The prognostic impact of the Stress Hyperglycemia Ratio on End‐Stage Renal Disease among patients with Diabetic Kidney Disease

The Stress Hyperglycemia Ratio (SHR), a new biomarker calculated from glucose and HbA1c levels, has been linked to significant clinical outcomes in diabetes. This study investigates the potential of the SHR to predict End-Stage Renal Disease (ESRD) among patients with Diabetic Kidney Disease (DKD). We included 316 participants from the West China Hospital T2DM-DKD cohort (January 2008-September 2020), divided into three SHR tertiles: T1 (SHR <0.7), T2 (SHR ≥0.7 to <0.94) and T3 (SHR ≥0.94). A second retrospective cohort of 625 DKD patients was recruited from Sichuan University Hospital (January 2019-May 2022), with similar inclusion criteria. SHR was analysed using Restricted Cubic Spline, Kaplan-Meier curves and Cox proportional hazards models. Key confounders such as eGFR, proteinuria, hypoalbuminemia and glucose-lowering medications were adjusted for in the analysis. In Cohort 1 (median follow-up 42 months), 38.6% developed ESRD. Kaplan-Meier curves showed a higher incidence of ESRD in the lowest and highest SHR tertiles compared to the middle group (p < 0.01). Multivariate analysis confirmed that SHR <0.7 (HR 1.71, 95% CI: 1.01-2.90) and SHR ≥0.94 (HR 1.93, 95% CI: 1.16-3.20) were significantly associated with ESRD. In Cohort 2 (median follow-up 18.6 months), patients with SHR <0.7 and ≥0.94 had significantly higher risks of ≥30% eGFR decline or ESRD, with adjusted HRs of 2.18 (95% CI: 1.15-4.11) and 2.68 (95% CI: 1.38-5.23), respectively. This study observed a U-shaped relationship between SHR and ESRD in patients with DKD. Both very high and very low SHR values correlate with increased risks, highlighting the critical importance of glucose management in chronic diabetes care.