Combined assessment with stress hyperglycemia ratio and time in range: Associations with twenty-eight-day mortality in surgical intensive care unit patients

doi:10.4239/wjd.v17.i1.112621

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World Journal of Diabetes

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1948-9358

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Diabetes. Jan 15, 2026; 17(1): 112621
Published online Jan 15, 2026. doi: 10.4239/wjd.v17.i1.112621

Combined assessment with stress hyperglycemia ratio and time in range: Associations with twenty-eight-day mortality in surgical intensive care unit patients

Shuang Liu, Bai-Ge Cao, Yue Ma, Jin-Fang Xu, Quan-Hong Zhou, Cong-Rong Wang

Shuang Liu, Bai-Ge Cao, Cong-Rong Wang, Department of Endocrinology and Metabolism, Shanghai Fourth People’s Hospital Affiliated to Tongji University, Shanghai 200434, China

Shuang Liu, Bai-Ge Cao, Yue Ma, Cong-Rong Wang, School of Medicine, Tongji University, Shanghai 200434, China

Yue Ma, Department of Laboratory Medicine, Zhongda Hospital Southeast University, Nanjing 210004, Jiangsu Province, China

Jin-Fang Xu, Department of Military Health Statistics, Naval Medical University, Shanghai 200433, China

Quan-Hong Zhou, Department of Critical Care Medicine, Shanghai Sixth People’s Hospital, Shanghai 200233, China

Co-first authors: Shuang Liu and Bai-Ge Cao.

Co-corresponding authors: Quan-Hong Zhou and Cong-Rong Wang.

Author contributions: Liu S and Cao BG made equal contributions as co-first authors; Wang CR and Zhou QH performed study design and interpretation as co-corresponding authors; Liu S assisted with data analyses; Ma Y, Liu S, and Cao BG were involved in study conduct and data acquisition. All authors were involved in data interpretation, participated in manuscript preparation, planned the initial draft of the manuscript, and approved the final version for submission.

Supported by Shanghai Science and Technology Development Funds, No. 22410713200; The Noncommunicable Chronic Diseases-National Science and Technology Major Project, No. 2023ZD0509206; National Natural Science Foundation of China, No. 82471893; Key Discipline Project of Hongkou District Health Commission, No. HKLCFC202403; and Research fund from Shanghai Fourth People’s Hospital, No. sykyqd01801 and No. SY-XKZT-2021-1001.

Institutional review board statement: This study protocol was approved by the Ethics Committees of Shanghai Sixth People’s Hospital, No. 2024-KY-012(K).

Informed consent statement: Written informed consent was obtained from all participants.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

Data sharing statement: The data supporting the conclusions of this article are available from the corresponding author upon reasonable request, subject to ethical approval and participant privacy protections.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Cong-Rong Wang, PhD, Professor, Department of Endocrinology and Metabolism, Shanghai Fourth People’s Hospital Affiliated to Tongji University, No. 1279 Sanmen Road, Shanghai 200434, China. crwang@tongji.edu.cn

Received: August 1, 2025
Revised: September 13, 2025
Accepted: November 28, 2025
Published online: January 15, 2026
Processing time: 166 Days and 13.2 Hours

Abstract

BACKGROUND

The stress hyperglycemia ratio (SHR) reflects patients’ acute hyperglycemia status, and the time in range (TIR) captures glucose control dynamics during their intensive care unit (ICU) stays.

AIM

To investigate the independent and combined associations of SHR and TIR with 28-day mortality among surgical ICU patients.

METHODS

In total, 706 adult patients with available glucose data were included. SHR was calculated as the ratio of admission glucose levels to glycosylated hemoglobin-derived estimated average glucose. TIR was calculated as percentages of glucose readings within the 3.9-10.0 mmol/L range during the ICU stay. SHR and TIR were divided into quartiles, and patients were allocated to four groups according to combinations of high/low values. The associations of the SHR, TIR, and both combined with mortality were assessed using logistic regression.

RESULTS

Logistic regression analysis demonstrated that patients in the highest SHR quartile had a significantly increased risk of 28-day mortality compared with the reference quartile [adjusted odds ratio (OR) = 2.24; 95% confidence interval (CI): 1.06-4.71; P = 0.033]. In contrast, higher TIR were associated with a reduced risk of 28-day mortality. Compared with the lowest TIR quartile (Q1), adjusted ORs in Q2, Q3, and Q4 were 0.43 (95%CI: 0.23-0.93; P = 0.030), 0.43 (95%CI: 0.19-0.99; P = 0.046), and 0.41 (95%CI: 0.17-0.98; P = 0.045), respectively. When the SHR and TIR were analyzed in combination, patients with high SHR and low TIR had the highest risk of 28-day mortality (adjusted OR = 2.19; 95%CI: 1.05-4.58; P = 0.038).

CONCLUSION

Combined SHR and TIR assessment offers prognostic value in surgical ICU patients. Maintaining glucose within the target range may be important to improve short-term outcomes in patients with stress hyperglycemia.

Keywords: Surgical intensive care unit; Stress hyperglycemia ratio; Time in range; Twenty-eight-day mortality; Hyperglycemia

Core Tip: While the stress hyperglycemia ratio (SHR) has been widely examined as a marker of acute glycemic disturbance, prior studies have largely emphasized its independent prognostic value, often neglecting its interaction with longitudinal glycemic control indicators. In this study, we evaluated the combined effect of SHR and time in range (TIR) on 28-day mortality in surgical ICU patients. We found that patients with both elevated SHR and reduced TIR exhibited the highest risk of death, with a 2.37-fold increase compared to those with low SHR and high TIR. These findings highlight the prognostic relevance of both acute hyperglycemia and persistent glycemic dysregulation, and emphasize the potential value of integrated glucose management strategies in critically ill patients.