Relative Adrenal Insufficiency in Decompensated Cirrhosis: Relationship to Short-Term Risk of Severe Sepsis, Hepatorenal Syndrome, and Death

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 g/dL after 250 g of intravenous corticotropin from basal values <35 g/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). Conclusion: 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. (Hepatology 2013;58:1757-1765)