Assessment of adrenocortical reserve in stable patients with cirrhosis.
OBJECTIVE
Adrenal insufficiency (AI) is reported in critically ill patients with cirrhosis and is associated with increased mortality. It is unclear if AI is an underlying condition or triggered by critical events (e.g. sepsis). We investigated AI in cirrhosis without infection or hemodynamic instability.


METHODS
A total of 101 consecutive patients with cirrhosis were studied. AI was defined by a total serum cortisol (TC) <18 μg/dl at 20 or 30 min after injection of 1 μg of tetracosactrin. Transcortin, calculated free cortisol (cFC), and free cortisol index (FCI) were assessed in a subgroup of 41 patients, with FCI>12 representing normal adrenal function.


RESULTS
AI was present in 38 patients (38%). Child score (median, 10 vs 7, p<0.0001), MELD score (median, 17 vs 12, p<0.0001), ascites (68% vs 37%, p<0.01), basal TC (median,7.6 vs 14.9 μg/dl, p<0.001), albumin (28 ± 0.8 vs 33 ± 0.7 g/L, p<0.0001), INR (median, 1.6 vs 1.2, p<0.0001), total bilirubin (median, 51 vs 31 μmol/L, p<0.05), total cholesterol (median, 120 vs 142, p<0.05), and LDL (median, 76 vs 81, p<0.05) were significantly different between those with and without AI. ROC curves showed a basal TC ≤ 12.8 μg/dl to be a cut-off value closely associated with AI. The cFC was significantly related to TC for baseline values (R=0.94, p<0.0001), peak values (R=0.90, p<0.0001), and delta values (R=0.95, p<0.0001), in patients with and without AI. However, no patient had a FCI<12.


CONCLUSIONS
AI defined by an abnormal response to 1 μg tetracosactrin is frequent in stable patients with cirrhosis, in the absence of infections or hemodynamic instability and is related to the severity of liver disease. However, evaluation of the true incidence of AI should comprise direct assays of free cortisol. Clinical consequences of AI need to be explored.
Internal Medicine, University of Catania - Garibaldi Hospital, Catania, Italy.
Giuseppe
G
Fede
Luisa
L
Spadaro
Tania
T
Tomaselli
Graziella
G
Privitera
Salvatore
S
Piro
Agata Maria
AM
Rabuazzo
Alexander
A
Sigalas
Elias
E
Xirouchakis
James
J
O'Beirne
Matteo
M
Garcovich
Emmanuel
E
Tsochatzis
Francesco
F
Purrello
Andrew Kenneth
AK
Burroughs
D000309:Adrenal Insufficiency / Q000175:diagnosis*; D002352:Carrier Proteins / Q000097:blood; D002784:Cholesterol / Q000097:blood; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008103:Liver Cirrhosis / Q000150:complications* / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012372:ROC Curve; D012709:Serum Albumin / Q000032:analysis
D002352:Carrier Proteins; D012709:Serum Albumin; C027091:cortisol binding globulin; D002784:Cholesterol; D006854:Hydrocortisone