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Karthik V, Jabbar PK, Krishnadas D, Nair A, George GS, Jayakumari C, Soumya S, Asok A, Basheer S. Long-acting porcine ACTH stimulated salivary cortisol reduces the overdiagnosis of adrenal insufficiency compared to serum cortisol in cirrhosis liver. Clin Endocrinol (Oxf) 2024; 100:421-430. [PMID: 38368601 DOI: 10.1111/cen.15030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/02/2024] [Accepted: 01/30/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND There are no reliable methods in clinical practice to diagnose adrenal insufficiency (AI) in patients with cirrhosis owing to variable cortisol-binding protein levels. This leads to unreliable results in ACTH stimulated serum cortisol test. We aimed to estimate the long-acting porcine (LA)ACTH-stimulated serum and salivary cortisol levels of patients at different stages of cirrhosis using second generation electrochemiluminescence and to determine the prevalence of true adrenal insufficiency in these patients. DESIGN, PATIENTS AND MEASUREMENTS We included 135 noncritical patients with cirrhosis (45 each from CHILD A, B and C) and 45 healthy controls. Serum and salivary samples were collected at baseline in the morning and at 1 and 2 h after LA-ACTH injection. RESULTS In healthy subjects, the 2.5th centile of 2 h ACTH stimulated serum and salivary cortisol were 19.8 and 0.97 μg/dL, which were used as cut-offs for defining AI based on serum and saliva respectively. The median (interquartile-range) 2-h stimulated salivary cortisol in Child A, B, C categories and controls were 1.36(1.23-2.38), 1.46(1.18-2.22), 1.72(1.2-2.2) and 2.12(1.42-2.72) μg/dL respectively. Six subjects (4.4%) were diagnosed to have AI based on stimulated salivary cortisol cut-off, whereas 39 (28.9%) cirrhosis subjects had inadequately stimulated serum cortisol. Three patients (symptomatic) required steroid replacement therapy. Hypoalbuminemia was identified as a major risk factor for the misdiagnosis of adrenal insufficiency by serum cortisol-based testing. CONCLUSIONS Long-acting porcine ACTH stimulated salivary cortisol reduces the overdiagnosis of adrenal insufficiency compared to serum cortisol in cirrhosis liver. Stimulated salivary cortisol is a promising investigation for evaluation of adrenal function in cirrhosis and more studies are required for its further validation before clinical use.
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Affiliation(s)
- Vijayakumar Karthik
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | | | - Devadas Krishnadas
- Department of Gastroenterology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Abilash Nair
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | | | - Chellamma Jayakumari
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Sarayu Soumya
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Arsha Asok
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
| | - Shameer Basheer
- Department of Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, India
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Kalafateli M, Aggeletopoulou I, Triantos C. Adrenal insufficiency in liver diseases - pathophysiology and underlying mechanisms. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09874-0. [PMID: 38305832 DOI: 10.1007/s11154-024-09874-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
Relative adrenal insufficiency (RAI) is common in critically ill patients with cirrhosis, but it has been also documented in non-critically ill patients. Its pathophysiology is complex and not well understood yet. In this review, we aimed to present potential mechanisms and causal pathways implicated in the pathogenesis of RAI in cirrhosis. There is accumulating evidence supporting a suboptimal baseline adrenal function in cirrhosis mainly due to decreased cortisol synthesis and metabolism rates from the adrenal gland. Apart from this peripheral impairment, more recent studies suggest that there is a greater defect in the central stimulation of the hypothalamic-pituitary-adrenal (HPA) axis (hypothalamus/pituitary gland). Pro-inflammatory mediators, which are elevated in cirrhosis, have been also implicated through suppression of the HPA axis, decrease in cortisol synthesis and tissue glucocorticoid resistance. All abovementioned support the hepatoadrenal syndrome hypothesis that during episodes of acute decompensation there is suboptimal adrenocortical response that leads to worse outcomes. In conclusion, the complex pathophysiology of adrenal dysfunction in cirrhosis has not been fully elucidated yet and further research is needed in order to better understand this rather common entity in cirrhosis.
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Affiliation(s)
- Maria Kalafateli
- Department of Gastroenterology, General Hospital of Patras, 26332, Patras, Greece
| | - Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504, Patras, Greece
- Laboratory of Immunohematology, Department of Internal Medicine, Medical School, University of Patras, 26504, Patras, Greece
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504, Patras, Greece.
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Wentworth BJ, Schliep M, Novicoff W, Henry ZH, Siragy HM. Basal cortisol levels do not predict adrenal responsiveness in acute decompensated cirrhosis. Eur J Gastroenterol Hepatol 2024; 36:238-244. [PMID: 38131427 PMCID: PMC10752291 DOI: 10.1097/meg.0000000000002694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
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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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Matthew Schliep
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Wendy Novicoff
- Departments of Public Health Sciences and Orthopaedic Surgery, School of Medicine, University of Virginia Charlottesville, VA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, VA
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Aggeletopoulou I, Tsounis EP, Kalafateli M, Michailidou M, Tsami M, Zisimopoulos K, Mandellou M, Diamantopoulou G, Kouskoura M, Michalaki M, Markopoulou CK, Thomopoulos K, Triantos C. Low Urinary Free Cortisol as a Risk Factor for Patients with Variceal Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2112. [PMID: 38138215 PMCID: PMC10744924 DOI: 10.3390/medicina59122112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Specificity and reliability issues of the current cortisol assessment methods lead to limitations on the accurate assessment of relative adrenal insufficiency. Although free cortisol provides a more accurate evaluation of adrenal cortisol production, the expense and time-consuming nature of these assays make them impractical for routine use. Research has, thus, focused on alternative methods, such as indirectly measuring free cortisol using Coolens' equation or directly assessing salivary cortisol concentration, which is considered a more favorable approach despite associated challenges like sampling issues and infection risks. The aim of this study was to explore correlations between 24 h urinary free cortisol (UFC), free plasma cortisol, serum total cortisol, and salivary cortisol as potential reliable indices of free cortisol in the setting of variceal bleeding. Additionally, we assessed the predictive value of UFC for 6-week mortality and 5-day treatment failure in patients with liver cirrhosis and variceal bleeding. Materials and Methods: A total of 40 outpatients with liver cirrhosis and variceal bleeding were enrolled. Free cortisol levels in serum, saliva, and urine were assessed using the electrochemiluminescence immunoassay method. For the measurement of plasma-free cortisol, a single quadrupole mass spectrometer was employed. The quantification of free cortisol was fulfilled by analyzing the signal response in the negative ESI-MS mode. Results: UFC was significantly correlated to free plasma cortisol. Negative correlations were demonstrated between UFC, the Child-Pugh (CP) score, and C reactive protein (CRP) levels. In the multivariate analysis, CP stage C was associated with 6-week mortality risk and portal vein thrombosis with 5-day treatment failure using Cox regression and binary logistic regression analyses, respectively. Patients who experienced rebleeding, infection, or death (or any combination of these events) presented with lower levels of UFC. Conclusions: This study suggests that low levels of UFC may impose a risk factor for patients with liver cirrhosis and variceal bleeding. The use of UFC as an index of adrenal cortisol production in variceal bleeding warrants further investigation.
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Affiliation(s)
- Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Efthymios P. Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kalafateli
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Michailidou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Tsami
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Zisimopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Martha Mandellou
- Department of Biochemistry, University Hospital of Patras, 26504 Patras, Greece;
| | - Georgia Diamantopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Maria Kouskoura
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Marina Michalaki
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Internal Medicine, University of Patras, 26504 Patras, Greece;
| | - Catherine K. Markopoulou
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (M.T.); (M.K.); (C.K.M.)
| | - Konstantinos Thomopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504 Patras, Greece; (I.A.); (E.P.T.); (M.K.); (M.M.); (K.Z.); (G.D.); (K.T.)
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Ekawaravong S, Treepongkaruna S, Poomthavorn P, Pongratanakul S, Khlairit P, Chanprasertyothin S, Mahachoklertwattana P. Overdiagnosis of adrenal insufficiency in children with biliary atresia. Clin Pediatr Endocrinol 2023; 32:147-154. [PMID: 37362167 PMCID: PMC10288293 DOI: 10.1297/cpe.2022-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/03/2023] [Indexed: 06/28/2023] Open
Abstract
Serum cortisol mainly binds to the cortisol-binding globulin (CBG). Children with biliary atresia (BA) may have low serum CBG levels; thus, low serum total cortisol (TC) levels and adrenal insufficiency (AI) may be overdiagnosed. This study aimed to assess adrenal function in children with BA. All the patients underwent adrenocorticotropic hormone (ACTH) stimulation tests. Plasma ACTH, serum TC, and CBG levels were measured at baseline, with additional TC measurements at 30 and 60 min during testing. Free cortisol (FC) index (FCI) and calculated FC (cFC) were also calculated. AI was defined as peak TC <500 nmol/L (<18 μg/dL), peak FCI <12 nmol/mg, or peak cFC <33 nmol/L (<1.2 μg/dL). This study enrolled 71 children with BA. The Median (IQR) age of the patients was 5.5 (1.7-11.4) years. Twenty-five (35%) patients were diagnosed with AI based on the peak TC. In the AI group, the median serum CBG level was significantly lower than that in the non-AI group (481 vs. 533 nmol/L, p = 0.03). Only eight patients (11%) met all three AI criteria (six secondary AI and two primary AI). In conclusion, low serum CBG levels contribute to reduced peak TC and, consequently, overdiagnosing AI. Peak FCI and cFC could help reduce the overdiagnosis of AI.
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Affiliation(s)
- Suparat Ekawaravong
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Preamrudee Poomthavorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sarunyu Pongratanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patcharin Khlairit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Pat Mahachoklertwattana
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Wentworth BJ, Schliep M, Novicoff W, Siragy HM, Geng CX, Henry ZH. Relative adrenal insufficiency in the non-critically ill patient with cirrhosis: A systematic review and meta-analysis. Liver Int 2023; 43:660-672. [PMID: 36354293 PMCID: PMC9974795 DOI: 10.1111/liv.15473] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022]
Abstract
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 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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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Matthew Schliep
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Wendy Novicoff
- Departments of Public Health Sciences and Orthopaedic Surgery, School of Medicine, University of Virginia Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, VA
| | - Calvin X Geng
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
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Wentworth BJ, Schliep M, Siragy HM, Henry ZH. Author's reply: Plasma corticosteroid-binding globulin levels in cirrhosis. Liver Int 2023; 43:742-743. [PMID: 36655408 DOI: 10.1111/liv.15525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew Schliep
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
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Abstract
Hypothalamus-pituitary-adrenal axis assessment in patients with cirrhosis is challenging. The phenotype of fatigue, hypotension, electrolyte disarray, and abdominal pain characterizing primary adrenal insufficiency (AI) overlaps significantly with decompensated liver disease. Reliance on total cortisol assays in hypoproteinemic states is problematic, yet abnormal stimulated levels in cirrhosis are associated with poor clinical outcomes. Alternative measures including free plasma or salivary cortisol levels have theoretical merit but are limited by unclear prognostic significance and undefined cirrhosis-specific reference ranges. Further complicating matters is that AI in cirrhosis represents a spectrum of impairment. Although absolute cortisol deficiency can occur, this represents a minority of cases. Instead, there is an emerging concept that cirrhosis, with or without critical illness, may induce a “relative” cortisol deficiency during times of stress. In addition, the limitations posed by decreased synthesis of binding globulins in cirrhosis necessitate re-evaluation of traditional AI diagnostic thresholds.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia , Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia , Charlottesville, VA
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9
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Michailidou M, Aggeletopoulou I, Kouskoura M, Zisimopoulos K, Tsounis EP, Karaivazoglou K, Tourkochristou E, Mandellou M, Diamantopoulou G, Koutras N, Michalaki M, Gogos C, Velissaris D, Markopoulou CK, Thomopoulos K, Triantos C. Urinary free cortisol is a reliable index of adrenal cortisol production in patients with liver cirrhosis. Endocrine 2022; 76:697-708. [PMID: 35449323 DOI: 10.1007/s12020-022-03055-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/02/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The measurement of total and free cortisol has been studied as a clinical index of adrenal cortisol production in patients with liver cirrhosis. Correlations between free plasma and salivary cortisol have previously been reported in stable cirrhotic patients. Urinary free cortisol constitutes an index of adrenal cortisol production; however, it has never been used in assessing adrenal function in patients with liver cirrhosis. AIMS The aim of this observational study was to determine associations between urinary free cortisol, serum total, salivary, measured and calculated plasma free cortisol levels in cirrhotics, determining which of them can be used as an indirect index of free cortisol levels. Moreover, we investigated the potential use of 24 h urinary free cortisol as a prognostic factor for mortality. METHODS Seventy-eight outpatients with liver cirrhosis were included. Serum, salivary and urinary free cortisol were measured using the electrochemiluminenscence immunoassay. Plasma free cortisol determination was conducted using a single quadrupole mass spectrometer. The quantification of free cortisol was achieved by determining the signal response on negative ESI-MS mode. RESULTS Twenty-four hour urinary free cortisol levels correlated with free cortisol determined by mass spectrometer, total cortisol and calculated free cortisol levels. Patients with low levels of urinary free cortisol presented a significantly higher mortality rate compared to those with high levels. The factors associated with death risk were determined by Cox regression. In the multivariate analysis, two models were applied; in the first model, CP score, PVT and urinary free cortisol were found to be significantly related to patients' survival, whereas in the second, MELD score, ascites and urinary free cortisol were independently related to survival. CONCLUSIONS This study suggests that 24 h urinary free cortisol could be considered as a potential index of adrenal cortisol production in patients with liver cirrhosis and it potentially detects patients with a high mortality risk.
