medigraphic.com
Órgano Oficial de la Asociación Mexicana de Hepatología

2017, Number 5

<< Back Next >>

Ann Hepatol 2017; 16 (5)

Algorithm for Screening of Adrenal Function in Stable Patients with Cirrhosis

Paz-Delgadillo J, Monreal-Robles R, Villarreal-Pérez JZ, Lavalle-González FJ, Maldonado-Garza HJ, Bosques-Padilla FJ

Language: English
References: 37
Page: 788-796
PDF size: 201.35 Kb.


ABSTRACT

Introduction and aims. Adrenal insufficiency (AI) is common in patients with cirrhosis. We aimed to assess the presence of AI in stable patients with cirrhosis using the gold-standard insulin tolerance test (ITT) and to propose an algorithm for screening AI in these patients. Material and methods. We studied 40 stable patients with cirrhosis. We determined the basal total (BTC) and peak cortisol (PTC) levels. Using the ITT, we defined AI as a serum PTC ‹ 18 µg/dL at 30 min after insulin-induced hypoglycemia. We assessed the diagnostic accuracy of BTC in different stages of liver disease to discriminate between those with NAF and AI. Results. Of the 40 patients, 24 (60%) presented with AI. Child-Pugh and MELD scores differed between the NAF and AI groups (Child-Pugh: NAF 7.2 ± 1.7 vs. AI 8.8 ± 2.4, p = 0.024 and MELD: NAF 9.9 ± 2.5 vs. AI 14.9 ± 6.3, p = 0.001). The BTC level was lower in patients with AI than in those with NAF (7.2 ± 2.4 vs. 12.5 ± 5.2, p ‹ 0.001). A BTC value ≤ 10.0 µg/dL had a 96% sensitivity (negative predictive value: 90%) for identifying AI. This cutoff value (BTC ≤ 10.0 µg/dL) provided 100% specificity (positive predictive value: 100%) in patients with advanced liver disease (Child-Pugh ≥ 9 or MELD ≥ 12). Conclusion. An algorithm including the use of BTC and the severity of liver disease may be a useful and simple method for assessing adrenal function in stable patients with cirrhosis.


REFERENCES

  1. Harry R, Auzinger G, Wendon J. The clinical importance of adrenal insufficiency in acute hepatic dysfunction. Hepatology 2002; 36: 395-402.

  2. Tsai MH, Peng YS, Chen YC, Liu NJ, Ho YP, Fang JT, Lien JM, et al. Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock. Hepatology 2006; 43: 673-81.

  3. Fede G, Spadaro L, Tomaselli T, Privitera G, Piro S, Rabuazzo AM, Sigalas A, et al. Assessment of adrenocortical reserve in stable patients with cirrhosis. J Hepatol 2011; 54: 243-50.

  4. Snijdewint FG, Kapsenberg ML, Wauben-Penris PJ, Bos JD. Corticosteroids class-dependently inhibit in vitro Th1- and Th2-type cytokine production. Immunopharmacology 1995; 29: 93-101.

  5. Yang S, Zhang L. Glucocorticoids and vascular reactivity. Curr Vasc Pharmacol 2004; 2: 1-12.

  6. Tan T, Chang L, Woodward A, McWhinney B, Galligan J, Macdonald GA, Cohen J, et al. Characterising adrenal function using directly measured plasma free cortisol in stable severe liver disease. J Hepatol 2010; 53: 841-8.

  7. Marik PE, Gayowski T, Starzl TE, Group ftHCRaAPS. The hepatoadrenal syndrome: A common yet unrecognized clinical condition. Crit Care Med 2005; 33: 1254-9.

  8. Galbois A, Massard J, Reignier S, Fulla Y, Bennani A, Bonnefont- Rousselo D, Poynard T, et al. Hepato-adrenal syndrome: myth or reality? Usefulness of salivary cortisol assay. Hepatology 2008; 48: 1054A.

  9. Araz F, Soydas B, Ozer B, Serin E. The importance of salivary cortisol in the diagnosis of adrenal insufficiency in cirrhosis. Turkish J Gastroenterol 2016; 27: 268-72.

  10. Plumpton FS, Besser GM. The adrenocortical response to surgery and insulin-induced hypoglycaemia in corticosteroid- treated and normal subjects. Br J Surg 1969; 56: 216-9.

  11. Erturk E, Jaffe CA, Barkan AL. Evaluation of the integrity of the hypothalamic-pituitary-adrenal axis by insulin hypoglycemia test. J Clin Endocrinol Metab 1998; 83: 2350-4.

  12. McDonald JA, Handelsman DJ, Dilworth P, Conway AJ, Mc- Caughan GW. Hypothalamic-pituitary adrenal function in endstage non-alcoholic liver disease. J Gastroenterol Hepatol 1993; 8: 247-53.

  13. Acevedo J, Fernandez J, Prado V, Silva A, Castro M, Pavesi M, Roca D, et al. Relative adrenal insufficiency in decompensated cirrhosis: Relationship to short-term risk of severe sepsis, hepatorenal syndrome, and death. Hepatology 2013; 58: 1757-65.

