Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock.
Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instability and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 +/- 8.0 vs. 8.5 +/- 5.9 microg/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End-Stage Liver Disease, and Child-Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 +/- 14 vs. 74.5 +/- 13 mm Hg, P < .001), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality.
Division of Gastroenterology, Chang Gung Memorial Hospital, Chia-Yi, Taipei, Taiwan.
Ming-Hung
MH
Tsai
Yun-Shing
YS
Peng
Yung-Chang
YC
Chen
Nai-Jeng
NJ
Liu
Yu-Pin
YP
Ho
Ji-Tseng
JT
Fang
Jau-Min
JM
Lien
Chun
C
Yang
Pang-Chi
PC
Chen
Cheng-Shyong
CS
Wu
D000311:Adrenal Glands / Q000503:physiopathology; D000309:Adrenal Insufficiency / Q000150:complications / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D000324:Adrenocorticotropic Hormone; D000328:Adult; D000368:Aged; D016470:Bacteremia / Q000150:complications; D001663:Bilirubin / Q000097:blood; D001794:Blood Pressure; D005260:Female; D006728:Hormones; D017052:Hospital Mortality; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008103:Liver Cirrhosis / Q000150:complications* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D018805:Sepsis / Q000150:complications* / Q000503:physiopathology; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000150:complications* / Q000503:physiopathology; D016019:Survival Analysis; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D006728:Hormones; D014662:Vasoconstrictor Agents; D000324:Adrenocorticotropic Hormone; D001663:Bilirubin; D006854:Hydrocortisone