The association between stress hyperglycemia ratio and adverse outcomes in patients with chronic kidney disease: a systematic review and meta-analysis

Abstract

Chronic kidney disease (CKD) increases risks of cardiovascular events and mortality, so reliable biomarkers are needed to improve risk stratification. Stress hyperglycemia ratio (SHR), which adjusts acute glucose levels for chronic glycemia using glycated hemoglobin, has shown prognostic value in various settings, but its role in predicting outcomes in CKD is still unclear. This study aimed to evaluate the association between SHR and adverse outcomes in patients with CKD. PubMed, Scopus, Web of Science, and Embase were searched up to March 15, 2025, for studies reporting the association between SHR and outcomes in patients with CKD. Observational studies and clinical trials were eligible if they reported SHR and at least one adverse outcomes. Data extraction and quality assessment using the Newcastle–Ottawa Scale were performed independently by two reviewers. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed with the I² statistic, publication bias with Egger’s and Begg’s tests, and sensitivity analyses with a leave-one-out approach. Out of 307 records initially identified, eight studies involving 19,740 patients with CKD were included. Most were cohort studies conducted in the United States or China. Four studies with 12,324 participants reported all-cause mortality, showing a non-significant association between higher SHR and risk of death (pooled OR: 1.39; 95% CI: 0.85–2.27). Three studies with 11,035 participants assessed cardiovascular mortality, also yielding a non-significant result (pooled OR: 1.50; 95% CI: 0.86–2.62). Sensitivity analyses demonstrated that the pooled estimates were sensitive to the exclusion of a single influential study, indicating limited robustness of the current evidence rather than confirming a prognostic effect of SHR. No publication bias was detected, and overall study quality was rated as good. Higher SHR was not consistently associated with all-cause or cardiovascular mortality in patients with CKD, although sensitivity analyses suggested SHR may have prognostic potential. These findings highlight the need for larger, well-designed studies with standardized SHR assessment to clarify its role as a prognostic marker in CKD.