The Prognostic Value of Stress Hyperglycemia Ratio in Hemodialysis Patients: A U-Shaped Association with Mortality

Objectives: To evaluate the prognostic value of the stress hyperglycemia ratio (SHR) in hemodialysis (HD) patients, focusing on its association with all-cause and cardiovascular mortality. Methods: We conducted a retrospective, longitudinal cohort study involving 1,306 HD patients from July 2017 to July 2022. The primary outcome was all-cause mortality, while cardiovascular disease (CVD) mortality was assessed as a secondary outcome. Cox proportional hazards models and Kaplan–Meier survival curves were employed to evaluate the association between SHR and mortality. Additionally, restricted cubic spline (RCS) analyses were performed to explore the non-linear relationship, and an iterative algorithm was used to identify inflection points. Results: During a median follow-up of 62 months, 464 all-cause deaths (35.5%) and 192 CVD-related deaths were observed. A U-shaped association was identified between SHR and both all-cause and CVD mortality, with inflection points at 0.804 and 0.817, respectively. For all-cause mortality, the adjusted hazard ratios (HRs) were 0.63 (95% CI: 0.04–0.78) for SHR < 0.86 and 2.73 (95% CI: 1.78–4.18) for SHR ≥ 0.86. For CVD mortality, the corresponding HRs were 0.57 (95% CI: 0.04–0.87) and 2.70 (95% CI: 1.76–4.14). Subgroup analysis revealed a significant interaction between SHR and body mass index (BMI) in relation to cardiovascular mortality. Conclusions: A U-shaped association exists between SHR and both all-cause and cardiovascular mortality in HD patients. These findings suggest that SHR may serve as a useful prognostic biomarker for risk stratification and may inform individualized glycemic management strategies in the HD population.