Department of Medicine, Chulabhorn International College of Medicine (CICM), Thammasat University, Pathumthani, Thailand.
Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.
Int J Clin Pract. 2021 Sep;75(9):e14362. doi: 10.1111/ijcp.14362. Epub 2021 May 26.
Relative adrenal insufficiency (RAI) is frequently found in patients with liver cirrhosis, especially in critically ill conditions. However, the prognostic impact of RAI in non-critically ill cirrhosis remains controversial. The aim of the present study was to assess the prevalence of RAI and its prognostic implication in non-critically ill cirrhotic patients.
From December 2015 to November 2017, hospitalised non-critically ill cirrhotic patients admitted with hepatic decompensation were prospectively enrolled in this study. Within 24 hours after admission, 250 mcg ACTH stimulation test was performed. RAI was defined as an increase in serum cortisol <9 mcg/dL in patients with basal serum cortisol <35 mcg/dL. Clinical outcomes were evaluated during admission and at 30-, 90-day visits.
One hundred and fifteen patients were included (66% male, mean age 59.9 ± 16 years, mean MELD 16.1 ± 6.8, Child A/B/C 15.7%/53.9%/30.4%). The main indications for admission were bacterial infection (44.6%) and portal hypertension-related bleeding (19.1%). RAI was detected in 35 patients (30.4%). Patients with RAI had higher Child-Pugh score (9.4 ± 1.9 vs 8.0 ± 1.7, P < .01), and MELD scores (18.3 ± 5.9 vs 15.1 ± 6.9, P = .02). The in-hospital, 30-, and 90-day mortality rates were 9.6%, 20.9%, and 26.1%, respectively. There was no significant difference in the incidence of nosocomial infection, severe sepsis, septic shock, HRS, and mortality rates between patients with and without RAI. By multivariate analysis, bacterial infection on admission (HR 3.13, P < .01) and acute-on-chronic liver failure (HR 4.98, P < .001) were independent predictors of 90-day survival.
RAI is found in about one-third of hospitalised non-critically ill cirrhotic patients and is associated with the severity of cirrhosis. However, the presence of RAI has no influence on short-term outcomes.
相对肾上腺功能不全（RAI）在肝硬化患者中很常见，尤其是在危重病患者中。然而，RAI 在非危重病肝硬化患者中的预后影响仍存在争议。本研究旨在评估非危重病肝硬化患者中 RAI 的患病率及其预后意义。
2015 年 12 月至 2017 年 11 月，前瞻性纳入因肝失代偿而住院的非危重病肝硬化患者。入院后 24 小时内进行 250 mcg ACTH 刺激试验。RAI 定义为基础血清皮质醇<35mcg/dL 的患者中，血清皮质醇升高<9mcg/dL。在入院期间和 30、90 天随访时评估临床结局。
共纳入 115 例患者（66%为男性，平均年龄 59.9±16 岁，平均 MELD 16.1±6.8，Child A/B/C 分别为 15.7%/53.9%/30.4%）。入院的主要指征为细菌感染（44.6%）和门静脉高压相关出血（19.1%）。35 例患者（30.4%）检测到 RAI。RAI 患者的 Child-Pugh 评分较高（9.4±1.9 比 8.0±1.7，P<0.01），MELD 评分较高（18.3±5.9 比 15.1±6.9，P=0.02）。住院、30 天和 90 天的死亡率分别为 9.6%、20.9%和 26.1%。RAI 患者和无 RAI 患者的院内感染、严重脓毒症、感染性休克、HRS 和死亡率发生率无显著差异。多变量分析显示，入院时的细菌感染（HR 3.13，P<0.01）和急性慢性肝衰竭（HR 4.98，P<0.001）是 90 天生存的独立预测因素。
RAI 在约三分之一的住院非危重病肝硬化患者中发现，与肝硬化的严重程度有关。然而，RAI 的存在对短期预后没有影响。
