118-fold higher hazards of complications and onset accelerated by 2-6 years. Frailty was associated with a tenfold higher risk of all-cause mortality and reduced survival by 4.5 years. Discrimination was good to excellent and outperformed individual conventional risk factors. Conclusions: Frailty is common in type 1 diabetes and independently predicts earlier and higher risk of complications and death. Routine assessment may improve risk stratification and support individualized care.