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Affiliation(s)
- Maria Michailidou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Maria Kouskoura
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Zisimopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Efthymios P Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Katerina Karaivazoglou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Evanthia Tourkochristou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Martha Mandellou
- Department of Biochemistry, University Hospital of Patras, Patras, Greece
| | - Georgia Diamantopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Nikolaos Koutras
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marina Michalaki
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Internal Medicine, University of Patras, Patras, Greece
| | - Charalampos Gogos
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Catherine K Markopoulou
- Laboratory of Pharmaceutical Analysis, Department of Pharmaceutical Technology, School of Pharmacy, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Thomopoulos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece.
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Martín Guerra JM, Moreta Rodríguez M. Adrenal insufficiency and hepatic cirrhosis, a relationship to discover. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:688. [DOI: 10.17235/reed.2022.8867/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Assessment of adrenal response in patients with stable cirrhosis and ascites using different short Synacthen tests and definitions. Eur J Gastroenterol Hepatol 2021; 33:e540-e547. [PMID: 33905212 DOI: 10.1097/meg.0000000000002153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS The definition of relative adrenal insufficiency (RAI) in patients with cirrhosis remains controversial. We investigated the serum and salivary cortisol (SalC) response after low-dose and standard-dose Synacthen test in patients with stable cirrhosis and ascites. METHODS Ninety-five cirrhotic patients with ascites were prospectively evaluated from January 2014 to January 2018. Low-dose [adrenocorticotrophic hormone (ACTH): 1 μg] and standard-dose (ACTH: 250 μg) Synacthen test were successively performed. Paired serum total and saliva cortisol were taken at baseline, 30 min (low-dose test) and 60 min (standard-dose test). Salivary and Δserum total cortisol criteria included post-ACTH SalC < 12.7 ng/ml and/or SalC increase <3 ng/ml and serum total cortisol increase <9 μg/dl, respectively. RESULTS The prevalence of RAI varied according to the definition used. SalC-defined RAI was significantly more common after low-dose than standard-dose test (54.7% vs. 20%; P < 0.001). Δserum total cortisol-defined RAI was also significantly more frequent after low-dose than standard-dose test (66.3% vs. 24.2%; P < 0.001). Considering low-dose test/SalC criteria as reference diagnostic criteria, standard-dose/salivary and Δserum total cortisol criteria showed low specificity for RAI diagnosis (43.9% and 52.7%, respectively). Survival probability was significantly lower in patients with low-dose test/SalC-defined RAI compared to those without (53.8% vs. 79.1%; P = 0.01). SalC-defined RAI after low-dose test was significantly more common than that defined after standard-dose test (72.7% vs. 30.3%; P < 0.001) among patients who died. CONCLUSION Low-dose test/SalC definition can identify RAI in about half of patients with stable cirrhosis and ascites and is associated with increased mortality.
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Siramolpiwat S, Kerdsuknirun J, Tharavanij T. An impact of relative adrenal insufficiency on short-term outcomes in non-critically ill cirrhotic patients: A prospective cohort study. Int J Clin Pract 2021; 75:e14362. [PMID: 33993598 DOI: 10.1111/ijcp.14362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Relative adrenal insufficiency (RAI) is frequently found in patients with liver cirrhosis, especially in critically ill conditions. However, the prognostic impact of RAI in non-critically ill cirrhosis remains controversial. The aim of the present study was to assess the prevalence of RAI and its prognostic implication in non-critically ill cirrhotic patients. METHODS From December 2015 to November 2017, hospitalised non-critically ill cirrhotic patients admitted with hepatic decompensation were prospectively enrolled in this study. Within 24 hours after admission, 250 mcg ACTH stimulation test was performed. RAI was defined as an increase in serum cortisol <9 mcg/dL in patients with basal serum cortisol <35 mcg/dL. Clinical outcomes were evaluated during admission and at 30-, 90-day visits. RESULTS One hundred and fifteen patients were included (66% male, mean age 59.9 ± 16 years, mean MELD 16.1 ± 6.8, Child A/B/C 15.7%/53.9%/30.4%). The main indications for admission were bacterial infection (44.6%) and portal hypertension-related bleeding (19.1%). RAI was detected in 35 patients (30.4%). Patients with RAI had higher Child-Pugh score (9.4 ± 1.9 vs 8.0 ± 1.7, P < .01), and MELD scores (18.3 ± 5.9 vs 15.1 ± 6.9, P = .02). The in-hospital, 30-, and 90-day mortality rates were 9.6%, 20.9%, and 26.1%, respectively. There was no significant difference in the incidence of nosocomial infection, severe sepsis, septic shock, HRS, and mortality rates between patients with and without RAI. By multivariate analysis, bacterial infection on admission (HR 3.13, P < .01) and acute-on-chronic liver failure (HR 4.98, P < .001) were independent predictors of 90-day survival. CONCLUSIONS RAI is found in about one-third of hospitalised non-critically ill cirrhotic patients and is associated with the severity of cirrhosis. However, the presence of RAI has no influence on short-term outcomes.
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Affiliation(s)
- Sith Siramolpiwat
- Department of Medicine, Chulabhorn International College of Medicine (CICM), Thammasat University, Pathumthani, Thailand
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Jitrapa Kerdsuknirun
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Thipaporn Tharavanij
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Wentworth BJ, Haug RM, Northup PG, Caldwell SH, Henry ZH. Abnormal cholesterol metabolism underlies relative adrenal insufficiency in decompensated cirrhosis. Liver Int 2021; 41:1913-1921. [PMID: 34028160 DOI: 10.1111/liv.14970] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/02/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Relative adrenal insufficiency (RAI) in patients with cirrhosis is associated with increased mortality. Although the pathogenesis of RAI remains unclear, disordered cholesterol metabolism may contribute. METHODS We performed a prospective cohort study of 96 non-critically ill subjects with decompensated cirrhosis at a tertiary care centre. Subjects were administered 250 µcg cosyntropin, with RAI defined as an increase in total cortisol <9 µg/dL. High-density lipoprotein (HDL) levels and serum cholesterol esterification percentage (%CE), a validated surrogate marker of lecithin-cholesterol acyltransferase (LCAT) activity, were measured to assess the relationship between disordered cholesterol metabolism and the presence of RAI. Subjects were followed until death, liver transplantation or a maximum of 6 months. RESULTS Subjects with RAI had decreased levels of HDL (18 vs 29 mg/dL, P < .01) and %CE (64% vs 66%, P = .03). Correlation was seen between HDL and %CE (r = 0.7, R2 = 0.49; P < .01) and each integer decrease in %CE predicted an approximately 2% increase in the probability of RAI. Transplant-free survival was reduced in subjects with RAI at both 6 months (43% vs 71%, P = .01) and 90 days (54% vs 81%, P < .01). CONCLUSIONS Disruption in cholesterol metabolism contributes to the development of RAI in cirrhosis, as decreased LCAT activity leads to reduced HDL trafficking to the adrenal gland.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Rebecca M Haug
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Zachary H Henry
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
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Lovato CM, Thévenot T, Borot S, Di Martino V, Qualls CR, Urban FK, Dorin RI. Decreased maximal cortisol secretion rate in patients with cirrhosis: Relation to disease severity. JHEP Rep 2021; 3:100277. [PMID: 34027338 PMCID: PMC8121968 DOI: 10.1016/j.jhepr.2021.100277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/13/2021] [Accepted: 03/07/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Hepatic enzymes play a major role in the metabolic elimination of cortisol, and reduced rates of cortisol clearance have been consistently observed in patients with chronic liver disease. It is less clear whether there are concomitant abnormalities of adrenocortical function in patients with cirrhosis. In the present study, we sought to assess adrenocortical function in patients with cirrhosis using measures of free cortisol appearance and elimination rates that are independent of serum concentrations of cortisol binding proteins. Methods Post hoc analysis used computer-assisted numerical and modelling methods with serial total and free cortisol concentration data to obtain rates of free cortisol appearance and elimination. Rate parameters were obtained in 114 patients with chronic liver disease, including Child-Pugh (CP) ≤8 (n = 53) and CP >8 (n = 61). Results Maximal cortisol secretion rate (CSRmax) was significantly decreased (p = 0.01) in patients with cirrhosis with CP >8 (0.28 nM/s; 95% CI 0.24–0.34) compared with those with CP ≤8 (0.39 nM/s; 95% CI 0.33–0.46), and CSRmax was negatively correlated with CP score (r = −0.19, p = 0.01). Free cortisol elimination rate was significantly (p = 0.04) decreased in the CP >8 group (0.16 ± 0.20 min−1) compared with that in the CP ≤8 group (0.21 ± 0.21 min−1), and free cortisol elimination rates were negatively correlated with CP score (r = −0.23, p = 0.01). A significant correlation between CSRmax and free cortisol elimination rate (r = 0.88, p <0.001) was observed. Conclusions CSRmax and free cortisol elimination rates were significantly reduced according to severity of cirrhosis. In contrast to stimulated total cortisol concentrations, CSRmax estimates were independent of cortisol-binding protein concentrations. Results provide additional evidence of subnormal adrenocortical function in patients with cirrhosis. Lay summary We applied numerical analytic methods to characterise adrenocortical function in patients with varying stages of chronic liver disease. We found that patients with more severe cirrhosis have decreased rate of free cortisol elimination and decreased maximal cortisol secretion rate, which is a measure of adrenocortical function. In contrast to conventional measures of adrenocortical function, those obtained using numerical methods were not affected by variation in corticosteroid binding globulin and albumin concentrations. We conclude that patients with cirrhosis demonstrate measurable abnormalities of adrenocortical function, evidence of which supports aspects of the hepatoadrenal syndrome hypothesis. Free cortisol appearance and elimination rates were obtained by computer-assisted numerical analysis. Maximal cortisol secretion rates, a measure of adrenocortical function, were inversely related to severity of cirrhosis. Variation in concentrations of cortisol binding proteins bias measures of adrenocortical function that rely on total cortisol. Chronically reduced rate of free cortisol elimination in patients with cirrhosis may contribute to the pathophysiology of subnormal adrenocortical function. Evidence of subnormal adrenocortical function supports the hepatoadrenal syndrome hypothesis.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACTH, adrenocorticotrophin
- AI, adrenal insufficiency
- Adrenal insufficiency
- CBG, corticosteroid-binding globulin
- CIRCI, critical illness-related corticosteroid insufficiency
- CP, Child-Pugh
- CPR, cortisol production rate
- CRP, C-reactive protein
- CRT, corticosteroid replacement therapy
- CSR, cortisol secretion rate
- CSRbase, basal CSR (before ACTH stimulation)
- CSRmax, maximal CSR
- Computer-assisted numerical analysis
- HPA, hypothalamic–pituitary–adrenal
- HSD, hydroxysteroid dehydrogenase
- Hydrocortisone
- INR, international normalised ratio
- Liver disease
- MCR, metabolic clearance rate
- MELD, model for end-stage liver disease
- Metabolic clearance rate
- PAI, primary adrenal insufficiency
- RAI, relative adrenal insufficiency
- RCT, randomised clinical trial
- SAI, secondary adrenal insufficiency
- SCOTCH, Supplemental Corticosteroids in Cirrhotic Hypotensive Patients With Suspicion of Sepsis
- STB, standardised beta
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Affiliation(s)
- Christina M Lovato
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Thierry Thévenot
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Sophie Borot
- Service d'Endocrinologie-Métabolisme et Diabétologie-Nutrition, Hôpital Jean Minjoz, Besançon, France
| | - Vincent Di Martino
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Clifford R Qualls
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
| | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, USA
| | - Richard I Dorin
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
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Köksal B. Is correlation between plasma and salivary cortisol levels an important indicator of stress?: A meta-analysis study. ACTA FACULTATIS MEDICAE NAISSENSIS 2021. [DOI: 10.5937/afmnai38-29970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The purpose of this study was to examine the practical importance of the correlation values between plasma and salivary cortisol levels using meta-analysis study. In this way, researchers focusing on cortisol levels in different individuals can use more systemic, practical and reliable evidence than using just salivary or plasma cortisol levels separately. For this purpose, correlational studies from 2000 up to now were collected and analyzed by meta-analysis. Results based on 18 effect sizes (n = 743) revealed that effect sizes of the correlations between plasma and salivary cortisol levels represented large effects. The overall combined effect size (Hedges's = 1.55) also represented a large effect. This finding indicates the practical importance of the correlation values for stress studies. The use of the correlation values for examining the cortisol levels in stress studies will be discussed in detail.
