title: Assessment of adrenal function in cirrhotic patients using concentration of serum-free and salivary cortisol.
abstract: OBJECTIVE
  Because over 90% of serum cortisol is bound to albumin and corticosteroid-binding globulin (CBG), changes in these proteins can affect measures of serum total cortisol levels in cirrhotics without altering serum-free and salivary cortisol concentrations.
  
  
  METHODS
  We assessed basal (T₀) and post-synacthen (T₆₀) serum total cortisol, serum-free and salivary cortisol in 125 consecutive cirrhotics (95 non-septic and 30 septic patients with a Child>8).
  
  
  RESULTS
  Serum total cortisol levels significantly decreased from the Child A-C non-septic group, as did albumin and CBG levels, with a non-significant rise in serum-free cortisol concentrations. Non-septic patients with low albumin (≤25 g/L) or CBG levels (≤35 mg/L) had lower T₀ serum total cortisol levels than patients with near-normal albumin (303.4 vs. 382.6 nmol/L; P=0.0035) or with normal CBG levels (289.9 vs. 441.4 nmol/L; P<0.0001), respectively, despite similar serum-free cortisol or salivary cortisol concentrations. Subnormal T₆₀ serum total cortisol concentrations (<510.4 nmol/L) were measured in 7.2% of all patients (Child C: 14.5% vs. Child A and B: 0%; P=0.0013) but no patients exhibited symptoms suggesting adrenal insufficiency. Patients with or without subnormal T₆₀ total cortisol had similar T₀ salivary cortisol and serum-free cortisol concentrations. A trend was observed towards high serum-free cortisol concentrations and mortality in multivariate analysis.
  
  
  CONCLUSIONS
  Serum total cortisol levels overestimated the prevalence of adrenal dysfunction in cirrhotics with end-stage liver disease. Since serum-free cortisol cannot be measured routinely, salivary cortisol testing could represent a useful approach but needs to be standardized.
authors.affiliation: Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon cedex, France. tthevenot@chu-besancon.fr
authors.forename: Thierry
authors.initials: T
authors.lastname: Thevenot
authors.forename: Sophie
authors.initials: S
authors.lastname: Borot
authors.forename: Agnès
authors.initials: A
authors.lastname: Remy-Martin
authors.forename: Remy
authors.initials: R
authors.lastname: Sapin
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Cervoni
authors.forename: Carine
authors.initials: C
authors.lastname: Richou
authors.forename: Claire
authors.initials: C
authors.lastname: Vanlemmens
authors.forename: Denis
authors.initials: D
authors.lastname: Cleau
authors.forename: Emilie
authors.initials: E
authors.lastname: Muel
authors.forename: Anne
authors.initials: A
authors.lastname: Minello
authors.forename: Simona
authors.initials: S
authors.lastname: Tirziu
authors.forename: Alfred
authors.initials: A
authors.lastname: Penfornis
authors.forename: Vincent
authors.initials: V
authors.lastname: Di Martino
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Monnet
mesh_terms: D000311:Adrenal Glands / Q000378:metabolism*; D000309:Adrenal Insufficiency / Q000097:blood* / Q000175:diagnosis / Q000209:etiology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000418:Albumins / Q000032:analysis; D058625:End Stage Liver Disease / Q000097:blood* / Q000150:complications / Q000175:diagnosis; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D008103:Liver Cirrhosis / Q000097:blood* / Q000150:complications / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012463:Saliva / Q000378:metabolism*
chemical_list: D000418:Albumins; D006854:Hydrocortisone