Impact of underlying chronic adrenal insufficiency on clinical course of hospitalized patients with adrenal crisis: A nationwide cohort study

Chronic adrenal insufficiency (AI) is an established risk factor for adrenal crisis (AC). However, the proportion of patients with newly diagnosed chronic AI during admission for AC is unclear. This retrospective cohort study used a Japanese claims database involving 7.39 million patients at 145 acute care hospitals between 2003 and 2014. Study patients with AC met these criteria: 1) newly coded in claims as AI; 2) glucocorticoid therapy administered; 3) admission; and 4) age ≥ 18 years. We investigated the prevalence of underlying chronic AI and assessed in-hospital mortality. Additionally, we explored risk factors for in-hospital mortality through multivariate analysis using a Cox proportional hazards model. Among 504 patients with AC, chronic AI was diagnosed before and during admission in 73 (14.5%) and 86 (17.1%) patients, respectively. In-hospital mortality rates were 1.4% and 5.8%, respectively, lower than that of the total population (14.1%). Significant risk factors for increased mortality were: age (hazard ratio [HR] 1.45/10 years; 95% confidence interval [CI] 1.17–1.78), requiring mechanical ventilation (HR 3.81; 95% CI 1.88–7.72), vasopressor administration (HR 2.05; 95% CI 1.16–3.64), sepsis (HR 3.79; 95% CI 1.57–9.14), AI-related symptoms (HR 2.00; 95% CI 1.02–3.93), and liver disease (HR 3.24; 95% CI 1.10–9.58). Relative to patients without chronic AI, those diagnosed before admission tended to survive to discharge; however, the difference with those diagnosed during admission was not significant. Hospital admission due to nonspecific AI-related symptoms was associated with an increased risk of in-hospital mortality. •Adrenal crisis may indicate underlying chronic adrenal insufficiency.•The proportions of newly- versus previously-diagnosed chronic AI cases were similar.•Pre-existing chronic AI is related to a favorable outcome.•AI-related symptoms are a significant risk factor for in-hospital death.