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16
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Kim YJ, Kim JH, Hong AR, Park KS, Kim SW, Shin CS, Kim SY. Stimulated Salivary Cortisol as a Noninvasive Diagnostic Tool for Adrenal Insufficiency. Endocrinol Metab (Seoul) 2020; 35:628-635. [PMID: 32981305 PMCID: PMC7520577 DOI: 10.3803/enm.2020.707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/20/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Salivary cortisol is routinely used as a diagnostic test for Cushing syndrome. The diagnostic use of salivary cortisol for adrenal insufficiency (AI), however, is less established. We aimed to investigate the utility of morning basal and adrenocorticotropic hormone-stimulated salivary cortisol in diagnosing AI in Korean adults. METHODS We prospectively included 120 subjects (female, n=70) from Seoul National University Hospital. AI was defined as a stimulated serum cortisol level of <496.8 nmol/L during the short Synacthen test (SST). Serum and saliva samples were drawn between 8:00 AM and 10:00 AM. Salivary cortisol levels were measured using an enzyme immunoassay kit. RESULTS Thirty-four patients were diagnosed with AI according to the SST results. Age, sex, body mass index, serum albumin levels, and serum creatinine levels did not significantly differ between the normal and AI groups. Basal and stimulated salivary cortisol levels were positively correlated with basal (r=0.538) and stimulated serum cortisol levels (r=0.750), respectively (all P<0.001). Receiver operating characteristic curve analysis yielded a cutoff level of morning basal salivary cortisol of 3.2 nmol/L (sensitivity, 84.9%; specificity, 73.5%; area under the curve [AUC]=0.822). The optimal cutoff value of stimulated salivary cortisol was 13.2 nmol/L (sensitivity, 90.7%; specificity, 94.1%; AUC=0.959). Subjects with a stimulated salivary cortisol level above 13.2 nmol/L but a stimulated serum cortisol level below 496.8 nmol/L (n=2) had lower serum albumin levels than those showing a concordant response. CONCLUSION The diagnostic performance of stimulated salivary cortisol measurements after the SST was comparable to serum cortisol measurements for diagnosing AI.
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Affiliation(s)
- Yoon Ji Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - A Ram Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyeong Seon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Piano S, Favaretto E, Tonon M, Antonelli G, Brocca A, Sticca A, Mareso S, Gringeri E, Scaroni C, Plebani M, Russo FP, Burra P, Cillo U, Angeli P. Including Relative Adrenal Insufficiency in Definition and Classification of Acute-on-Chronic Liver Failure. Clin Gastroenterol Hepatol 2020; 18:1188-1196.e3. [PMID: 31589973 DOI: 10.1016/j.cgh.2019.09.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/14/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Relative adrenal insufficiency (RAI) is defined by insufficient production of cortisol relative to organ demand. RAI is observed frequently in hospitalized patients with cirrhosis, but there is disagreement over the clinical effects of RAI in these patients. We evaluated the prevalence and the clinical effects of RAI in hospitalized patients with cirrhosis. METHODS We performed a prospective study of 160 patients admitted to a hospital in Italy for acute decompensation of cirrhosis from May 2011 through September 2016. Patients were followed up until death, liver transplantation, or a maximum of 90 days. Serum and salivary levels of cortisol were measured before and after a 1-hour Short Synacthen Test. A diagnosis of RAI was given to patients with an increase in serum cortisol of less than 9 μg/dL, after Synacthen administration, in patients with baseline serum levels of cortisol less than 35 μg/dL. We collected blood samples before the Synacthen test and analyzed them for blood cell counts, liver and renal function, levels of C-reactive protein, and lipid profiles (total cholesterol, high-density lipoprotein cholesterol, apolipoprotein-A1). RESULTS A diagnosis of RAI was made for 78 patients (49%). Age (odds ratio [OR], 0.95; P = .030), number of leukocytes (OR, 3.10; P = .006), and levels of high-density lipoprotein cholesterol (OR, 0.30; P = .039) were associated independently with RAI. Patients with RAI had a significantly higher risk of developing bacterial infections (hazard ratio [HR], 1.60; P = .038), sepsis (HR, 2.95; P = .001), septic shock (HR, 4.94; P = .038), new organ failures (HR, 2.45; P = .014), and acute-on-chronic liver failure (HR, 2.27; P = .037) than patients without RAI. RAI was associated independently with death within 90 days of diagnosis (subdistribution HR, 4.83; P = .001). Patients with RAI and mild renal dysfunction or hepatic encephalopathy had no significant difference in cumulative incidence of 28-day mortality vs patients with acute-on-chronic liver failure grade 1 (25% vs 22%). CONCLUSIONS We found RAI to occur in almost half of patients admitted to a hospital for acute decompensation of cirrhosis. RAI was associated with a deficit of substrates for steroidogenesis and an increase in markers of inflammation. Patients with RAI have a high risk of developing sepsis, septic shock, organ failure, and death within 90 days. RAI has similar prognostic value to nonrenal organ failures.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Elisa Favaretto
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Giorgia Antonelli
- Unit of Laboratory Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Alessandra Brocca
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Antonietta Sticca
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Sara Mareso
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Carla Scaroni
- Unit of Endocrinology, Department of Medicine, University of Padova, Padova, Italy
| | - Mario Plebani
- Unit of Laboratory Medicine, Department of Medicine, University of Padova, Padova, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy.
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18
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Gibbison B, Keenan DM, Roelfsema F, Evans J, Phillips K, Rogers CA, Angelini GD, Lightman SL. Dynamic Pituitary-Adrenal Interactions in the Critically Ill after Cardiac Surgery. J Clin Endocrinol Metab 2020; 105:dgz206. [PMID: 31738827 PMCID: PMC7089849 DOI: 10.1210/clinem/dgz206] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/15/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with critical illness are thought to be at risk of adrenal insufficiency. There are no models of dynamic hypothalamic-pituitary-adrenal (HPA) axis function in this group of patients and thus current methods of diagnosis are based on aggregated, static models. OBJECTIVE To characterize the secretory dynamics of the HPA axis in the critically ill (CI) after cardiac surgery. DESIGN Mathematical modeling of cohorts. SETTING Cardiac critical care unit. PATIENTS 20 male patients CI at least 48 hours after cardiac surgery and 19 healthy (H) male volunteers. INTERVENTIONS None. MAIN OUTCOME MEASURES Measures of hormone secretory dynamics were generated from serum adrenocorticotrophic hormone (ACTH) sampled every hour and total cortisol every 10 min for 24 h. RESULTS All CI patients had pulsatile ACTH and cortisol profiles. CI patients had similar ACTH secretion (1036.4 [737.6] pg/mL/24 h) compared to the H volunteers (1502.3 [1152.2] pg/mL/24 h; P = .20), but increased cortisol secretion (CI: 14 447.0 [5709.3] vs H: 5915.5 [1686.7)] nmol/L/24 h; P < .0001). This increase in cortisol was due to nonpulsatile (CI: 9253.4 [3348.8] vs H: 960 [589.0] nmol/L/24 h, P < .0001), rather than pulsatile cortisol secretion (CI: 5193.1 [3018.5] vs H: 4955.1 [1753.6] nmol/L/24 h; P = .43). Seven (35%) of the 20 CI patients had cortisol pulse nadirs below the current international guideline threshold for critical illness-related corticosteroid insufficiency, but an overall secretion that would not be considered deficient. CONCLUSIONS This study supports the premise that current tests of HPA axis function are unhelpful in the diagnosis of adrenal insufficiency in the CI. The reduced ACTH and increase in nonpulsatile cortisol secretion imply that the secretion of cortisol is driven by factors outside the HPA axis in critical illness.
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Affiliation(s)
- Ben Gibbison
- Department of Anaesthesia, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel M Keenan
- Department of Statistics, University of Virginia, Charlottesville, VA, US
| | - Ferdinand Roelfsema
- Department of Internal Medicine, Section Endocrinology, University of Leiden, Leiden, The Netherlands
| | - Jon Evans
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Kirsty Phillips
- Department of Pathology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, UK
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Dichtel LE, Schorr M, Loures de Assis C, Rao EM, Sims JK, Corey KE, Kohli P, Sluss PM, McPhaul MJ, Miller KK. Plasma Free Cortisol in States of Normal and Altered Binding Globulins: Implications for Adrenal Insufficiency Diagnosis. J Clin Endocrinol Metab 2019; 104:4827-4836. [PMID: 31009049 PMCID: PMC6735741 DOI: 10.1210/jc.2019-00022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/16/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Accurate diagnosis of adrenal insufficiency is critical because there are risks associated with overdiagnosis and underdiagnosis. Data using liquid chromatography tandem mass spectrometry (LC/MS/MS) free cortisol (FC) assays in states of high or low cortisol-binding globulin (CBG) levels, including cirrhosis, critical illness, and oral estrogen use, are needed. DESIGN Cross-sectional. OBJECTIVE Determine the relationship between CBG and albumin as well as total cortisol (TC) and FC in states of normal and abnormal CBG. Establish the FC level by LC/MS/MS that best predicts TC of <18 μg/dL (497 nmol/L) (standard adrenal insufficiency diagnostic cutoff) in healthy individuals. SUBJECTS This study included a total of 338 subjects in four groups: healthy control (HC) subjects (n = 243), patients with cirrhosis (n = 38), intensive care unit patients (ICU) (n = 26), and oral contraceptive (OCP) users (n = 31). MAIN OUTCOME MEASURE(S) FC and TC by LC/MS/MS, albumin by spectrophotometry, and CBG by ELISA. RESULTS TC correlated with FC in the ICU (R = 0.91), HC (R = 0.90), cirrhosis (R = 0.86), and OCP (R = 0.70) groups (all P < 0.0001). In receiver operator curve analysis in the HC group, FC of 0.9 μg/dL (24.8 nmol/L) predicted TC of <18 μg/dL (497 nmol/L; 98% sensitivity, 91% specificity; AUC, 0.98; P < 0.0001). Decreasing the cutoff to 0.7 μg/dL led to a small decrease in sensitivity (92%) with similar specificity (91%). CONCLUSIONS A cutoff FC of <0.9 μg/dL (25 nmol/L) in this LC/MS/MS assay predicts TC of <18 μg/dL (497 nmol/L) with excellent sensitivity and specificity. This FC cutoff may be helpful in ruling out adrenal insufficiency in patients with binding globulin derangements.
