title: Clinical factors associated with biochemical adrenal-cortisol insufficiency in hospitalized patients.
abstract: BACKGROUND
  Diagnosis of adrenal-cortisol insufficiency is often misleading in hospitalized patients, as clinical and biochemical features overlap with comorbidities. We analyzed clinical determinants associated with a biochemical diagnosis of adrenal-cortisol insufficiency in non-intensive care unit (ICU) hospitalized patients.
  
  
  METHODS
  In a retrospective cohort study we reviewed 4668 inpatients with random morning cortisol levels ≤15 μg/dL hospitalized in our center between 2003 and 2010. Using serum cortisol threshold level of 18 μg/dL 30 or 60 minutes after Cortrosyn (250 μg; Amphastar Pharmaceuticals, Inc., Rancho Cucamonga, Calif) injection to define biochemical adrenal-cortisol status, we characterized and compared insufficient (n = 108, serum cortisol ≤18 μg/dL) and sufficient (n = 394; serum cortisol >18 μg/dL) non-ICU hospitalized patients.
  
  
  RESULTS
  Commonly reported clinical and routine biochemical adrenal-cortisol insufficiency features were similar between insufficient and sufficient inpatients. Biochemical adrenal-cortisol insufficiency was associated with increased frequency of liver disease, specifically hepatitis C (P = .01) and prior orthotopic liver transplantation (P <.001), human immunodeficiency virus (HIV; P = .005), and reported pre-existing male hypogonadism (P <.001), as compared with the biochemical adrenal-cortisol sufficiency group. Forty percent of insufficient inpatients were not treated with glucocorticoids after diagnosis. Multivariable logistic analysis demonstrated that inpatients with higher cortisol levels (P = .0001) and higher diastolic blood pressure (P = .05), and females (P = .009) were more likely not to be treated, while those with previous short-term glucocorticoid treatment (P = .002), other coexisting endocrine diseases (P = .005), or who received an in-hospital endocrinology consultation (P <.0001), were more likely to be replaced with glucocorticoids.
  
  
  CONCLUSIONS
  Commonly reported adrenal-cortisol insufficiency features do not reliably identify hospitalized patients biochemically confirmed to have this disorder. Comorbidities including hepatitis C, prior orthotopic liver transplantation, HIV, and reported pre-existing male hypogonadism may help identify hospitalized non-ICU patients for more rigorous adrenal insufficiency assessment.
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Anat
authors.initials: A
authors.lastname: Ben-Shlomo
authors.affiliation: Biostatistics Core, Research Institute, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: James
authors.initials: J
authors.lastname: Mirocha
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Gwin
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Annika K
authors.initials: AK
authors.lastname: Khine
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Ning-Ai
authors.initials: NA
authors.lastname: Liu
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Renee C
authors.initials: RC
authors.lastname: Sheinin
authors.affiliation: Pituitary Center, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California 90048.
authors.forename: Shlomo
authors.initials: S
authors.lastname: Melmed
mesh_terms: D000293:Adolescent; D000309:Adrenal Insufficiency / Q000097:blood* / Q000175:diagnosis*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D006854:Hydrocortisone
keywords: Adrenal insufficiency; Cortisol; Inpatient