title: Relative adrenal insufficiency in decompensated cirrhosis: Relationship to short-term risk of severe sepsis, hepatorenal syndrome, and death.
abstract: The prevalence of relative adrenal insufficiency (RAI) in critically ill cirrhosis patients with severe sepsis is over 60% and associated features include poor liver function, renal failure, refractory shock, and high mortality. RAI may also develop in noncritically ill cirrhosis patients but its relationship to the clinical course has not yet been assessed. The current study was performed in 143 noncritically ill cirrhosis patients admitted for acute decompensation. Within 24 hours after hospitalization adrenal function, plasma renin activity, plasma noradrenaline and vasopressin concentration, and serum levels of nitric oxide, interleukin-6 and tumor necrosis factor alpha were determined. RAI was defined as a serum total cortisol increase <9 μg/dL after 250 μg of intravenous corticotropin from basal values <35 μg/dL. Patients were followed for 3 months. RAI was detected in 26% of patients (n = 37). At baseline, patients with RAI presented with lower mean arterial pressure (76 ± 12 versus 83 ± 14 mmHg, P = 0.009) and serum sodium (131 ± 7 versus 135 ± 5 mEq/L, P = 0.007) and higher blood urea nitrogen (32 ± 24 versus 24 ± 15 mg/dl, P = 0.06), plasma renin activity (7.1 ± 9.9 versus 3.4 ± 5.6 ng/mL*h, P = 0.03), and noradrenaline concentration (544 ± 334 versus 402 ± 316 pg/mL, P = 0.02). During follow-up, patients with RAI exhibited a higher probability of infection (41% versus 21%, P = 0.008), severe sepsis (27% versus 9%, P = 0.003), type-1 hepatorenal syndrome (HRS) (16% versus 3%, P = 0.002), and death (22% versus 7%, P = 0.01).
  
  
  CONCLUSIONS
  RAI is frequent in noncritically ill patients with acute decompensation of cirrhosis. As compared with those with normal adrenal function, patients with RAI have greater impairment of circulatory and renal function, higher probability of severe sepsis and type-1 HRS, and higher short-term mortality.
authors.affiliation: Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Acevedo
authors.forename: Javier
authors.initials: J
authors.lastname: Fernández
authors.forename: Verónica
authors.initials: V
authors.lastname: Prado
authors.forename: Anibal
authors.initials: A
authors.lastname: Silva
authors.forename: Miriam
authors.initials: M
authors.lastname: Castro
authors.forename: Marco
authors.initials: M
authors.lastname: Pavesi
authors.forename: Daria
authors.initials: D
authors.lastname: Roca
authors.forename: Wladimiro
authors.initials: W
authors.lastname: Jimenez
authors.forename: Pere
authors.initials: P
authors.lastname: Ginès
authors.forename: Vicente
authors.initials: V
authors.lastname: Arroyo
mesh_terms: D000309:Adrenal Insufficiency / Q000150:complications* / Q000209:etiology / Q000401:mortality; D000368:Aged; D002784:Cholesterol / Q000097:blood; D005260:Female; D006530:Hepatorenal Syndrome / Q000209:etiology*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000209:etiology*
chemical_list: D002784:Cholesterol