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Affiliation(s)
- Laura E Dichtel
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Laura E. Dichtel, MD, MHS, Neuroendocrine Unit, Massachusetts General Hospital, BUL457B, 55 Fruit Street, Boston, Massachusetts 02114. E-mail:
| | - Melanie Schorr
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | - Elizabeth M Rao
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica K Sims
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen E Corey
- Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Puja Kohli
- Harvard Medical School, Boston, Massachusetts
- Division of Pulmonology and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Patrick M Sluss
- Harvard Medical School, Boston, Massachusetts
- Clinical Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael J McPhaul
- Endocrinology, Quest Diagnostics Nichols Institute, San Juan Capistrano, California
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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20
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Theocharidou E, Giouleme O, Anastasiadis S, Markopoulou A, Pagourelias E, Vassiliadis T, Fotoglidis A, Agorastou P, Slavakis A, Balaska A, Kouskoura MG, Gossios TD, Karagiannis A, Mantzoros CS. Free Cortisol Is a More Accurate Marker for Adrenal Function and Does Not Correlate with Renal Function in Cirrhosis. Dig Dis Sci 2019; 64:1686-1694. [PMID: 30659471 DOI: 10.1007/s10620-019-5460-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The accuracy of diagnosis and clinical implications of the hepatoadrenal syndrome, as currently diagnosed using total cortisol, remain to be validated. AIM The aim of this study was to assess adrenal function using free cortisol in stable cirrhosis and study the potential implications of any abnormalities for renal and/or cardiac function. METHODS Sixty-one stable consecutively enrolled patients with cirrhosis underwent assessment of adrenal function using the low-dose short Synacthen test, renal function by 51Cr-EDTA glomerular filtration rate (GFR), and cardiac function by two-dimensional echocardiography. RESULTS Eleven patients (18%) had total peak cortisol (PC) < 500 nmol/L, but no patient had free PC < 33 nmol/L indicating that diagnosis of AI using total cortisol is not confirmed using free cortisol. Free cortisol did not correlate with GFR or parameters of cardiac function. Patients with higher Child-Pugh class had progressively lower free cortisol. Patients with low GFR < 60 mL/min (N = 22) had more frequently grade II-III diastolic dysfunction (66.7% vs. 17.6%; p = 0.005) and had higher Child-Pugh and MELD score compared to those with normal GFR. CONCLUSIONS Diagnosis of AI using total cortisol is not confirmed using free cortisol and is thus considered unreliable in cirrhosis. Free cortisol is not associated with renal or cardiac dysfunction. Lower free cortisol in more advanced stages of liver disease might be secondary to decreased synthesis due to lower cholesterol levels. Irrespective of free cortisol, parameters of cardiac dysfunction are associated with renal impairment supporting the cardio-renal hypothesis.
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Affiliation(s)
| | - Olga Giouleme
- 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Sotirios Anastasiadis
- 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Aikaterini Markopoulou
- School of Pharmacy, Laboratory of Pharmaceutical Analysis, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Efstathios Pagourelias
- 3rd Department of Cardiology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Themistoklis Vassiliadis
- 3rd Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Athanasios Fotoglidis
- 3rd Department of Cardiology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Polyxeni Agorastou
- 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Aristeidis Slavakis
- Department of Biochemistry, Hippokration General Hospital, Thessaloníki, Greece
| | - Aikaterini Balaska
- Laboratory of the 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Maria G Kouskoura
- School of Pharmacy, Laboratory of Pharmaceutical Analysis, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Thomas D Gossios
- 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Asterios Karagiannis
- 2nd Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Christos S Mantzoros
- Division of Endocrinology and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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Albert L, Profitós J, Sánchez-Delgado J, Capel I, González-Clemente JM, Subías D, Cano A, Berlanga E, Espinal A, Hurtado M, Pareja R, Rigla M, Dalmau B, Vergara M, Miquel M, Casas M, Giménez-Palop O. Salivary Cortisol Determination in ACTH Stimulation Test to Diagnose Adrenal Insufficiency in Patients with Liver Cirrhosis. Int J Endocrinol 2019; 2019:7251010. [PMID: 31320899 PMCID: PMC6609341 DOI: 10.1155/2019/7251010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The prevalence of adrenal insufficiency (AI) in patients with decompensated liver cirrhosis is unknown. Because these patients have lower levels of cortisol-binding carrier proteins, their total serum cortisol (TSC) correlates poorly with free serum cortisol (FC). Salivary cortisol (SaC) correlates better with FC. We aimed to establish SaC thresholds for AI for the 250 μg intravenous ACTH test and to estimate the prevalence of AI in noncritically ill cirrhotic patients. METHODS We included 39 patients with decompensated cirrhosis, 39 patients with known AI, and 45 healthy volunteers. After subjects fasted ≥8 hours, serum and saliva samples were collected for determinations of TSC and SaC at baseline 0'(T0) and at 30-minute intervals after intravenous administration of 250 μg ACTH [30'(T30), 60'(T60), and 90'(T90)]. RESULTS Based on the findings in healthy subjects and patients with known AI, we defined AI in cirrhotic patients as SaC-T0< 0.08 μg/dL (2.2 nmol/L), SaC-T60 < 1.43 μg/dl (39.5 nmol/L), or ΔSaC<1 μg/dl (27.6 nmol/L). We compared AI determination in cirrhotic patients with the ACTH test using these SaC thresholds versus established TSC thresholds (TSC-T0< 9 μg/dl [248 nmol/L], TSC-T60 < 18 μg/dl [497 nmol/L], or ΔTSC<9 μg/dl [248 nmol/L]). SaC correlated well with TSC. The prevalence of AI in cirrhotic patients was higher when determined by TSC (48.7%) than by SaC (30.8%); however, this difference did not reach statistical significance. AI was associated with sex, cirrhosis etiology, and Child-Pugh classification. CONCLUSIONS Measuring SaC was more accurate than TSC in the ACTH stimulation test. Measuring TSC overestimated the prevalence of AI in noncritically ill cirrhotic patients.
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Affiliation(s)
- Lara Albert
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Joaquím Profitós
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Jordi Sánchez-Delgado
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Ismael Capel
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - José Miguel González-Clemente
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - David Subías
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Albert Cano
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Eugenio Berlanga
- Clinical Laboratory Department, Institut d'Investigació i Innovació Parc Taulí I3PT, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | - Anna Espinal
- Servei d'Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Marta Hurtado
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Rocío Pareja
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Rigla
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Blai Dalmau
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Vergara
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Mireia Miquel
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Meritxell Casas
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Olga Giménez-Palop
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
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Theiler-Schwetz V, Zaufel A, Schlager H, Obermayer-Pietsch B, Fickert P, Zollner G. Bile acids and glucocorticoid metabolism in health and disease. Biochim Biophys Acta Mol Basis Dis 2019; 1865:243-251. [DOI: 10.1016/j.bbadis.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/18/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
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Kumar M, Gupta GK, Wanjari SJ, Tak V, Ameta M, Nijhawan S. Relative Adrenal Insufficiency in Patients with Alcoholic Hepatitis. J Clin Exp Hepatol 2019; 9:215-220. [PMID: 31024204 PMCID: PMC6477128 DOI: 10.1016/j.jceh.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/04/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/AIMS Alcoholic hepatitis (AH) is an acute hepatic inflammation associated with high morbidity and mortality. Treatment with steroids is known to decrease short-term mortality in severe AH patients. Hence, we hypothesize that adrenal insufficiency can be associated with severe AH and affects prognosis. The aim of this study was (1) to evaluate relative adrenal insufficiency (RAI) in patients with AH and (2) to Compare RAI with the severity of AH. METHODS Newly diagnosed cases of AH hospitalized in SMS Medical College and Hospital, Department of Gastroenterology were, enrolled. All patients of AH were classified as mild and severe AH on the basis of Maddrey discriminant function (DF). After baseline serum cortisol, 25 IU ACTH (Adreno Corticotrophic Hormone) was injected intramuscularly and blood sample was collected after 1 h and assessed for serum cortisol. RAI was defined as <7 μg increase in the cortisol level from baseline. RAI was compared with severity of AH. RESULTS Of 120 patients of AH, 58 patients fulfilled the inclusion criteria, in which 48 patients were diagnosed as severe AH and 10 patients were diagnosed as mild AH. In patients with severe AH, the baseline mean serum cortisol level was significantly high as compared with mild AH; 26 patients (54.16 %) of 48 patients with severe AH showed RAI (P ≤ 0.001).Whereas in patients with mild AH, none of patients showed RAI. RAI also showed negative correlation with DF. There was no difference in RAI with respect to acute kidney injury (AKI). CONCLUSION RAI is a common entity in patients with severe AH, and it is related with the severity of disease.
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Key Words
- ACTH, Adreno Corticotrophic Hormone
- AH, Alcoholic Hepatitis
- AI, Adrenal Insuffiency
- AKI, Acute Kidney Injury
- ALD, Alcoholic Liver Disease
- ALT, Alanine Aminotranferase
- AST, Aspartate Aminotransferase
- CIRCI (Critical Illness Related Corticosteroid Insufficiency)
- CIRCI, Critical Illness Related Corticosteroid Insufficiency
- DF, Discriminant Function
- HPA, Hypothalamic Pituitary Adrenal
- INR, International Normalised Ratio
- MELD, Model for End-stage Liver Disease
- PT, Prothrombin Time
- RAI, Relative Adrenal Insuffiency
- TLC, Total Leucocyte Count
- alcoholic hepatitis
- relative adrenal insufficiency
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Affiliation(s)
| | - Gaurav K. Gupta
- Address for correspondence: Gaurav Kumar Gupta, MD, DM. Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, India. Tel.: +91 9214027938.
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Singh RR, Walia R, Sachdeva N, Bhalla A, Singh A, Singh V. Relative adrenal insufficiency in cirrhotic patients with ascites (hepatoadrenal syndrome). Dig Liver Dis 2018; 50:1232-1237. [PMID: 29887344 DOI: 10.1016/j.dld.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/11/2018] [Accepted: 05/12/2018] [Indexed: 02/08/2023]
Abstract
AIM Relative adrenal insufficiency (RAI) has been reported in critically ill patients with cirrhosis. We evaluated the prevalence of RAI and its relationship to clinical course in non-septic cirrhosis patients with ascites. METHODS The study included 66 consecutive non-septic cirrhosis patients with ascites. RAI was defined by a delta cortisol lower than 9 μg/dL and/or a peak cortisol lower than 18 μg/dL. RESULTS Sixty-six patients with cirrhosis and ascites were studied. The mean Child-Turcotte-Pugh (CTP) and model for end stage liver disease (MELD) scores were 10.6 ± 1.9 and 21.5 ± 7.3, respectively. The prevalence of RAI in patients with cirrhosis and ascites was 47% (31/66). The prevalence of RAI in patients with and without spontaneous bacterial peritonitis, renal failure and type 1 hepatorenal syndrome (HRS) was comparable. Baseline hyponatremia was common in RAI (42% versus 17%, p = 0.026). There was a significant correlation of prevalence of RAI with prothrombin time, international normalized ratio, MELD scores and CTP class. During follow-up, there was no association between RAI and the risk to develop new infections, severe sepsis, type 1 HRS and death. CONCLUSIONS RAI is common in non-septic cirrhotic patients with ascites and its prevalence increases with severity of liver disease. However, it does not affect the short-term outcome in these patients.
