Impact of the stress hyperglycemia ratio on short-term outcomes in critically ill patients with chronic kidney disease: A comparative analysis of diabetic and non-diabetic populations

Abstract

Background Stress-induced hyperglycemia is common in critically ill patients and may worsen outcomes, especially in those with chronic kidney disease (CKD). The stress hyperglycemia ratio (SHR), defined as admission glucose divided by the estimated average glucose from HbA1c, reflects acute relative hyperglycemia, but its prognostic value in CKD remains unclear. Objective To investigate the impact of SHR on ICU and 28-day mortality in critically ill CKD patients and to compare prognostic differences between diabetic and non-diabetic populations. Methods Data of 1,836 CKD patients from the MIMIC-IV database were analyzed. SHR was categorized into quartiles, and patients were stratified by diabetes status. Kaplan–Meier survival analysis assessed ICU and 28-day mortality; Cox proportional hazards and restricted cubic spline (RCS) analyzes evaluated associations between SHR and outcomes. Subgroup analyzes explored effect modification by age, sex, and comorbidities. Results In non-diabetic patients, higher SHR levels were independently associated with increased ICU and 28-day mortality. The adjusted hazard ratios (HRs) for ICU and 28-day mortality in the highest SHR quartile were 3.19 (95% CI: 1.60–6.53, P < 0.001) and 1.93 (95% CI: 1.14–3.27, P = 0.015), respectively. In diabetic patients, similar upward trends were observed, but the associations were not statistically significant after multivariate adjustment. Conclusions Elevated SHR levels were associated with adverse short-term outcomes, particularly increased ICU and 28-day mortality in non-diabetic patients with chronic kidney disease. These findings suggest that stress-induced hyperglycemia may exert a harmful effect on critically ill patients without preexisting diabetes, emphasizing the importance of individualized glycemic management in this population.