S1225 Relative Adrenal Insufficiency in Decompensated Cirrhosis: A Systematic Review and Meta-Analysis

Introduction: Relative adrenal insufficiency (RAI) is associated with increased mortality in critically ill patients. It can be seen in patients with cirrhosis, especially with decompensated disease, often described as “hepato-adrenal syndrome”. We conducted a systematic review and meta-analysis to assess the true incidence of RAI among decompensated cirrhotics and its effects on outcomes. Methods: We conducted a comprehensive search of Ovid Cochrane, Ovid Embase, Ovid Medline, Scopus, and Web of Science (inception to July 2021) to identify studies reporting on relative adrenal insufficiency in decompensated cirrhosis. RAI was diagnosed as an increase in serum total cortisol < 9 mcg/dl after standard dose-synacthen stimulation test. The primary outcome was incidence of RAI; secondary outcomes were risk ratio of ascites, hepato-renal syndrome, ICU admission and in-hospital mortality. Standardized mean difference and meta-analysis of proportions was done for outcomes. Results: Out of 249 studies, 8 were included in final analysis based on inclusion criteria. 710 patients, with 502 males (70.7%), mean age 56.53 ± 3.81 years were analyzed. Pooled incidence of RAI in decompensated cirrhosis was 38% (8 studies; CI: 29.5 - 47.6; I2= 82.19%). Patients with RAI had higher MELD score with mean difference 0.383 (8 studies; CI: 0.124 - 0.642; I2 = 58.5%), lower mean arterial pressure -0.182 (5 studies; CI: -0.368 - -0.004; I2 = 9.09%), serum albumin -0.460 (7 studies; CI: -0.702 - -0.271, I2 = 38.53%) and sodium -0.254 (6 studies; CI: -0.509 - 0, I2 = 48.2%). Effects of RAI on outcomes is shown in the Table. Conclusion: Our meta-analysis reveals a 38% incidence of relative adrenal insufficiency among cirrhotics. Despite a high incidence, RAI did not impact outcomes in terms of ascites, hepato-renal syndrome, ICU admissions, and mortality. Table 1. - Effects of relative adrenal insufficiency on outcomes in non-critically ill decompensated cirrhosis Outcomes Number of studies Risk ratio I2 p-value Ascites 6 1.04 (0.90 - 1.19) 0% 0.59 Hepato-renal syndrome 3 1.31 (0.45 - 3.84) 38.52% 0.62 ICU admission 3 1.79 (0.90 - 3.53) 0% 0.09 In-hospital mortality 5 1.63 (0.94 - 2.83) 0% 0.08