High serum levels of free cortisol indicate severity of cirrhosis in hemodynamically stable patients.
OBJECTIVE
We investigated: (i) the association between severity of cirrhosis and serum levels of free cortisol (SFC) and total cortisol (STC), measured before and 30 min after (T(30)) the low-dose 1-µg short synacthen test (LD-SST); and (ii) the prognostic value of SFC and STC.


METHODS
Consecutive, hemodynamically stable, cirrhotic patients (34 Child-Pugh class A, 29B, and 32C) underwent the LD-SST. Patients were followed for at least 12 months to assess non-transplant-related mortality.


RESULTS
Child-Pugh class C patients had significantly higher basal levels of SFC than Child-Pugh class A or B patients. Prevalence of suspected adrenal dysfunction ranged between 7.4% (T(0) STC < 138 nmol/L) and 49.4% (change in STC < 250 nmol/L) according to the threshold used. In receiver-operator curve analysis, the area-under-the-curve values were 0.67 for T(30) SFC (0.51-0.79), 0.81 for Child-Pugh score (0.70-0.88), and 0.79 for albumin level (0.63-0.88). During the follow-up period, 16 patients with high T(30) SFC (≥ 78.9 nmol/L) (26.2%) and one patient with low T(30) SFC (< 78.9 nmol/L) (3.4%) died (P = 0.027 for high vs low T(30) SFC, log-rank test). Albeit not statistically significant, the risk of death for patients with T(30) SFC ≥ 78.9 nmol/L was fivefold higher than for patients with lower levels after adjusting for cirrhosis severity and level of albumin.


CONCLUSIONS
One-year, non-transplant-related mortality is high among patients with T(30) levels of SFC ≥ 78.9 nmol/L (26.2%). These findings might result from latent inflammatory stress in hemodynamically stable cirrhotic patients, detected by adrenal testing.
Department of Hepatology, University Hospital Jean Minjoz, France. tthevenot@chu-besancon.fr
Thierry
T
Thevenot
Richard
R
Dorin
Elisabeth
E
Monnet
Clifford R
CR
Qualls
Remy
R
Sapin
Emilie
E
Grandclement
Sophie
S
Borot
Frances
F
Sheppard
Delphine
D
Weil
Thibault
T
Degand
Vincent
V
Di Martino
Rasa
R
Kazlauskaite
D000304:Adrenal Cortex Function Tests; D000307:Adrenal Gland Diseases / Q000097:blood / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D003366:Cosyntropin; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000097:blood / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D015854:Up-Regulation
D015415:Biomarkers; D003366:Cosyntropin; C006418:adrenocorticotropin zinc; D006854:Hydrocortisone