Circulatory and renal dysfunction and overactivity of the renin-angiotensin and sympathetic nervous systems are well-known risk factors of HRS development in patients with decompensated cirrhosis.[45] On the other hand, bacterial infections in cirrhosis are frequently associated Inhibitor Library screening to the development of type-1 HRS.[45, 46] These factors could account for the higher risk of type-1 HRS observed in patients with RAI. Another interesting observation of our study was that patients with RAI and bacterial infection developed more frequently severe sepsis or shock. The more

severe impairment in circulatory function prior to infection and perhaps an exaggerated inflammatory response due to low circulating cortisol levels could account for this feature. The probability of death was significantly higher in noncritically ill patients with RAI than in those with normal adrenal function. The main cause of death was ACLF, a recently defined syndrome in patients with acute decompensation of cirrhosis characterized by one or more organ failures, intense systemic inflammatory response, and very high mortality.[31] The second cause of mortality in this series was septic shock. In the analysis of independent risk factors for the development of severe sepsis, type-1 HRS, and death, click here delta cortisol together with three important predictive variables (MELD, which estimates the degree

of liver and renal dysfunction, and plasma renin activity and norepinephrine concentration, which estimate the degree of circulatory dysfunction) were introduced in the models. Delta cortisol and MELD were found to be independent predictors of severe sepsis, type-1 HRS, and mortality. Plasma renin activity and plasma noradrenaline were also independent risk factors of severe sepsis and death, Histone demethylase respectively. A potential

weakness of our study is the heterogeneity of patients included. The study was designed to evaluate the prevalence of RAI and its relationship to clinical course in noncritically ill cirrhosis patients with acute clinical decompensation, thereby including subjects with ascites, encephalopathy, bacterial infection, variceal bleeding, or HRS. Although the prevalence of RAI did not significantly differ among different patient groups (except for type-1 HRS), mechanisms of adrenal dysfunction and its association with clinical events may differ among different decompensations of cirrhosis. Further studies should clarify this point. In summary, our study shows that RAI is a relatively frequent event in noncritically ill cirrhosis patients with acute decompensation and appears to be associated with impairment in circulatory and renal function and higher risk of short-term development of bacterial infections, severe sepsis, type-1 HRS, and death. Additional Supporting Information may be found in the online version of this article.