Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA.
Department of Medicine, School of Medicine, University of Virginia, Charlottesville, Virginia, USA.
Liver Int. 2023 Mar;43(3):660-672. doi: 10.1111/liv.15473. Epub 2022 Nov 21.
BACKGROUND & AIMS: Characterization of relative adrenal insufficiency (RAI) in cirrhosis is heterogeneous with regard to studied patient populations and diagnostic methodology. We aimed to describe the prevalence and prognostic importance of RAI in non-critically ill patients with cirrhosis.
A systematic review and meta-analysis was performed using MeSH terms and Boolean operators to search five large databases (Ovid-MEDLINE, ScienceDirect, Web of Science, Cochrane Library and ClinicalTrials.gov). The population of interest was patients with cirrhosis and without critical illness. The primary outcome was the pooled prevalence of RAI as defined by a peak total cortisol level <18 μg/dl, delta total cortisol <9 μg/dl or composite of the two thresholds in response either a standard-dose or low-dose short synacthen test. Odds ratios and standardized mean differences from random-effects models estimated important clinical outcomes and patient characteristics by adrenal functional status.
Twenty-two studies were included in final analysis, comprising 1991 patients with cirrhosis. The pooled prevalence of RAI was 37% (95% CI 33-42%). The prevalence of RAI varied by Child-Pugh classification, type of stimulation test used, specific diagnostic threshold and by severity of illness. Ninety-day mortality was significantly higher in patients with RAI (OR 2.88, 95% CI 1.69-4.92, I2 = 15%, p < 0.001).
Relative adrenal insufficiency is highly prevalent in non-critically ill patients with cirrhosis and associated with increased mortality. Despite the proposed multifactorial pathogenesis, no studies to date have investigated therapeutic interventions in this specific population.
肝硬化患者的相对肾上腺功能不全（RAI）特征在研究患者人群和诊断方法方面存在差异。我们旨在描述非危重症肝硬化患者中 RAI 的患病率和预后重要性。
使用 MeSH 术语和布尔运算符进行系统评价和荟萃分析，以搜索五个大型数据库（Ovid-MEDLINE、ScienceDirect、Web of Science、Cochrane 图书馆和 ClinicalTrials.gov）。感兴趣的人群是患有肝硬化且无危重病的患者。主要结局是通过峰值总皮质醇水平<18μg/dl、总皮质醇差值<9μg/dl 或对标准剂量或低剂量短 Synacthen 测试的两种阈值中的任何一种反应的复合阈值定义的 RAI 的汇总患病率。来自随机效应模型的比值比和标准化均数差异估计了按肾上腺功能状态划分的重要临床结局和患者特征。
最终分析包括 22 项研究，共纳入 1991 例肝硬化患者。RAI 的总体患病率为 37%（95%CI 33-42%）。RAI 的患病率因 Child-Pugh 分类、使用的刺激试验类型、特定诊断阈值和疾病严重程度而异。RAI 患者的 90 天死亡率显著更高（OR 2.88，95%CI 1.69-4.92，I2=15%，p<0.001）。
非危重症肝硬化患者中 RAI 患病率很高，与死亡率增加相关。尽管提出了多因素发病机制，但迄今为止尚无研究调查过该特定人群中的治疗干预措施。
