Patients with Hyperglycemia Carry Substantially Higher Perioperative Risk Than Those with Diabetes Alone

Kim S, Saad B, Bracamontes G, Tu B, et al. Glycemic Status and Elective Surgery Risk: Clinically Recognized Hyperglycemia Versus Diabetes Diagnosis Alone in a National Cohort. J Am Coll Surg. April 2026.

In a retrospective cohort study of the National Inpatient Sample (2016–2022), 2,104,338 adults undergoing elective joint arthroplasty, lumbar spine fusion, cholecystectomy, colectomy, cardiac surgery, or hysterectomy were stratified by glycemic status as no diabetes, diabetes without clinically recognized hyperglycemia, or diabetes with hyperglycemia.

Overall, 78.0% had no diabetes, 18.9% had diabetes without hyperglycemia, and 3.1% had diabetes with hyperglycemia. The primary outcome was a composite major adverse event including mortality, acute kidney injury, sepsis, myocardial infarction, ischemic stroke, or venous thromboembolism. After multivariable adjustment, the probability of major adverse events was 5.31% in patients without diabetes, 5.85% in those with diabetes without hyperglycemia, and 9.16% in those with diabetes and hyperglycemia.

Compared with no diabetes, diabetes without hyperglycemia was associated with only a modest increase in risk (aOR 1.13, 95% CI 1.11–1.15; absolute risk difference 0.55%; NNH 183), whereas diabetes with hyperglycemia was associated with substantially greater risk (aOR 2.00, 95% CI 1.94–2.05; absolute risk difference 3.85%; NNH 26).

These findings suggest that diabetes without clinically recognized hyperglycemia is a relatively weak perioperative risk factor, whereas clinically recognized hyperglycemia identifies a distinctly higher-risk population. Glycemic status may therefore be more informative than diabetes diagnosis alone for elective surgical risk stratification.