Indian Journal of Critical Care Medicine
Volume 25 | Issue 11 | Year 2021

Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19

Rohan Magoon1https://orcid.org/0000-0003-4633-8851, Jes Jose2https://orcid.org/0000-0003-1734-9519

1Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, India

2Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Corresponding Author: Jes Jose, Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India, Phone: +91 9741447662, e-mail: drjesjoseworkmail@gmail.com

How to cite this article: Magoon R, Jose J. Stress Hyperglycemia Ratio may Portend Poor Outcomes in COVID-19. Indian J Crit Care Med 2021;25(11):1329.

Source of support: Nil

Conflict of interest: None

Keywords: Admission blood glucose, COVID-19, Diabetes mellitus, Poor outcomes, Relative hyperglycemia, Stress hyperglycemia ratio.

Dear Editor,

Amidst an ardent interest in the pathophysiological and prognostic links between diabetes mellitus and coronavirus disease-2019 (COVID-19), the concept of stress hyperglycemia merits concurrent research attention. This becomes particularly relevant in the background of reports of an augmented disease severity in COVID-19 patients demonstrating elevated admission blood glucose levels, irrespective of the preexisting diabetic status.1,2

The absolute degree of admission hyperglycemia has been described to be associated with poor COVID-19 outcomes by Lazarus et al. (33% increase in the risk of severe disease for every 1 mmol/L rise in the admission fasting blood glucose) in their dose-response meta-analysis.1 Moreover, few independent researchers outline a worsened attributable prognosis (owing to admission hyperglycemia) in nondiabetics ahead of the diabetics.2

While hyperglycemia at presentation emerges as a pertinent prognostic finding, the findings of a French nationwide multicenter CORONADO study [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and diabetes outcomes] simultaneously undermine the isolated prognostic implications of the background glycemic control [assessed by glycated hemoglobin (HbA1c)].3 This highlights the outcome predictive significance of acute hyperglycemia over and above the chronic glycemic control, particularly in the absence of long-term adaptations to deal with the hyperglycemia-exacerbated constellation of endotheliitis, oxidative stress, and thrombosis (well-known features of a severe COVID-19 infection, inflammation being the common denominator).4

In this context, stress hyperglycemia ratio (SHR), introduced by Roberts et al., is computed as the ratio of admission blood glucose and the estimated average blood glucose derived from HbA1c, thereby adjusting for the background glycemia adequately. Withstanding this fact, SHR can potentially be a superior marker of the relative extent of the stress glycemic response to the intercurrent critical illnesses, such as an underlying COVID-19 infection.5 The findings of Fabbri et al., revealing a significantly accentuated mortality prediction with an odds ratio of 5.25 and area under the receiver-operating characteristic curve of 0.864 attributable to a SHR ≥1.14 in critically ill septic diabetics, bear testimony to the same.5 In addition, independent research groups also emphasize the importance of disease-related glycemic alterations in contemplating risk stratification of the critically ill based on their depiction of an improved inhospital mortality prediction with the inclusion of the component of stress-induced hyperglycemia to the Acute Physiology and Chronic Health Evaluation (APACHE II) score.5

Therefore, premised on the aforementioned discussion, future research endeavors focusing on the concept of relative hyperglycemia are advocated wherein an elevated SHR may portend poor outcomes in the setting of COVID-19.


Rohan Magoon https://orcid.org/0000-0003-4633-8851

Jes Jose https://orcid.org/0000-0003-1734-9519


1. Lazarus G, Audrey J, Wangsaputra VK, Tamara A, Tahapary DL. High admission blood glucose independently predicts poor prognosis in COVID-19 patients: a systematic review and dose-response meta-analysis. Diabetes Res Clin Pract 2021;171:108561. DOI: 10.1016/j.diabres.2020.108561.

2. Cai Y, Shi S, Yang F, Yi B, Chen X, Li J, et al. Fasting blood glucose level is a predictor of mortality in patients with COVID-19 independent of diabetes history. Diabetes Res Clin Pract 2020;169:108437. DOI: 10.1016/j.diabres.2020.108437.

3. Cariou B, Hadjadj S, Wargny M, Pichelin M, Al-Salameh A, Allix I, et al. CORONADO investigators. Phenotypic characteristics and prognosis of inpatients with COVID-19 and diabetes: the CORONADO study. Diabetologia 2020;63(8):1500–1515. DOI: 10.1007/s00125-020-05180-x.

4. Magoon R. Pulmonary vasculature in COVID-19: mechanism to monitoring! Korean J Anesthesiol 2021;74(2):186–187. DOI: 10.4097/kja.20536.

5. Fabbri A, Marchesini G, Benazzi B, Morelli A, Montesi D, Bini C, et al. Stress hyperglycemia and mortality in subjects with diabetes and sepsis. Crit Care Explor 2020;2(7):e0152. DOI: 10.1097/CCE.0000000000000152.

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