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Affiliation(s)
- Rajiv Ranjan Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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25
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1476] [Impact Index Per Article: 246.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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26
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Park SH, Joo MS, Kim BH, Yoo HN, Kim SE, Kim JB, Jang MK, Kim DJ, Lee MS. Clinical characteristics and prevalence of adrenal insufficiency in hemodynamically stable patients with cirrhosis. Medicine (Baltimore) 2018; 97:e11046. [PMID: 29952944 PMCID: PMC6039635 DOI: 10.1097/md.0000000000011046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
It is well known that adrenal insufficiency is common in septic shock or hemodynamically unstable patients. But, there is as yet no sufficient clinically significant data about the exact prevalence or differences in the cause of cirrhosis with adrenal insufficiency. To investigate adrenal insufficiency prevalence in hemodynamically stable patients with cirrhosis and determine differences based on cirrhosis severity or etiology.From July 2011 to December 2012, 69 hemodynamically stable patients with cirrhosis without infection admitted at Hallym University Medical Center were enrolled. Adrenal insufficiency was defined as a peak cortisol level < 18 μg/dL, 30 or 60 minutes after 250 μg Synacthen injection.The study included 55 male patients (79.7%), and the mean age was 57.9 ± 12.9 years. Cirrhosis etiology was alcohol consumption, HBV, HCV, both viral and alcohol related, and cryptogenic in 49, 15, 7, 11, 9 patients, respectively. Adrenal insufficiency occurred in 24 patients (34.8%). No differences were found in age, sex, mean arterial pressure, heart rate, HDL, cirrhosis etiology, degree of alcohol consumption, encephalopathy, variceal bleeding history, or hepatocellular carcinoma between patients with or without adrenal insufficiency. Serum albumin level was lower (P < .05), and INR was higher (P < .05) in patients with than in those without adrenal insufficiency. However, multivariate analysis revealed no independent adrenal insufficiency predictor. Significant negative correlations were found between Child-Pugh score and peak cortisol levels (γ=-0.365, P = .008).Adrenal insufficiency was frequent even in hemodynamically stable patients with cirrhosis and tended to be associated with only liver disease severity, being unrelated to cirrhosis etiology.
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Paz-Delgadillo J, Monreal-Robles R, Villarreal-Pérez JZ, Maldonado-Garza HJ, Bosques-Padilla FJ, Lavalle-González FJ. Algorithm for Screening of Adrenal Function in Stable Patients with Cirrhosis. Ann Hepatol 2018; 16:788-796. [PMID: 28809735 DOI: 10.5604/01.3001.0010.2797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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.
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Affiliation(s)
- Jonathan Paz-Delgadillo
- Universidad Autónoma de Nuevo León, Monterrey, México Gastroenterology Service, Hospital Universitario "Dr. José E. González"
| | - Roberto Monreal-Robles
- Universidad Autónoma de Nuevo León, Monterrey, México Gastroenterology Service, Hospital Universitario "Dr. José E. González"
| | - Jesús Z Villarreal-Pérez
- Universidad Autónoma de Nuevo León, Monterrey, México Endocrinology Service, Hospital Universitario "Dr. José E. González"
| | - Héctor J Maldonado-Garza
- Universidad Autónoma de Nuevo León, Monterrey, México Gastroenterology Service, Hospital Universitario "Dr. José E. González"
| | - Francisco J Bosques-Padilla
- Universidad Autónoma de Nuevo León, Monterrey, Mexico Gastroenterology Division, Hospital Universitario "Dr. José Eleuterio González"
| | - Francisco J Lavalle-González
- Universidad Autónoma de Nuevo León, Monterrey, México Gastroenterology Service, Hospital Universitario "Dr. José E. González"
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Ambrogio AG, Danesi L, Baldini M, Radin R, Cassinerio E, Graziadei G, Mirra N, D'Angelo E, Marcon A, Mancarella M, Orsatti A, Bonetti F, Scacchi M, Cappellini MD, Persani L, Pecori Giraldi F. Low-dose Synachten test with measurement of salivary cortisol in adult patients with β-thalassemia major. Endocrine 2018; 60:348-354. [PMID: 29572711 PMCID: PMC5893656 DOI: 10.1007/s12020-018-1562-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/04/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE Beta-thalassemia major is a severe, congenital hematological disorder and, if untreated, leads to early mortality. Progress in therapeutical strategies improved clinical outcomes and life expectancy; however, increased survival led to the development of new disorders, including endocrinopathies. Little is known on the possible impairment of adrenocortical function, a potentially life-threatening condition, in long-term thalassaemic survivors. We therefore decided to assess adrenal reserve and the value of salivary cortisol during ACTH stimulation in the diagnosis of adrenocortical insufficiency in adult patients with β-thalassemia major. METHODS Cross-sectional study including 72 adults with β-thalassemia major. Patients were tested with 1 µg ACTH for serum and salivary cortisol. RESULTS Subnormal serum cortisol responses to ACTH stimulation (i.e., <500 nmol/l) were registered in 15 out of 72 patients. Salivary cortisol increased in parallel with serum cortisol and a clear-cut positive correlation was detected at each timepoint. Moreover, peak salivary cortisol values after ACTH stimulation were significantly lower in patients with impaired adrenal reserve (513.6 ± 52.33 vs. 914.1 ± 44.04 nmol/l p < 0.0001). CONCLUSIONS Our results attest to the need for testing for adrenal insufficiency among adult thalassaemic patients, as up to 20% presented impaired adrenal reserve. Salivary and serum cortisol levels during stimulation with ACTH were closely correlated and the use of salivary cortisol sampling during ACTH testing may represent a surrogate to serum cortisol in these patients.
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Affiliation(s)
- Alberto G Ambrogio
- Neuroendocrine Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Leila Danesi
- Division of Endocrine and Metabolic Diseases, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Marina Baldini
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raffaella Radin
- Division of Endocrine and Metabolic Diseases, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Elena Cassinerio
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Graziadei
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nadia Mirra
- Fondazione Policlinico Mangiagalli Regina Elena, Second Pediatric Clinic, University of Milan, Milan, Italy
| | - Emanuela D'Angelo
- Fondazione Policlinico Mangiagalli Regina Elena, Second Pediatric Clinic, University of Milan, Milan, Italy
| | - Alessia Marcon
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Mancarella
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Orsatti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Federico Bonetti
- Pediatric Haematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimo Scacchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of General Medicine, Istituto Auxologico Italiano IRCCS, Ospedale San Giuseppe, Piancavallo-Verbania, Via San Vittore, Italy
| | - Maria Domenica Cappellini
- Department of Medicine and Medical Specialties, Rare Diseases Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesca Pecori Giraldi
- Neuroendocrine Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Cholongitas E, Goulis I, Pagkalidou E, Haidich A, Karagiannis A, Nakouti T, Pipili C, Oikonomou T, Gerou S, Akriviadis E. Relative Adrenal Insufficiency is Associated with the Clinical Outcome in Patients with Stable Decompensated Cirrhosis. Ann Hepatol 2018; 16:584-590. [PMID: 28611262 DOI: 10.5604/01.3001.0010.0298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The clinical impact of relative adrenal insufficiency (AI) on patients with stable decompensated cirrhosis (DeCi) has not been yet elucidated. AIM Explore the association between AI and outcome [death or liver transplantation (LT)] in patients with DeCi. MATERIAL AND METHODS Patients with DeCi presenting no active complication have been included. Clinical and laboratory data, including serum levels of corticosteroid-binding globulin (CBG), interleukin (IL)-1b, IL-6 and tumor necrosis factor (TNFα) were recorded in each participant. Salivary cortisol (SC) and serum total cortisol (STC) were assessed at (T0) and 1 h (T60) after intravenous injection of 250 μg corticotropin. RESULTS 113 consecutive patients were totally tested. Median SC was 3.9 ng/mL and 15.5 ng/mL and median STC was 10.7 μg/dL and 22.7 μg/dL at T0 and T60 respectively. The patients with AI [group 1, n = 34 (30%)] had significantly lower systolic blood pressure (106 ± 12 vs. 113 ± 13 mmHg, p = 0.05), serum sodium (133 ± 7 vs. 137 ± 12 mEq/ L, p = 0.04), HDL (29.9 ± 14 vs. 38.6 ± 18 mg/dL, p = 0.034) and albumin (2.7 ± 0.5 vs. 3.1 ± 0.5 g/dL, p = 0.002), but higher direct bilirubin (median: 1.6 vs. 0.8 mg/dL, p = 0.029) compared to those without AI [group 2, n = 79 (70%)]. Moreover, group 1 patients presented more frequently past history of spontaneous bacterial peritonitis (SBP) [10/34 (29.4%) vs. 6/79 (7.5%), p = 0.002]. AI was significantly associated with death [HR = 2.65, 95% C.I.: 1.55 - 4.52, p = 0.003 over a follow up period of 12 (6-48) months.] Conclusions. The presence of AI in patients with stable DeCi predispose to obvious clinical implications since it is associated with circulatory dysfunction, previous history of SBP and worse survival.
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Affiliation(s)
- Evangelos Cholongitas
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Ioannis Goulis
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Eirini Pagkalidou
- Department of Hygiene and Epidemiology, School of Medicine, Thessaloniki, Greece
| | - Anna Haidich
- Department of Hygiene and Epidemiology, School of Medicine, Thessaloniki, Greece
| | - Apostolos Karagiannis
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Theodora Nakouti
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Chrysoula Pipili
- Division of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Theodora Oikonomou
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Spyros Gerou
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
| | - Evangelos Akriviadis
- 4th Department of Internal Medicine, Hippokration General Hospital, Medical School Aristotle University of Thessaloniki, Greece
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Nolan BJ, Sorbello J, Brown N, Dimeski G, Inder WJ. Characterization of the serum and salivary cortisol response to the intravenous 250 µg ACTH 1-24 stimulation test. Endocrine 2018; 59:520-528. [PMID: 29299794 DOI: 10.1007/s12020-017-1505-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The ACTH1-24 stimulation test is commonly used to assess the hypothalamic-pituitary-adrenal (HPA) axis. Given variations in CBG concentration and binding affinity, serum total cortisol may misclassify some patients. Salivary cortisol correlates well with serum free cortisol but is easier to measure and widely available in commercial laboratories. The aim of this study was to investigate the utility of measuring salivary cortisol during the ACTH1-24 stimulation test. DESIGN AND METHODS Case-control study in a clinical research facility. Eighty-seven patients with suspected cortisol deficiency, twenty-four healthy controls, and ten healthy women on the oral contraceptive (OC) underwent an intravenous 250 µg ACTH1-24 stimulation test. Concordance of ACTH1-24 stimulated serum and salivary cortisol was evaluated. RESULTS There was a significant difference in serum cortisol between the healthy volunteers and the women on the OC (P < 0.001) but no difference in salivary cortisol. The lower limit of the reference interval for salivary cortisol at 60 min was 26 nmol/L. 27/89 (30%) of tests with suspected HPA axis disorder failed the 60 min serum cortisol cut-off of 500 nmol/L. Of these, 24/27 (89%) had a salivary cortisol of <26 nmol/L. In contrast, 12/19 (63%) tests and 5/43 (12%) tests where the 60 min serum cortisol was 500-599 and ≥600 nmol/L, respectively had a salivary cortisol of <26 nmol/L. CONCLUSIONS Salivary cortisol provides additional diagnostic value during the 250 µg ACTH1-24 stimulation test in patients with proven or suspected alterations in CBG and potentially those with a borderline 60 min serum cortisol 500-599 nmol/L.
