Adrenal insufficiency in patients with cirrhosis and septic shock: Effect of treatment with hydrocortisone on survival

Abstract

Relative adrenal insufficiency is frequent in patients with severe sepsis and is associated with hemodynamic instability, renal failure, and increased mortality. This study prospectively evaluated the effects of steroids on shock resolution and hospital survival in a series of 25 consecutive patients with cirrhosis and septic shock (group 1). Adrenal function was evaluated by the short corticotropin test within the first 24 hours of admission. Patients with adrenal insufficiency were treated with stress doses of intravenous hydrocortisone (50 mg/6 h). Data were compared to those obtained from the last 50 consecutive patients with cirrhosis and septic shock admitted to the same intensive care unit in whom adrenal function was not investigated and who did not receive treatment with steroids (group 2). Incidence of adrenal insufficiency in group 1 was 68% (17 patients). Adrenal dysfunction was frequent in patients with advanced cirrhosis (Child C: 76% vs. Child B: 25%, P ‫؍‬ .08). Resolution of septic shock (96% vs. 58%, P ‫؍‬ .001), survival in the intensive care unit (68% vs. 38%, P ‫؍‬ .03), and hospital survival (64% vs. 32%, P ‫؍‬ .003) were significantly higher in group 1. The main causes of death in group 1 were hepatorenal syndrome or liver failure (7 of 9 patients). In contrast, refractory shock caused most of the deaths in group 2 (20 of 34 patients). In conclusion, relative adrenal insufficiency is very frequent in patients with advanced cirrhosis and septic shock. Hydrocortisone administration in these patients is associated with a high frequency of shock resolution and high survival rate. (HEPATOLOGY 2006;44:1288-1295 B acterial infections are a frequent complication and an important cause of death in patients with advanced cirrhosis. 1-3 The mortality rate for patients admitted to the hospital with severe bacterial infections but without septic shock is approximately 30%, 4-6 although it may decrease to 10% if circulatory support with intravenous albumin is given at infection diagnosis. 7 The development of a complex syndrome characterized by acute deterioration of circulatory, hepatic, and renal function and hepatic encephalopathy is the main cause of death in these patients. 6,7 Prognosis of patients with cirrhosis admitted with septic shock is even worse. Hospital mortality in these patients ranges between 60% and 100%, 8,9 which is higher than that reported in the general population of patients with septic shock (25%-70%). [10][11][12] In our experience, survival of patients with cirrhosis in septic shock has not improved greatly during the past decades despite important advances in antibiotic treatment and general supportive measures.During the last few years, several studies have shown that septic shock is frequently associated with relative adrenal insufficiency, a condition characterized by an inadequate production of cortisol with respect to the peripheral demands. [11][12][13][14][15][16][17][18] It also has been reported that patients with septic shock and relative adrenal insufficiency sho...

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