U-shaped association of the stress hyperglycemia ratio for all-cause and cardiovascular mortality in patients with NAFLD: results from the NHANES database prospective cohort study

ObjectiveStress hyperglycemia ratio (SHR), an index reflecting relative hyperglycemia under stress conditions, has been linked to adverse outcomes in various clinical settings. However, its prognostic significance in individuals with nonalcoholic fatty liver disease (NAFLD) remains poorly understood. This study aimed to examine the association between SHR and mortality risk in adults with NAFLD.MethodsWe analyzed 12,604 adults with NAFLD from the NHANES 1999-2018 database. Multivariable Cox proportional hazards models, restricted cubic spline (RCS) analysis, and Fine-Gray competing risk models were employed to evaluate associations between SHR and all-cause and cardiovascular mortality,ResultsDuring an overall mean follow-up time of 99.26 months, a U-shaped relationship was observed between SHR and all-cause mortality in adults aged 40-59 years and >= 60 years. Risk increased at both low and high SHR levels, with identified thresholds at 0.89 for middle-aged and 0.94 for older adults. No significant association was found with cardiovascular mortality. Findings were consistent across subgroups.ConclusionSHR showed a U-shaped association with all-cause mortality in middle-aged and older adults with NAFLD. Monitoring SHR may help identify high-risk individuals and guide clinical management.