title: Adrenal insufficiency in liver disease - what is the evidence?
abstract: Recently, treatment with corticosteroids in the setting of septic shock and adrenal insufficiency has been shown to decrease mortality. In septic patients, a blunted response to adrenal stimulation identifies patients with a poorer prognosis who may benefit from corticosteroid supplementation. This condition has been termed relative adrenal insufficiency (RAI). Given the similarities between septic shock and liver failure, a number of groups have now studied the incidence of RAI in various forms of liver disease. Although different definitions of RAI exist, the current literature suggests that RAI is common, being seen in 33% of acute liver failure patients and up to 65% of patients with chronic liver disease and sepsis. The finding that RAI can exist in the absence of sepsis and may be as high as 92% of patients undergoing liver transplantation using a steroid free protocol has led one group to propose the term hepatoadrenal syndrome. The purpose of this review is to summarise the existing evidence for adrenal insufficiency in liver disease, to examine the possibility that adrenal dysfunction in liver disease may have a separate pathogenesis to that observed in sepsis and to provide insight into the potential areas for further research into this condition.
authors.affiliation: Department of Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, Pond Street, Hampstead, London, UK. james.obeirne@royalfree.nhs.co.uk
authors.forename: James
authors.initials: J
authors.lastname: O'Beirne
authors.forename: Michael
authors.initials: M
authors.lastname: Holmes
authors.forename: Banwari
authors.initials: B
authors.lastname: Agarwal
authors.forename: Pierre
authors.initials: P
authors.lastname: Bouloux
authors.forename: Steve
authors.initials: S
authors.lastname: Shaw
authors.forename: David
authors.initials: D
authors.lastname: Patch
authors.forename: Andrew
authors.initials: A
authors.lastname: Burroughs
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use; D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D004305:Dose-Response Relationship, Drug; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D008107:Liver Diseases / Q000150:complications* / Q000601:surgery; D016031:Liver Transplantation; D015995:Prevalence; D018805:Sepsis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy; D012772:Shock, Septic / Q000150:complications / Q000188:drug therapy / Q000378:metabolism
chemical_list: D000305:Adrenal Cortex Hormones; D006854:Hydrocortisone