title: Adrenal insufficiency predicts early mortality in patients with cirrhosis.
abstract: BACKGROUND
  Adrenal insufficiency (AI), also known as hepato-adrenal syndrome, is a well-known entity in cirrhotic patients. However, factors associated with AI and its effect on survival are still not clear. We determined the prevalence of AI in patients with cirrhosis who had no hemodynamic instability or any acute deterioration, and studied its influence on short-term survival.
  
  
  METHODS
  In consecutive cirrhotic patients, presence of AI was determined either by total serum cortisol <18 µg/dl, 60 minutes after 250 µg synacthen injection, or when the delta-fraction (post-synacthen serum cortisol minus basal serum cortisol) was <9 µg/dl.
  
  
  RESULTS
  A total of 120 patients were included in the study (median age 50 years (range 27-73), males 87%). The median CTP and MELD scores were 10 (range 6-13) and 20 (range 6-40). The etiology of cirrhosis was alcohol (51%), cryptogenic (28%), viral (19%) and autoimmune (2%). Sixty-nine patients (58%) had AI and the remaining 51 (42%) had normal adrenal function. Serum bilirubin was significantly higher (p < 0.05) in the AI group, and total cholesterol, HDL, LDL and hemoglobin were significantly lower (p < 0.05) in the AI group. CTP score, MELD score, and basal cortisol levels were not different between those with and without AI (p = NS). By 120 days of follow-up, 41 patients had died. Thus, the 120-day survival was 66%, and this was higher in patients without AI than in patients with AI (78% vs 56%; p = 0.019). On multivariate analysis absence of AI, low WBC and low CTP score independently predicted 120-day survival.
  
  
  CONCLUSIONS
  AI is present in more than half of cirrhotic patients but does not parallel the severity scores of cirrhosis. Its presence predicts early mortality in these patients, and this prediction is independent of CTP or MELD scores.
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Romesh
authors.initials: R
authors.lastname: Chawlani
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Anil
authors.initials: A
authors.lastname: Arora
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Piyush
authors.initials: P
authors.lastname: Ranjan
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Praveen
authors.initials: P
authors.lastname: Sharma
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Tyagi
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Naresh
authors.initials: N
authors.lastname: Bansal
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Vikas
authors.initials: V
authors.lastname: Singla
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Veronica
authors.initials: V
authors.lastname: Arora
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Hardik L
authors.initials: HL
authors.lastname: Kotecha
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Vijendra
authors.initials: V
authors.lastname: Kirnake
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Jay
authors.initials: J
authors.lastname: Toshniwal
authors.affiliation: Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Kumar
keywords: Adrenal insufficiency; CTP; MELD; cirrhosis; mortality; severity