Relative Hyperglycemia, a Marker of Critical Illness: Introducing the Stress Hyperglycemia Ratio.
BACKGROUND
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.


METHODS
The study was an observational cohort study.


METHODS
A total of 2290 patients acutely admitted to a tertiary hospital.


METHODS
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.
Pharmacy 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.
Gregory W
GW
Roberts
Pharmacy 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.
Stephen J
SJ
Quinn
Pharmacy 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.
Nyoli
N
Valentine
Pharmacy 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.
Tariq
T
Alhawassi
Pharmacy 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.
Hazel
H
O'Dea
Pharmacy 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.
Stephen N
SN
Stranks
Pharmacy 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.
Morton G
MG
Burt
Pharmacy 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.
Matthew P
MP
Doogue
D000328:Adult; D001315:Australia / Q000453:epidemiology; D015415:Biomarkers / Q000097:blood*; D001786:Blood Glucose / Q000378:metabolism; D015331:Cohort Studies; D003422:Critical Care; D016638:Critical Illness / Q000401:mortality*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D006943:Hyperglycemia / Q000097:blood*; D008297:Male; D008875:Middle Aged; D013312:Stress, Physiological
D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin