Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
PROGNOSTIC VALUE OF RELATIVE ADRENAL INSUFFICIENCY IN DECOMPENSATED CIRRHOSIS
J. Acevedo*, J. Fernandez, M. Castro, D. Roca, P. Gines, V. Arroyo
Liver Unit, Hospital Clinic i Provincial de Barcelona, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain. *email@example.com
Relative adrenal insufficiency (RAI) is frequent in cirrhotic patients with severe sepsis or septic shock and it is related to a poor prognosis. Its clinical impact on other decompensations of cirrhosis is unknown.
Objectives: To evaluate the prevalence and prognostic value of RAI in decompensated cirrhosis.
Methods: Prospective study that evaluated, at the first 24 hours of hospital admission using the corticotropin stimulation test (250 µg IV), the presence of RAI defined as basal total cortisol < 15 µg/dl and/or delta cortisol < 9 µg/dl (criteria 1) or as a delta cortisol < 9 µg/dl (criteria 2) in all patients with decompensated cirrhosis hospitalized in our Liver Unit between February 2007 and October 2009. Free cortisol at baseline was also determined (basal total cortisol /transcortin).
Results: 188 patients presented 220 admissions. The prevalence of RAI following criteria 1 and 2 was: 64 and 27% in the whole series, 52 & 21% in SBP, 69 & 24% in non SBP infections, 82 & 46% in not infected ascites, 54 & 31% in hepatic encephalopathy, 58 & 26% in gastrointestinal bleeding, 71 & 29% in hepatorenal syndrome, 49 & 36% in shock and 80 & 22% in a group of 10 ambulatory patients (p=ns). Prevalence of RAI was similar in Child-Pugh A/B patients vs. C (67 vs. 59% and 26 vs. 29%; criteria 1 & 2, respectively). Free cortisol index was significantly higher in decompensated cirrhosis with (48.3±30.6) or without shock (17.3±9.2) than in compensated patients (8.1±2.2); p=0.007. Hospital mortality was 18% (21% at 3 months). There were no significant differences in mortality between patients with and without RAI. Multivariate analysis identified the presence of shock (OR:4.9) and MELD score (OR:1.06) as independent predictors of hospital mortality. These 2 factors and a high basal total cortisol levels (OR:1.06) were identified as independent predictors of poor survival at three months.
Conclusions: Prevalence of RAI is high in decompensated cirrhosis but it is not clinically relevant. By the contrary, activation of hypothalamus-pituitary-adrenal axis is a predictor of poor short term survival in advanced cirrhosis.