title: Adrenal-exhaustion syndrome in patients with liver disease.
abstract: OBJECTIVE
  Adrenal failure is emerging as an important cause of excess morbidity and mortality in critically ill patients. We have recently reported the high incidence of adrenal failure in patients with liver disease, the so called "hepato-adrenal syndrome." It has been noted that patients who on initial testing may have "normal" adrenal function subsequently progress to overt adrenal failure, the adrenal-exhaustion syndrome. The goal of this study was to further characterize this syndrome.
  
  
  METHODS
  Retrospective review of the "Hepatic Cortisol Research and Adrenal Pathophysiology Study" database.
  
  
  METHODS
  Liver transplant ICU of a tertiary care university hospital.
  
  
  METHODS
  Patients who on initial testing had "normal" adrenal function were followed, and adrenal function testing was repeated in those who failed to improve. The patients were grouped as follows: (1) patients who developed adrenal failure on follow-up testing; and (2) patients who had normal adrenal function during their ICU stay. The incidence and risk factors for the development of adrenal-exhaustion syndrome were determined.
  
  
  RESULTS
  The study cohort consisted of 221 patients, of whom 120 (54%) were diagnosed with adrenal insufficiency on initial diagnostic testing and were excluded from further analysis. The remaining 101 patients comprised those who made up the group of interest. On follow-up, 16 (16%) of these developed adrenal failure a mean of 3 days after initial testing. The only factor that predicted the development of adrenal-exhaustion syndrome was a low HDL level (p<0.001).
  
  
  CONCLUSIONS
  This study demonstrates that adrenal failure is a dynamic process and that repeat adrenal function testing is indicated in patients who remain hemodynamically unstable or fail to improve with aggressive supportive treatment. Low HDL levels may be pathogenetically linked to the development of adrenal failure.
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. paul.marik@jefferson.edu.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Marik
mesh_terms: D000304:Adrenal Cortex Function Tests; D000309:Adrenal Insufficiency / Q000209:etiology*; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008107:Liver Diseases / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D013577:Syndrome