Moinak Sen Sarma1, Umesh Reddy1, Parijat Ram Tripathi1, Anup Kumar1, Surender Kumar Yachha1, Anshu Srivastava1
1Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Background/Aims: Relative adrenal insufficiency (RAI), a silent predisposing factor of poor outcome has not been described in pediatric literature till date. We aimed to study the outcome of cirrhotics diagnosed with RAI over one year of followup.
Methods: Hemodyamically stable cirrhotics were assessed for RAI (peak-cortisol <500 nmol/L after 30 minutes of 1 mcg intravenous synacthen) and followed up >1 year of specific therapy to assess for adrenal, laboratory, pediatric end-stage liver disease(PELD) score and clinical outcome. Those on corticosteroids and concurrent infections were excluded. Delta-cortisol was defined as difference between basal and peak cortisol. PELD-delta cortisol predictive model was applied to assess outcome and morbidity events (new-onset organ failures, variceal bleeding, infections and hospital readmissions).
Results: Fourty-two of 57 cirrhotics aged 10.8±3.7 years survived with native liver 15±2.9 months. Table 1 compares survivors vs. poor outcome. PELD-delta cortisol was the best model to predict morbidity events and death [AUROC 0.77 (95%CI:0.67-0.87), p<0.001, cut-off:0.35, sensitivity87%, specificity:60%]. Using multivariate analysis, baseline PELD-delta cortisol score (OR:6.8, 95%CI: 1.5-9.7,p=0.004) was an independent predictor of survival. 29 (50%) cirrhotics had baseline RAI, of whom 9(31%) with RAI died over 8.6±6.2 months. In 25 patients who were reassessed after 1 year, RAI resolved (n=10), persisted (n=7), newly developed (n=3) and 5 had persisting normal adrenal functions. RAI at follow-up (n=10) vs no RAI (n=15) had higher one year cumulative morbidity events (n=11 vs. n=6,p=0.03).
Conclusion: Morbidity events in pediatric cirrhosis are higher in baseline and persistent RAI patients. 60% have normal adrenal functions at follow up.
Keywords: adrenal insufficiency, children, cirrhotic, cortisol, outcome