Relative Hyperglycemia, a Marker of Critical Illness: Introducing the Stress Hyperglycemia Ratio
Gregory W Roberts1, Stephen J Quinn1, Nyoli Valentine1
1Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand.
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:
A total of 2290 patients acutely admitted to a tertiary hospital.
Main Outcome Measure:
The 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% confidence interval, 1.18-1.28]; P < .001) and glucose (odds ratio, 1.18 per mmol/L [1.13-1.23]; P < .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]; P < .001), but not glucose (odds ratio, 1.03 per mmol/L [0.97-1.11]; P = .31). Background hyperglycemia affected the relationship between glucose (P = .002) and critical illness, but not SHR (P = .35) and critical illness. In patients with admission glucose ≤ 10 mmol/L, the odds ratio for critical illness was higher in the fourth (2.4 [1.4-4.2]; P = .001) and fifth (3.9 [2.3-6.8]; P < .001) SHR quintiles than in 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 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.
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