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Affiliation(s)
- Brendan J Nolan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jane Sorbello
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Nigel Brown
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Goce Dimeski
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
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Saevik ÅB, Åkerman AK, Grønning K, Nermoen I, Valland SF, Finnes TE, Isaksson M, Dahlqvist P, Bergthorsdottir R, Ekwall O, Skov J, Nedrebø BG, Hulting AL, Wahlberg J, Svartberg J, Höybye C, Bleskestad IH, Jørgensen AP, Kämpe O, Øksnes M, Bensing S, Husebye ES. Clues for early detection of autoimmune Addison's disease - myths and realities. J Intern Med 2018; 283:190-199. [PMID: 29098731 DOI: 10.1111/joim.12699] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early detection of autoimmune Addison's disease (AAD) is important as delay in diagnosis may result in a life-threatening adrenal crisis and death. The classical clinical picture of untreated AAD is well-described, but methodical investigations are scarce. OBJECTIVE Perform a retrospective audit of patient records with the aim of identifying biochemical markers for early diagnosis of AAD. MATERIAL AND METHODS A multicentre retrospective study including 272 patients diagnosed with AAD at hospitals in Norway and Sweden during 1978-2016. Scrutiny of medical records provided patient data and laboratory values. RESULTS Low sodium occurred in 207 of 247 (84%), but only one-third had elevated potassium. Other common nonendocrine tests were largely normal. TSH was elevated in 79 of 153 patients, and hypoglycaemia was found in 10%. Thirty-three per cent were diagnosed subsequent to adrenal crisis, in whom electrolyte disturbances were significantly more pronounced (P < 0.001). Serum cortisol was consistently decreased (median 62 nmol L-1 [1-668]) and significantly lower in individuals with adrenal crisis (38 nmol L-1 [2-442]) than in those without (81 nmol L-1 [1-668], P < 0.001). CONCLUSION The most consistent biochemical finding of untreated AAD was low sodium independent of the degree of glucocorticoid deficiency. Half of the patients had elevated TSH levels. Only a minority presented with marked hyperkalaemia or other nonhormonal abnormalities. Thus, unexplained low sodium and/or elevated TSH should prompt consideration of an undiagnosed AAD, and on clinical suspicion bring about assay of cortisol and ACTH. Presence of 21-hydroxylase autoantibodies confirms autoimmune aetiology. Anticipating additional abnormalities in routine blood tests may delay diagnosis.
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Affiliation(s)
- Å B Saevik
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - A-K Åkerman
- Department of Medicine, Örebro University Hospital, Örebro, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - K Grønning
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - I Nermoen
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - S F Valland
- Division of Endocrinology, Innlandet Hospital Trust, Hamar, Norway
| | - T E Finnes
- Division of Endocrinology, Innlandet Hospital Trust, Hamar, Norway
| | - M Isaksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - P Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - R Bergthorsdottir
- Department of Endocrinology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - O Ekwall
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Rheumatology and Inflammation Research, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Endocrine Division, Department of Medicine, Karlstad City Hospital, Karlstad, Sweden
| | - B G Nedrebø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Haugesund Hospital, Haugesund, Norway
| | - A-L Hulting
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J Wahlberg
- Division of Endocrinology, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - J Svartberg
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway.,Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - C Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - I H Bleskestad
- Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway
| | - A P Jørgensen
- Department of Endocrinology, Oslo University Hospital, Oslo, Norway
| | - O Kämpe
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,K.G. Jebsen center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - M Øksnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - S Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - E S Husebye
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,K.G. Jebsen center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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32
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Tana MM, Alao H, Morris N, Bernstein S, Hattenbach J, Rehman RB, Brychta R, Sarkar S, Zhao X, Walter M, Buckley A, Chen K, Rotman Y. Fatigued Patients with Chronic Liver Disease Have Subtle Aberrations of Sleep, Melatonin and Cortisol Circadian Rhythms. FATIGUE : BIOMEDICINE, HEALTH & BEHAVIOR 2017; 6:5-19. [PMID: 30546968 PMCID: PMC6287634 DOI: 10.1080/21641846.2018.1408539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIMS We sought to examine whether disturbances in central and peripheral circadian rhythms were related to the experience of fatigue in patients with chronic liver disease (CLD). METHODS Fatigued and non-fatigued patients with compensated CLD were enrolled in a prospective pilot study. Patients underwent a one week evaluation of free-living sleep and physical activity patterns, followed by a 24-hour admission, during which they underwent serial blood sampling, polysomnography, a 6-minute walk test and continuous core temperature measurements under standardized conditions. Blood samples were analyzed for liver tests, melatonin levels, lipids, and cortisol. Circadian rhythms were analyzed using single cosinor analyses. RESULTS Six fatigued and six non-fatigued patients were studied; five participants had cirrhosis. Fatigue severity was positively associated higher peak melatonin levels (rho=0.59, p=0.04) and a delay in night-time melatonin peak and inversely associated with sleep efficiency (rho=-0.63, p=0.04). Polysomnography, 6-minute walk test, and core temperature measurements did not differ significantly between the fatigued and non-fatigued patients. Although liver enzymes, bilirubin and albumin demonstrated a circadian pattern, it was not associated with fatigue. Fatigued patients showed a blunted and delayed cortisol rhythm and fatigue was strongly correlated with cortisol amplitude (rho=-0.77, p=0.004) and phase (r=-0.66, p=0.02). CONCLUSION Subtle aberrations in melatonin and adrenal circadian rhythms, as well as reduced sleep efficiency, likely contribute to fatigue in patients with CLD. These abnormalities may ultimately be a therapeutic target to improve quality of life for fatigued patients with CLD.
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Affiliation(s)
- Michele M. Tana
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- The UCSF Liver Center, San Francisco, CA, USA
- Co-first authors
| | - Hawwa Alao
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
- Co-first authors
| | - Nevitt Morris
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Shanna Bernstein
- National Institute of Digestive Diseases and Kidney Diseases, Bethesda, MD, USA
| | - Jacob Hattenbach
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Rahiya B. Rehman
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Robert Brychta
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Souvik Sarkar
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Xiongce Zhao
- National Institute of Digestive Diseases and Kidney Diseases, Bethesda, MD, USA
| | - Mary Walter
- National Institute of Digestive Diseases and Kidney Diseases, Bethesda, MD, USA
| | - Ashura Buckley
- Sleep and Neurodevelopment Service, Office of the Clinical Director, National Institute of Mental Health, Bethesda, MD, USA
| | - Kong Chen
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Yaron Rotman
- Liver & Energy Metabolism Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
- Co-first authors
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33
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Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I). Crit Care Med 2017; 45:2078-2088. [DOI: 10.1097/ccm.0000000000002737] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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34
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Annane D, Pastores SM, Rochwerg B, Arlt W, Balk RA, Beishuizen A, Briegel J, Carcillo J, Christ-Crain M, Cooper MS, Marik PE, Umberto Meduri G, Olsen KM, Rodgers S, Russell JA, Van den Berghe G. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Med 2017; 43:1751-1763. [PMID: 28940011 DOI: 10.1007/s00134-017-4919-5] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients. PARTICIPANTS A multispecialty task force of 16 international experts in Critical Care Medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine. DESIGN/METHODS The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members. RESULTS The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 µg/dl) after cosyntropin (250 µg) administration and a random plasma cortisol of <10 µg/dl may be used by clinicians. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence). CONCLUSIONS Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.
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Affiliation(s)
- Djillali Annane
- General ICU Department, Raymond Poincaré Hospital (APHP), Helath Science Centre Simone Veil, Universite Versailles SQY-Paris Saclay, Garches, France.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-1179, New York, NY, 10065, USA.
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wiebke Arlt
- Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Institute of Metabolism and Systems Research (IMSR), University of Birmingham and Centre for Endocrinology, Birmingham, UK
| | - Robert A Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Josef Briegel
- Anesthesiology and Critical Care Medicine, Klinik für Anästhesiologie, Klinikum der Universität, Munich, Germany
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Mark S Cooper
- Department of Endocrinology, Concord Hospital, University of Sydney, Sydney, NSW, Australia
| | - Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Keith M Olsen
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sophia Rodgers
- Clinical Adjunct Faculty, University of New Mexico and Sandoval Regional Medical Center, Albuquerque, NM, USA
| | - James A Russell
- Division of Critical Care Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University and Hospitals, Louvain, 3000, Belgium
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35
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Rakici H. Adrenal Insufficiency in Cirrhosis Patients: Evaluation of 108 Case Series. Euroasian J Hepatogastroenterol 2017; 7:150-153. [PMID: 29201798 PMCID: PMC5670259 DOI: 10.5005/jp-journals-10018-1237] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/23/2017] [Indexed: 12/26/2022] Open
Abstract
AIM Adrenal insufficiency (AI) in cirrhosis is an issue that has recently gained momentum. It can be seen in both stable and critically ill (sepsis, septic shock, and gastrointestinal system bleeding) cirrhotic patients. Its prevalence exists in a wide range since standardization of diagnostic methods is lacking. We aimed to scrutinize this issue in a 108 case series. MATERIALS AND METHODS We studied the presence of AI and its stage in patients with cirrhosis and its complications by using cross-sectional study. Standard-dose short synacthen test (SD-SST) was performed in 108 patients that had Child C decompensated cirrhosis without critical illness and it was aimed to determine the prevalence of AI based on basal cortisol, peak cortisol, and delta cortisol (basal total cortisol minus peak cortisol after stimulation) levels. RESULTS The prevalence of AI in cirrhosis was found to be 25% based on basal cortisol level of <140 nmol/L, 22.2% based on delta cortisol level of <250 nmol/L, and 29.6% based on peak cortisol level of <500 nmol/L. CONCLUSION Prevalence of AI shows variation in decompensated cirrhosis without critical illness depending on different measures used. More definite results can be obtained when more standardized criteria are widely put into use.How to cite this article: Rakici H. Adrenal Insufficiency in Cirrhosis Patients: Evaluation of 108 Case Series. Euroasian J Hepato-Gastroenterol 2017;7(2):150-153.
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Affiliation(s)
- Hali Rakici
- Department of Gastroenterology, Recep Tayyip Erdogan Universitesi, Riza, Turkey
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36
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Abstract
PURPOSE OF REVIEW A resurgence of interest in salivary biomarkers has generated evidence for their value in assessing adrenal function. The advantages of salivary measurements include only free hormone is detected, samples can be collected during normal daily routines and stress-induced cortisol release is less likely to occur than during venepuncture. We review the use of salivary biomarkers to diagnose and monitor patients for conditions of cortisol excess and deficiency and discuss the value of measuring salivary cortisone versus salivary cortisol. RECENT FINDINGS Developments in laboratory techniques have enabled the measurement of salivary hormones with a high level of sensitivity and specificity. In states of altered cortisol binding, salivary biomarkers are more accurate measures of adrenal reserve than serum cortisol. Salivary cortisone is a superior marker of serum cortisol compared with salivary cortisol, specifically when serum cortisol is low and during hydrocortisone therapy when contamination of saliva may result in misleading salivary cortisol concentrations. SUMMARY Salivary cortisol and cortisone can be used to assess cortisol excess, deficiency and hydrocortisone replacement, with salivary cortisone having the advantage of detection when serum cortisol levels are low and there is no interference from oral hydrocortisone.
