Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial.

BACKGROUND: Recent studies have reported a high prevalence of relative adrenal insufficiency in patients with liver cirrhosis. However, the effect of corticosteroid replacement on mortality in this high-risk group remains unclear. We examined the effect of low-dose hydrocortisone in patients with cirrhosis who presented with septic shock. METHODS: We enrolled patients with cirrhosis and septic shock aged 18 years or older in a randomized double-blind placebo-controlled trial. Relative adrenal insufficiency was defined as a serum cortisol increase of less than 250 nmol/L or 9 µg/dL from baseline after stimulation with 250 µg of intravenous corticotropin. Patients were assigned to receive 50 mg of intravenous hydrocortisone or placebo every six hours until hemodynamic stability was achieved, followed by steroid tapering over eight days. The primary outcome was 28-day all-cause mortality. RESULTS: The trial was stopped for futility at interim analysis after 75 patients were enrolled. Relative adrenal insufficiency was diagnosed in 76% of patients. Compared with the placebo group (n = 36), patients in the hydrocortisone group (n = 39) had a significant reduction in vasopressor doses and higher rates of shock reversal (relative risk [RR] 1.58, 95% confidence interval [CI] 0.98-2.55, p = 0.05). Hydrocortisone use was not associated with a reduction in 28-day mortality (RR 1.17, 95% CI 0.92-1.49, p = 0.19) but was associated with an increase in shock relapse (RR 2.58, 95% CI 1.04-6.45, p = 0.03) and gastrointestinal bleeding (RR 3.00, 95% CI 1.08-8.36, p = 0.02). INTERPRETATION: Relative adrenal insufficiency was very common in patients with cirrhosis presenting with septic shock. Despite initial favourable effects on hemodynamic parameters, hydrocortisone therapy did not reduce mortality and was associated with an increase in adverse effects. (Current Controlled Trials registry no. ISRCTN99675218.).

Incidence trends of viral hepatitis A, B, and C seropositivity over eight years of surveillance in Saudi Arabia.

OBJECTIVES: In Saudi Arabia, viral hepatitis ranked the second most common reportable viral disease in 2007, with almost 9000 new cases diagnosed in that year. The objective of this study was to determine the incidence trends of viral hepatitis seropositivity among the population served by the National Guard Health Affairs (NGHA) hospitals in the central, eastern, and western Saudi Arabia regions. METHODS: The surveillance system at King Abdulaziz Medical City in Riyadh receives weekly reports of laboratory confirmed hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV) cases from all NGHA-served regions. In this study the viral hepatitis surveillance data for the period from January 2000 through December 2007 were analyzed. RESULTS: Between 2000 and 2007, a total of 14 224 seropositive cases of viral hepatitis were reported to the surveillance system. The average annual incidence of seropositivity per 100 000 served population was highest for HBV (104.6), followed by HCV (78.4), and lowest for HAV (13.6). Saudis had higher HBV and HAV incidence, but lower HCV incidence compared to non-Saudis. Over the eight years (2000-2007), the incidence of all three viral hepatitis types showed a 20-30% declining trend. Only HAV incidence followed a clear seasonal cyclic pattern. CONCLUSIONS: Despite the declining trend over the eight-year period, viral hepatitis, especially that caused by HBV and HCV, remains a major public health problem in Saudi Arabia, and has probably been underestimated in previous reports. There is a need for more comprehensive prevention strategies.