Session Title: Category 2b. CIRRHOSIS AND ITS COMPLICATIONS: b. CLINICAL ASPECTS
Presentation Date: Apr 15, 2010
ASSESSMENT OF ADRENOCORTICAL RESERVE IN STABLE PATIENTS WITH CIRRHOSIS
G. Fede1*, L. Spadaro1, T. Tomaselli1, G. Privitera1, J. O'Beirne2, M. Garcovich2, E. Tsochatzis2, A.K. Burroughs2, F. Purrello1
1Internal Medicine, University of Catania - Garibaldi Hospital, Catania, Italy, 2Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK. *firstname.lastname@example.org
Introduction: Adrenal insufficiency has been documented in critically ill patients with chronic liver diseases and this has been associated with increased mortality. However, it is still unclear if adrenal insufficiency is an underlying condition in chronic liver disease or whether it is triggered by critical events (e.g. sepsis or hemodynamic instability). Our aim was to investigate the adrenal function in cirrhosis without infections or hemodynamic instability and to assess the risk factors associated with abnormal adrenal response in these patients.
Patients/methods: We evaluated 101 consecutive cirrhotics (60 men and 41 women, mean age 59 ± 1.9 years) without infection or hemodynamic instability. Serum cortisol was assessed as basal (between 8 and 9 a.m.) and 20 and 30 minutes after i.v. injection of 1 µg of tetracosactrin (Low Dose Short Synacthen Test). Adrenal insufficiency was defined by a plasma cortisol < 18 µg/dl at 20 or 30 minutes after injection. Statistical analysis was performed with unpaired student t test, χ2 test, logistic regression and ROC curves.
Results: Adrenal insufficiency was present in 38 patients (38%). No significant differences were observed in age (57±2.1 vs.60±1.6), gender (men:23vs37,women:15vs26), aetiology (viral:20vs27,alcoholic:12vs13,other:6vs23), encephalopathy (11vs5), creatinine (79±3.5vs89±5 µmol/L), sodium (136±0.7vs136±0.9 mEq/L), and potassium (4.2±0.08vs4.1±0.08 mEq/L) between those with and without adrenal insufficiency. However in adrenal insufficiency group Child-Pugh score (10vs8,p< 0.0001), MELD score (18vs13,p< 0.0001), ascites (64%vs37%,p< 0.01), basal cortisol (7.9±0.5vs16.4±1 µg/dl,p< 0.001), albumin (28±0.8vs 33±0.7 g/L,p< 0.0001), INR (1.7±0.07vs1.3±0.3, p< 0.0001) and total bilirubin (71±8.3vs49±6.5 µmol/L, p< 0.05) were significantly different. Multivariately indipendent associations with adrenal insufficiency were baseline cortisol level, total bilirubin, and MELD score. Moreover, by plotting ROC curves a basal cortisol £ 12.8 µg/dl (c-value:0.79), Child-Pugh score ≥ 7 (c-value:0.78), and MELD score ≥ 12 (c-value:0.75) were cut-off values with useful diagnostic accuracy for the presence of adrenal insufficiency.
Conclusions: Adrenal insufficiency is frequent in stable patients with cirrhosis, in the absence of infections or hemodynamic instability. This was related to the severity of liver disease. Morning basal cortisol could be useful to identify cirrhotics with high risk of adrenal insufficiency. Clinical consequences of this need to be explored.