Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock

Abstract

Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instabity and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 ؎ 8.0 vs. 8.5 ؎ 5.9 g/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End-Stage Liver Disease, and Child-Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 ؎ 14 vs. 74.5 ؎ 13 mm Hg, P < .001 ), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality. (HEPATOLOGY 2006;43:673-681.) C ritical illness is accompanied by the activation of the hypothalamic-pituitary-adrenal (HPA) axis, which is highlighted by increased serum corticotropin and cortisol levels. [1][2][3] The activation of the HPA axis is a crucial component of the host's adaptation to severe stress. Cortisol is essential for the normal function of the immune system, maintenance of vascular tone, and various cellular functions. In patients with severe sepsis, the integrity of the HPA axis can be impaired by a variety of mechanisms. 1,4 Recently, the concept of relative adrenal insufficiency has been used to describe a subnormal adrenal response to adrenocorticotropin in severe illness, in which the cortisol levels, even though high in terms of absolute value, are inadequate to control the inflammatory situation. 1 The short corticotropin stimulation test (SST) is most commonly used to evaluate the appropriateness of the adrenal response in this setting. In patients with septic shock, a decreased response to the SST, namely, an absolute increment of the serum cortisol level less than 9 g/dL, is associated with an impaired vascular reactivity to vasopressors 5 and a high mortalit...

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

“…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.…”

“…The second study was performed in 101 patients with cirrhosis and severe sepsis requiring intensive monitoring or treatment. 8 According to the criteria used in the current study, 50 of these 101 patients had septic shock. Adrenal insufficiency was diagnosed in 52% of the patients and was significantly associated with septic shock, disease severity, renal failure, and hospital mortality.…”

Bacterial infections in cirrhosis

“…Adrenal insufficiency was found to be a common cause of hemodynamic instability in patients with cirrhosis and concomitant sepsis (52-77%) as well. This condition was associated with hypotension, which was refractory to volume administration and vasopressor drugs, and leaded to mortality rate 81% vs. 37% in patients without adrenal dysfunction [116]. Despite of it the efficacy of stress dose steroids on the outcome of cirrhotic patients with septic shock is unclear and gastrointestinal bleedings may develop more frequently.…”

Development of 365-day Life Expectancy Models: Application of Machine Learning Methods to a Prospective Study of Critically Ill Cirrhotic Patients (Preprint)

“…The high mortality rate is attributed to multiple organ dysfunction [1][2][3]. Disturbed systemic circulation in end-stage liver disease is caused by arterial vasodilation in the splanchnic circulation, reduced total peripheral vascular resistance and arterial pressure causing a secondary increase in cardiac output [4][5][6].…”