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Affiliation(s)
- Joanne Blair
- aAlder Hey Children's Hospital, Liverpool bUniversity Hospital South Manchester cManchester Healthcare Academy, Manchester dThe University of Sheffield, Sheffield, UK
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Relative Adrenal Insufficiency in Patients with Cirrhosis: A Systematic Review and Meta-Analysis. Dig Dis Sci 2017; 62:1067-1079. [PMID: 28176190 DOI: 10.1007/s10620-017-4471-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Relative adrenal insufficiency (RAI) is frequently observed in patients with cirrhosis. We sought to identify evidence in the literature regarding the impact of RAI on clinical outcomes in cirrhotic patients. METHODS We conducted a systematic review (SR) and meta-analysis (MA) using the Ovid-MEDLINE, EMBASE, and Cochrane Library databases to identify relevant studies in the literature. RESULTS Of the 182 studies identified, 16 were eligible according to our inclusion criteria. The prevalence of RAI was 49.4% (744/1507), and cirrhotic patients with acute critical illnesses such as sepsis were more likely to have RAI compared to those without critical illnesses (P < 0.001). With respect to clinical outcomes, patients with RAI had poorer survival rates and an increased risk of complications such as bleeding and hepatorenal syndrome compared to those without RAI. Corticosteroid therapy had a beneficial effect on critically ill cirrhotic patients in terms of hospital survival rate. CONCLUSIONS Based on this SR and MA, critically ill patients with cirrhosis have a high risk of RAI, and the presence of RAI is related to a poor prognosis and occurrence of cirrhotic complications.
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El-Farhan N, Rees DA, Evans C. Measuring cortisol in serum, urine and saliva - are our assays good enough? Ann Clin Biochem 2017; 54:308-322. [PMID: 28068807 DOI: 10.1177/0004563216687335] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cortisol is a steroid hormone produced in response to stress. It is essential for maintaining health and wellbeing and leads to significant morbidity when deficient or present in excess. It is lipophilic and is transported bound to cortisol-binding globulin (CBG) and albumin; a small fraction (∼10%) of total serum cortisol is unbound and biologically active. Serum cortisol assays measure total cortisol and their results can be misleading in patients with altered serum protein concentrations. Automated immunoassays are used to measure cortisol but lack specificity and show significant inter-assay differences. Liquid chromatography - tandem mass spectrometry (LC-MS/MS) offers improved specificity and sensitivity; however, cortisol cut-offs used in the short Synacthen and Dexamethasone suppression tests are yet to be validated for these assays. Urine free cortisol is used to screen for Cushing's syndrome. Unbound cortisol is excreted unchanged in the urine and 24-h urine free cortisol correlates well with mean serum-free cortisol in conditions of cortisol excess. Urine free cortisol is measured predominantly by immunoassay or LC-MS/MS. Salivary cortisol also reflects changes in unbound serum cortisol and offers a reliable alternative to measuring free cortisol in serum. LC-MS/MS is the method of choice for measuring salivary cortisol; however, its use is limited by the lack of a single, validated reference range and poorly standardized assays. This review examines the methods available for measuring cortisol in serum, urine and saliva, explores cortisol in disease and considers the difficulties of measuring cortisol in acutely unwell patients and in neonates.
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Affiliation(s)
- Nadia El-Farhan
- 1 Biochemistry Department, Royal Gwent Hospital, Newport, UK
| | - D Aled Rees
- 2 Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Carol Evans
- 3 Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
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Mezzullo M, Fanelli F, Fazzini A, Gambineri A, Vicennati V, Di Dalmazi G, Pelusi C, Mazza R, Pagotto U, Pasquali R. Validation of an LC-MS/MS salivary assay for glucocorticoid status assessment: Evaluation of the diurnal fluctuation of cortisol and cortisone and of their association within and between serum and saliva. J Steroid Biochem Mol Biol 2016; 163:103-12. [PMID: 27108942 DOI: 10.1016/j.jsbmb.2016.04.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/21/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023]
Abstract
Salivary steroid testing represents a valuable source of biological information; however, the proper measurement of low salivary levels is challenging for direct immunoassays, lacking adequate sensitivity and specificity and causing poor inter-laboratory reproducibility. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has overcome previous analytical limits, often providing results deviating from previous knowledge. Nowadays, LC-MS/MS is being introduced in clinical laboratories for salivary cortisol testing; however, so far only a few studies have reported thorough biological validation based on LC-MS/MS data. In this study, we provide a thorough analytical, pre-analytical and biological validation of an LC-MS/MS method for the measurement of salivary cortisol (F) and of its inactive metabolite cortisone (E). Analytes were extracted from 50μl of saliva, were then separated in 7.5min LC-gradient and detected by negative electrospray ionization-multiple reaction monitoring. The reliability of a widely diffused collection device, Salivette(®), was assessed and the overall procedure was validated. The diurnal cortisol and cortisone fluctuation in saliva and serum was described by a four paired collection protocol (8 am, 12 am, 4 pm and 8 pm) in 19 healthy subjects. The assay allowed the quantitation of F and E down to 39.1 and 78.1pg/ml, with an imprecision range of 5.5-9.5%, 3.9-14.1% and 2.6-14.4%, and an accuracy range of 105.5-113.1%, 88.5-98.7% and 90.7-96.7% for both analytes at low, medium and high levels, respectively. Salivette(®) provided comparable results and better precision (CV<1.0%) as referred to direct spitting (CV<13.0%). A parallel diurnal rhythm in saliva and serum was observed for cortisol and cortisone, with values lowering from the morning to the evening time points (P<0.0001). While salivary E linearly correlated to total serum F (R(2)=0.854, P<0.001), salivary F showed an exponential relationship (R(2)=0.903, P<0.001) with serum F reflecting the free circulating fraction. A non linear association between E and F was observed in saliva (R(2)=0.941, p<0.001) consistent with the type II 11β-HSD activity. We concluded that our LC-MS/MS method allowed a sensitive evaluation of salivary levels of cortisol and cortisone. The simultaneous determination of both hormones in saliva allowed the differential estimation of the active and of the total glucocorticoid exposure over the daytime. The assay could provide further insight into the comprehension of normal and dysfunctional glucocorticoid circadian rhythm.
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Affiliation(s)
- Marco Mezzullo
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Flaminia Fanelli
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Alessia Fazzini
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Alessandra Gambineri
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Valentina Vicennati
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Guido Di Dalmazi
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Carlotta Pelusi
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Roberta Mazza
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Uberto Pagotto
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Renato Pasquali
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy.
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Bertino G, Privitera G, Purrello F, Demma S, Crisafulli E, Spadaro L, Koukias N, Tsochatzis EA. Emerging hepatic syndromes: pathophysiology, diagnosis and treatment. Intern Emerg Med 2016; 11:905-16. [PMID: 27273018 DOI: 10.1007/s11739-016-1478-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide, mainly due to complications of portal hypertension. In this article, we review the current understanding on the pathophysiology, the diagnostic criteria and the available therapeutic options for patients with emerging hepatic syndromes in cirrhosis, namely the hepatorenal, hepato-adrenal and hepatopulmonary syndrome. The hepatorenal syndrome is a well-recognized complication of advanced cirrhosis and is usually associated with an accelerated course to death unless liver transplantation is performed. The hepatopulmonary syndrome is often missed in the evaluation of patients with cirrhosis; however, early recognition is essential for the efficient management of individual patients. The hepato-adrenal syndrome, although not fully characterized, offers an exciting field for research and potential therapeutic interventions.
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Affiliation(s)
- Gaetano Bertino
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Graziella Privitera
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Francesco Purrello
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Shirin Demma
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Emanuele Crisafulli
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Luisa Spadaro
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Nikolaos Koukias
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
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Abstract
PURPOSE To improve performance of the cosyntropin stimulation test (CST) used for diagnosis of adrenal-cortisol insufficiency by implementing an electronic medical record (EMR) system protocol. METHODS We implemented a SmartForm protocol of the validated CST in our EMR system (CS-Link™, EPIC) system and compared medical staff test performance before and after protocol implementation. RESULTS Correct performance of the CST improved significantly after EMR implementation. The number of correctly performed CSTs increased from 16.1 % before to 53.5 % after implementation (p < 0.0001) while those performed incorrectly and were uninterpretable decreased from 36.2 to 7.1 % (p < 0.0001). This performance improvement result in a calculated cost savings of $50,414 for every 100 tests performed. CONCLUSIONS The EMR system is useful for guiding medical staff to accurately perform the CST, reduce the number of wasted tests, and maximize staff time and resources.
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Affiliation(s)
- Anat Ben-Shlomo
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Davis Building, Room 3021, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - Joseph Guzman
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Davis Building, Room 3021, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
| | - James Mirocha
- Biostatistics Core, Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Chiriac Ş, Stanciu C, Negru R, Trifan A. ASSESSMENT OF ADRENOCORTICAL DYSFUNCTION IN PATIENTS WITH STABLE LIVER CIRRHOSIS. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2016; 12:262-267. [PMID: 31149099 PMCID: PMC6535276 DOI: 10.4183/aeb.2016.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Relative adrenal insufficiency (RAI) is common in the setting of critical illness as well as in hemodynamically instable cirrhotic patients with sepsis. Several studies have also shown that RAI is frequent in patients with stable cirrhosis without sepsis. The aim of this study was to prospectively assess the incidence of RAI in patients with stable cirrhosis. PATIENTS AND METHODS Forty-seven patients with hemodynamically stable liver cirrhosis without sepsis were prospectively included. RAI, assessed by using low dose-short Synacthen test (LD-SST), was defined as either a basal total cortisol concentration below 3.6 µg/dL or a peak total serum cortisol ≤ 16 µg/dL at 30 min after stimulation. RESULTS RAI was present in 10 (21.3%) of 47 cirrhotic patients. Peak cortisol level was negatively correlated with the severity of cirrhosis evaluated by Child-Turcotte-Pugh (CTP) (r=-0.46; P=0.001) and Model for End-Stage Liver Disease (MELD) (r=-0.51; P=0.001) scores. The frequency of RAI increased from CTP-A (10%) to CTP-B (30%) to CTP-C (60%). CONCLUSION RAI diagnosed by LD-SST is frequent in patients with stable cirrhosis and is related to the severity of liver disease. Further studies are needed to define clinical importance of RAI in stable cirrhotic patients.
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Affiliation(s)
- Ş. Chiriac
- “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
| | - C. Stanciu
- “St. Spiridon” Emergency Hospital - Institute of Gastroenterology and Hepatology, Iaşi, Romania
- *Correspondence to: Carol Stanciu MD, PhD, “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 1 Independentei street, Iasi, 700111, Romania, E-mail:
| | - R. Negru
- “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
| | - A. Trifan
- “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
- “St. Spiridon” Emergency Hospital - Institute of Gastroenterology and Hepatology, Iaşi, Romania
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Rauschecker M, Abraham SB, Abel BS, Wesley R, Saverino E, Trivedi A, Heller T, Nieman LK. Cosyntropin-Stimulated Serum Free Cortisol in Healthy, Adrenally Insufficient, and Mildly Cirrhotic Populations. J Clin Endocrinol Metab 2016; 101:1075-81. [PMID: 26647150 PMCID: PMC4803155 DOI: 10.1210/jc.2015-2285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Serum free cortisol (SFF) responses to cosyntropin simulation test (CST) may more accurately assess adrenal function than total cortisol (TF). OBJECTIVE The objective of the study was to evaluate the diagnostic utility of SFF responses during a 250-μg CST. DESIGN We recruited healthy volunteers (HV; n = 27), patients with primary and secondary adrenal insufficiency (n = 19 and n = 24, respectively), and subjects with Child-Pugh class A cirrhosis (CH; n = 15). Each received 250 μg cosyntropin with measurement of ACTH and corticosteroid binding globulin (CBG) at time 0 and TF and SFF at 0, 30, and 60 minutes. Salivary cortisol was measured at all time points in CH subjects. RESULTS Peak SFF and TF were significantly higher in HVs vs both AI groups (P < .05). Peak SFF and TF (6.8 μg/dL vs 2.2 μg/dL; [188 nmol/L vs 62 nmol/L]; P < .01) were significantly higher in the secondary adrenal insufficiency vs primary adrenal insufficiency patients. The optimal peak SFF criterion to identify adrenal insufficiency patients vs HV was 0.9 μg/dL (25 nmol/L) (sensitivity of 95%, specificity of 100%). Mean CBG and albumin levels were similar among all four groups. CH patients had a higher peak SFF than HV (2.4 vs 2.0 μg/dL; P = .02. In the CH patients, peak salivary cortisol levels correlated well with peak SFF (rs = 0.84, P = .005). CBG levels were similar among the groups. CONCLUSION We provide normative data for SFF values in HV and AI during the CST. Normal CBG levels in mild cirrhosis did not affect the interpretation of the CST.