  14. Theocharidou E, Krag A, Bendtsen F, Moller S, Burroughs AK. Cardiac dysfunction in cirrhosis - does adrenal function play a role? A hypothesis. Liver Int 2012; 32: 1327-32.

  15. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 2002; 35: 716-21.

  16. Abboud CF. Laboratory diagnosis of hypopituitarism. Mayo Clin Proc 1986; 61: 35-48.

  17. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973; 60: 646-9.

  18. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464-70.

  19. Streeten DH, Anderson GH, Jr., Dalakos TG, Seeley D, Mallov JS, Eusebio R, Sunderlin FS, et al. Normal and abnormal function of the hypothalamic-pituitary-adrenocortical system in man. Endocr Rev 1984; 5: 371-94.

  20. Agha A, Tomlinson JW, Clark PM, Holder G, Stewart PM. The long-term predictive accuracy of the short synacthen (corticotropin) stimulation test for assessment of the hypothalamic-pituitary- adrenal axis. J Clin Endocrinol Metab 2006; 91: 43-7.

  21. Jones SL, Trainer PJ, Perry L, Wass JA, Bessser GM, Grossman A. An audit of the insulin tolerance test in adult subjects in an acute investigation unit over one year. Clin Endocrinol (Oxf) 1994; 41: 123-8.

  22. Thevenot T, Borot S, Remy-Martin A, Sapin R, Cervoni JP, Richou C, Vanlemmens C, et al. Assessment of adrenal func tion in cirrhotic patients using concentration of serum-free and salivary cortisol. Liver Int 2011; 31: 425-33.

  23. de Lange WE, Sluiter WJ. The assessment of the functional capacity of the hypothalamic-pituitary-adrenal axis by measurement of basal plasma and urinary cortisol in comparison with insulin-induced hypoglycaemia and metyrapone tests. Neth J Med 1993; 43: 64-8.

  24. Hagg E, Asplund K, Lithner F. Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency. Clin Endocrinol (Oxf) 1987; 26: 221-6.

  25. Fernandez J, Escorsell A, Zabalza M, Felipe V, Navasa M, Mas A, Lacy AM, et al. Adrenal insufficiency in patients with cirrhosis and septic shock: Effect of treatment with hydrocortisone on survival. Hepatology 2006; 44: 1288-95.

  26. Adinoff B, Martin PR, Bone GH, Eckardt MJ, Roehrich L, George DT, Moss HB, et al. Hypothalamic-pituitary-adrenal axis functioning and cerebrospinal fluid corticotropin releasing hormone and corticotropin levels in alcoholics after recent and long-term abstinence. Arch Gen Psychiatry 1990; 47: 325-30.

  27. Inder WJ, Joyce PR, Ellis MJ, Evans MJ, Livesey JH, Donald RA. The effects of alcoholism on the hypothalamic-pituitaryadrenal axis: interaction with endogenous opioid peptides. Clin Endocrinol (Oxf) 1995; 43: 283-90.

  28. Wand GS, Dobs AS. Alterations in the hypothalamic-pituitaryadrenal axis in actively drinking alcoholics. J Clin Endocrinol Metab 1991; 72: 1290-5.

  29. Garcia-Compean D, Jaquez-Quintana JO, Lavalle-Gonzalez FJ, Reyes-Cabello E, Gonzalez-Gonzalez JA, Munoz-Espinosa LE, Vazquez-Elizondo G, et al. The prevalence and clinical characteristics of glucose metabolism disorders in patients with liver cirrhosis. A prospective study. Ann Hepatol 2012; 11: 240-8.

  30. Arafah BM, Nishiyama FJ, Tlaygeh H, Hejal R. Measurement of salivary cortisol concentration in the assessment of adrenal function in critically ill subjects: a surrogate marker of the circulating free cortisol. J Clin Endocrinol Metab 2007; 92: 2965-71.

  31. Galbois A, Rudler M, Massard J, Fulla Y, Bennani A, Bonnefont- Rousselot D, Thibault V, et al. Assessment of adrenal function in cirrhotic patients: salivary cortisol should be preferred. J Hepatol 2010; 52: 839-45.

  32. Hamrahian AH, Oseni TS, Arafah BM. Measurements of serum free cortisol in critically ill patients. N Engl J Med 2004; 350: 1629-38.

  33. Ho JT, Al-Musalhi H, Chapman MJ, Quach T, Thomas PD, Bagley CJ, Lewis JG, et al. Septic shock and sepsis: a comparison of total and free plasma cortisol levels. J Clin Endocrinol Metab 2006; 91: 105-14.

  34. Widmer IE, Puder JJ, Konig C, Pargger H, Zerkowski HR, Girard J, Muller B. Cortisol response in relation to the severity of stress and illness. J Clin Endocrinol Metab 2005; 90: 4579-86.

  35. Raff H, Brock S, Findling JW. Cosyntropin-stimulated salivary cortisol in hospitalized patients with hypoproteinemia. Endocrine 2008; 34: 68-74.

  36. Asrani SK, Simonetto DA, Kamath PS. Acute-on-Chronic Liver Failure. Clin Gastroenterol Hepatol 2015; 13: 2128-39.

  37. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426-1437, 1437.e1421-1429.




2020     |     www.medigraphic.com