How I Approach It: Adrenal Insufficiency in Cirrhosis

Wentworth, Brian J.; Henry, Zachary; Siragy, Helmy M.

doi:10.14309/ajg.0000000000001939

Cited by 3 publications

(4 citation statements)

References 16 publications

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“…Our study demonstrates multiple relevant findings related to the assessment of the HPA axis in hospitalized, To our knowledge, this is the first study to describe a lack of association between basal TC levels and adrenal responsiveness to ACTH stimulation testing in noncritically ill patients with acute decompensated cirrhosis. Consideration of adrenal insufficiency in this population may occur when hypotension, hyponatremia, and/ or hyperkalemia are otherwise not well explained by the current clinical presentation [1]. Clinicians often order morning cortisol levels for screening purposes and may extrapolate a result of less than 5 µg/dl as being suggestive of adrenal insufficiency.…”

Section: Discussionmentioning

confidence: 99%

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Basal cortisol levels do not predict adrenal responsiveness in acute decompensated cirrhosis

Wentworth,

Schliep,

Novicoff

et al. 2023

European Journal of Gastroenterology &Amp; Hepatology

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Objective Morning total cortisol (TC) levels have been shown to predict adrenal dysfunction (AD) in the general population, but their utility in cirrhosis is unknown. Methods A retrospective cohort study was performed including all noncritically ill patients at our institution between 2011 and 2022 admitted with acute decompensated cirrhosis who underwent standard-dose adrenocorticotropic hormone (ACTH) stimulation testing. Adrenal dysfunction was defined as an increase in TC (delta TC) level <9 µg/dl 60 minutes after ACTH dosing. Spearman correlation was utilized to assess the relationship between binding globulins and cortisol levels. Multivariate regression analysis was performed to determine if basal TC level or common clinical parameters were predictive of AD. Results One hundred and nineteen patients were included, with a median model for end-stage liver disease score of 18. Albumin levels did not correlate with basal TC levels (ρ = 0.127; P = 0.169); basal TC did not correlate with delta TC (ρ = 0.050; P = 0.591). The degree of hypoalbuminemia did not alter these relationships. On multivariate regression, only albumin level [odds ratio (OR) = 0.418; 95% confidence interval (CI), 0.196–0.890; P = 0.024] and MELD score (OR, 1.094; 95% CI, 1.019–1.174; P = 0.014) were predictive of AD. Basal TC levels were not predictive of AD (OR = 0.991; 95% CI, 0.903–1.088; P = 0.855) or delta TC (β = 0.000; 95% CI −0.147 to 0.147; P = 0.999). Conclusion Baseline TC levels do not predict ACTH stimulation testing response in patients with acute decompensated cirrhosis. Clinicians should avoid utilizing an isolated morning cortisol result as a screening method for AD in this population.

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Section: Discussionmentioning

confidence: 99%

“…Adrenal dysfunction (AD) is common in cirrhosis but infrequently diagnosed in clinical practice [1]. Its prevalence correlates with the severity of underlying liver disease and carries prognostic implications [2,3].…”

Section: Introductionmentioning

confidence: 99%

Basal cortisol levels do not predict adrenal responsiveness in acute decompensated cirrhosis

Wentworth,

Schliep,

Novicoff

et al. 2023

European Journal of Gastroenterology &Amp; Hepatology

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“…4,6 In contrast, prevalence rates, outcomes and the benefits of corticosteroid replacement are less well established in the non-critically ill population given significant study heterogeneity. 2,11 Numerous factors contribute to this heterogeneity, including severity of illness and/or liver impairment, selection of stimulation test, biological properties of the measured form of cortisol and thresholds utilized to define RAI. The lack of consensus around an optimal methodology to diagnose and treat RAI in cirrhosis (particularly in the noncritically ill population) is a source of confusion for clinicians.…”

Section: Introductionmentioning

confidence: 99%

“…Relative adrenal insufficiency (RAI) in patients with cirrhosis is common and thought to have a complex pathophysiology. 1,2 While the literature has consistently demonstrated an association with severity of liver disease, the presence of acute illness may also alter adrenal responsiveness. There is a high prevalence of RAI in critically ill patients with cirrhosis and its presence is associated with increased mortality.…”

Section: Introductionmentioning

confidence: 99%

Relative adrenal insufficiency in the non‐critically ill patient with cirrhosis: A systematic review and meta‐analysis

Wentworth

Schliep

Novicoff

et al. 2022

Liver International

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Background & Aims Characterization of relative adrenal insufficiency (RAI) in cirrhosis is heterogeneous with regard to studied patient populations and diagnostic methodology. We aimed to describe the prevalence and prognostic importance of RAI in non‐critically ill patients with cirrhosis. Methods A systematic review and meta‐analysis was performed using MeSH terms and Boolean operators to search five large databases (Ovid‐MEDLINE, ScienceDirect, Web of Science, Cochrane Library and http://clinicaltrials.gov). The population of interest was patients with cirrhosis and without critical illness. The primary outcome was the pooled prevalence of RAI as defined by a peak total cortisol level <18 μg/dl, delta total cortisol <9 μg/dl or composite of the two thresholds in response either a standard‐dose or low‐dose short synacthen test. Odds ratios and standardized mean differences from random‐effects models estimated important clinical outcomes and patient characteristics by adrenal functional status. Results Twenty‐two studies were included in final analysis, comprising 1991 patients with cirrhosis. The pooled prevalence of RAI was 37% (95% CI 33–42%). The prevalence of RAI varied by Child–Pugh classification, type of stimulation test used, specific diagnostic threshold and by severity of illness. Ninety‐day mortality was significantly higher in patients with RAI (OR 2.88, 95% CI 1.69–4.92, I2 = 15%, p < 0.001). Conclusions Relative adrenal insufficiency is highly prevalent in non‐critically ill patients with cirrhosis and associated with increased mortality. Despite the proposed multifactorial pathogenesis, no studies to date have investigated therapeutic interventions in this specific population.

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Intensive care management of acute-on-chronic liver failure

et al. 2023

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How I Approach It: Adrenal Insufficiency in Cirrhosis

Abstract: All reported values are based on response to a standard-dose (250 mg) short Synacthen test using a threshold of delta total cortisol ,9 mg/dL. RAI, relative adrenal insufficiency.

Cited by 3 publications

References 16 publications

Basal cortisol levels do not predict adrenal responsiveness in acute decompensated cirrhosis

Basal cortisol levels do not predict adrenal responsiveness in acute decompensated cirrhosis

Relative adrenal insufficiency in the non‐critically ill patient with cirrhosis: A systematic review and meta‐analysis

Intensive care management of acute-on-chronic liver failure

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