Relative hyperglycemia, a marker of critical illness: introducing the stress hyperglycemia ratio
Journal Article
, Gregory, W. R., Quinn, S. J., Valentine, N., Alhawassi, T., O’Dea, H., Stranks, S. N., Burt, M. G., Doogue, M. P. . 2015
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Context: Hyperglycemia in hospitalized patients is associated with increased morbidity and mortality. Objective: We examined whether critical illness is more strongly associated with relative or absolute hyperglycemia. Design: The study was an observational cohort study. Patients and setting: 2290 patients acutely admitted to a tertiary hospital. Main outcome measure: Relative hyperglycemia (Stress Hyperglycemia Ratio, (SHR)) was defined as admission glucose divided by estimated average glucose derived from glycosylated hemoglobin. The relationships between glucose and SHR with critical illness (in-hospital death or critical care) were examined. Results: In univariable analyses, SHR (odds ratio 1.23 per 0.1 increment [95% CI 1.18, 1.28]; p0.001) and glucose (odds ratio 1.18 per mmol/L [95% CI 1.13, 1.23]; p0.001) were associated with critical illness. In multivariable analysis, the association was maintained for SHR (odds ratio 1.20 per 0.1 increment [1.13, 1.28]; p0.001), but not glucose (odds ratio 1.03 per mmol/L [0.97, 1.11]; p0.31). Background hyperglycemia affected the relationship between glucose (p0.002) and critical illness, but not SHR (p0.35) and critical illness. In patients with glucose 10 mmol/L, the odds ratio for critical illness was higher in the fourth (2.4 [1.4, 4.2]; p0.001) and fifth (3.9 [2.3, 6.8]; p0.001) SHR quintiles compared to the lowest SHR quintile. Conclusions: SHR controls for background glycemia and is a better biomarker of critical illness than absolute hyperglycemia. SHR identifies patients with relative but not absolute hyperglycemia at risk of critical illness. Future studies should explore whether basing glucose-lowering therapy on relative, rather than absolute, hyperglycemia improves outcomes in hospitalized patients.