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Affiliation(s)
- Mitra Rauschecker
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Smita Baid Abraham
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Brent S Abel
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Robert Wesley
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Elizabeth Saverino
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Apurva Trivedi
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Theo Heller
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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Yamashita M, Kageyama K, Murakami H, Sugiyama A, Yanagimachi M, Sato E, Murasawa S, Matsui J, Tamasawa N, Daimon M. The Evaluation of Adrenal Function in Two Cases of Hypocortisolism Accompanied by Liver Cirrhosis. Intern Med 2016; 55:765-8. [PMID: 27041161 DOI: 10.2169/internalmedicine.55.5604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Adrenal insufficiency may occur in patients with liver cirrhosis. The assessment of hypothalamus-pituitary-adrenal function is important in such patients, but there is no consensus as to how it should be performed. We herein report the results of our evaluation of the adrenal function in two patients with hypocortisolism accompanied by liver cirrhosis. The patients lacked the typical features of hypocortisolism. One was diagnosed with hypocortisolism accompanied by liver cirrhosis while the other had secondary adrenal insufficiency caused by a hypothalamic disorder. Hypocortisolism accompanied by liver cirrhosis should be evaluated by endocrine tests to determine its pathogenesis. A low-dose adrenocorticotropic hormone test may be appropriate for non-critically ill cirrhotic patients.
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Affiliation(s)
- Maki Yamashita
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Japan
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Fede G, Spadaro L, Privitera G, Tomaselli T, Bouloux PM, Purrello F, Burroughs AK. Hypothalamus-pituitary dysfunction is common in patients with stable cirrhosis and abnormal low dose synacthen test. Dig Liver Dis 2015; 47:1047-51. [PMID: 26364559 DOI: 10.1016/j.dld.2015.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 08/03/2015] [Accepted: 08/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Adrenal insufficiency is often present in cirrhosis. We hypothesize that a prolonged adrenocorticotropic hormone (ACTH) stimulus can restore cellular capacity of adrenal glands to secrete cortisol. Aim of our study was to assess adrenal responsiveness to prolonged ACTH stimulation in cirrhotics. METHODS Prospective observational study in 121 consecutively admitted cirrhotic patients undergoing a low dose short synacthen test and plasma ACTH measurement using a chemiluminescence immunoassay. Long synacthen test was performed if the low dose was abnormal. RESULTS 46 patients had abnormal low dose short test (38%), and 29 underwent the long test: 41% showed normal response (Group 1), 55% showed delayed response (Group 2) and 1 had abnormal response (4%). Baseline ACTH levels did not significantly differ between the two groups. Median basal cortisol was higher in Group 1 (296 vs. 198 nmol/L; p=0.02). Using ROC curve basal cortisol <254 nmol/L was associated with a delayed long synacthen test response (AUC 0.78, p=0.001) with good accuracy (sensitivity 67%, specificity 81%). CONCLUSION A delayed cortisol response after a prolonged ACTH stimulation is found in over fifty percent of cirrhotics with abnormal low dose short synacthen test, confirming that the mechanism of hypoadrenalism in these patients could be related both to adrenal cellular dysfunction and hypothalamus-pituitary adrenal axis impairment.
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Affiliation(s)
- Giuseppe Fede
- The Royal Free Sheila Sherlock Liver Centre and Institute of Liver and Digestive Health, University College London and Royal Free Hospital, London, UK; Department of Clinical and Molecular Biomedicine, University of Catania, Garibaldi Hospital, Catania, Italy.
| | - Luisa Spadaro
- Department of Clinical and Molecular Biomedicine, University of Catania, Garibaldi Hospital, Catania, Italy
| | - Graziella Privitera
- Department of Clinical and Molecular Biomedicine, University of Catania, Garibaldi Hospital, Catania, Italy
| | - Tania Tomaselli
- Department of Clinical and Molecular Biomedicine, University of Catania, Garibaldi Hospital, Catania, Italy
| | | | - Francesco Purrello
- Department of Clinical and Molecular Biomedicine, University of Catania, Garibaldi Hospital, Catania, Italy
| | - Andrew Kenneth Burroughs
- The Royal Free Sheila Sherlock Liver Centre and Institute of Liver and Digestive Health, University College London and Royal Free Hospital, London, UK
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Ruiz-del-Árbol L, Serradilla R. Cirrhotic cardiomyopathy. World J Gastroenterol 2015; 21:11502-11521. [PMID: 26556983 PMCID: PMC4631957 DOI: 10.3748/wjg.v21.i41.11502] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/17/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
During the course of cirrhosis, there is a progressive deterioration of cardiac function manifested by the disappearance of the hyperdynamic circulation due to a failure in heart function with decreased cardiac output. This is due to a deterioration in inotropic and chronotropic function which takes place in parallel with a diastolic dysfunction and cardiac hypertrophy in the absence of other known cardiac disease. Other findings of this specific cardiomyopathy include impaired contractile responsiveness to stress stimuli and electrophysiological abnormalities with prolonged QT interval. The pathogenic mechanisms of cirrhotic cardiomyopathy include impairment of the b-adrenergic receptor signalling, abnormal cardiomyocyte membrane lipid composition and biophysical properties, ion channel defects and overactivity of humoral cardiodepressant factors. Cirrhotic cardiomyopathy may be difficult to determine due to the lack of a specific diagnosis test. However, an echocardiogram allows the detection of the diastolic dysfunction and the E/e′ ratio may be used in the follow-up progression of the illness. Cirrhotic cardiomyopathy plays an important role in the pathogenesis of the impairment of effective arterial blood volume and correlates with the degree of liver failure. A clinical consequence of cardiac dysfunction is an inadequate cardiac response in the setting of vascular stress that may result in renal hypoperfusion leading to renal failure. The prognosis is difficult to establish but the severity of diastolic dysfunction may be a marker of mortality risk. Treatment is non-specific and liver transplantation may normalize the cardiac function.
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Abstract
Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. Apart from the liver, this may involve the heart, lungs, kidneys, the immune system, the adrenal glands, and other organ systems. As the disease progresses, the circulation becomes hyperdynamic, and signs of cardiac, pulmonary, and renal dysfunction are observed, in addition to reduced survival. Infections and an altered cardiac function known as cirrhotic cardiomyopathy may be precipitators for the development of other complications such as hepatorenal syndrome. In patients with chronic organ dysfunction, various precipitating events may induce an acute-on-chronic renal failure and acute-on-chronic liver failure that negatively affect the prognosis. Future research on the pathophysiologic mechanisms of the complications and the precipitating factors is essential to understand the basics of the treatment of these challenging conditions. The aim of the present review is to focus on the development and precipitating factors of various organ failures in patients with decompensated cirrhosis.
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Bancos I, Erickson D, Bryant S, Hines J, Nippoldt TB, Natt N, Singh R. PERFORMANCE OF FREE VERSUS TOTAL CORTISOL FOLLOWING COSYNTROPIN STIMULATION TESTING IN AN OUTPATIENT SETTING. Endocr Pract 2015; 21:1353-63. [PMID: 26340138 DOI: 10.4158/ep15820.or] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Free cortisol (FC) is potentially superior to total cortisol (TC) measurements in selected clinical settings; however, the advantages of uniform use of FC in outpatient settings are unclear. The objectives of this study were to describe the dynamic response of FC during cosyntropin stimulation testing (CST) compared to TC and to determine the rates of discordance. METHODS This is a cross-sectional study of 295 stable patients who underwent CST in an outpatient Endocrine Testing Center. The main outcome measures were TC and FC measurements during CST. RESULTS The mean age of the 295 subjects was 49.1 (16.9) years. Of 218 females, 43 were taking estrogen therapy (ET) at the time of testing. Adrenal insufficiency (AI) was diagnosed in 41/295 (14%) patients. The FC concentrations were associated with TC concentrations at baseline (R(2) = 0.77, P<.001), 30 minutes (R(2) = 0.87, P<.001), and 60 minutes (R(2) = 0.90, P<.001). The FC cutoffs for AI were 873 and 1,170 ng/dL at 30 and 60 minutes, respectively. The FC had a more pronounced fold change from baseline to peak than TC (median 3.2 vs. 1.7, P<.001). Both TC and FC at baseline were higher in females on ET compared to those who were not and to males; however, peak TC and FC values were similar. In 3/43 females on ET, FC, and TC results were discordant (P = .003). CONCLUSION We report 99% concordance of TC and FC measurements in a large outpatient cohort. The discordant rates were high in females treated with ET (7%). The FC measurements during CST in females on ET may provide a more rapid and accurate diagnosis of AI.
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49
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Graupera I, Pavel O, Hernandez-Gea V, Ardevol A, Webb S, Urgell E, Colomo A, Llaó J, Concepción M, Villanueva C. Relative adrenal insufficiency in severe acute variceal and non-variceal bleeding: influence on outcomes. Liver Int 2015; 35:1964-73. [PMID: 25644679 DOI: 10.1111/liv.12788] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 01/09/2015] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Relative adrenal insufficiency (RAI) is common in critical illness and in cirrhosis, and is related with worse outcomes. The prevalence of RAI may be different in variceal and non-variceal bleeding and whether it may influence outcomes in these settings is unclear. This study assesses RAI and its prognostic implications in cirrhosis with variceal bleeding and in peptic ulcer bleeding. METHODS Patients with severe bleeding (systolic pressure <100 mmHg and/or haemoglobin <8 g/L) from oesophageal varices or from a peptic ulcer were included. Adrenal function was evaluated within the first 24 h and RAI was diagnosed as delta cortisol <250 nmol/L after 250 μg of i.v. corticotropin. RESULTS Sixty-two patients were included, 36 had cirrhosis and variceal bleeding and 26 without cirrhosis had ulcer bleeding. Overall, 15 patients (24%) had RAI, 8 (22%) with variceal and 7 (24%) with ulcer bleeding. Patients with RAI had higher rate of bacterial infections. Baseline serum and salivary cortisol were higher in patients with RAI (P < 0.001) while delta cortisol was lower (P < 0.001). There was a good correlation between plasma and salivary cortisol (P < 0.001). The probability of 45-days survival without further bleeding was lower in cirrhotic patients with variceal bleeding and RAI than in those without RAI (25% vs 68%, P = 0.02), but not in non-cirrhotic patients with peptic ulcer bleeding with or without RAI (P = 0.75). CONCLUSION The prevalence of RAI is similar in ulcer bleeding and in cirrhosis with variceal bleeding. Cirrhotic patients with RAI, but not those with bleeding ulcers, have worse prognosis.
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Affiliation(s)
- Isabel Graupera
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Oana Pavel
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Virginia Hernandez-Gea
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Alba Ardevol
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Susan Webb
- Department of Endocrinology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER), Barcelona, Spain
| | - Eulalia Urgell
- Department of Clinical Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Alan Colomo
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Jordina Llaó
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Mar Concepción
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain
| | - Càndid Villanueva
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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50
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Karagiannis AKA, Nakouti T, Pipili C, Cholongitas E. Adrenal insufficiency in patients with decompensated cirrhosis. World J Hepatol 2015; 7:1112-1124. [PMID: 26052400 PMCID: PMC4450188 DOI: 10.4254/wjh.v7.i8.1112] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/12/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
Adrenal reserve depletion and overstimulation of the hypothalamus-pituitary-adrenal (HPA) axis are causes for adrenal insufficiency (AI) in critically ill individuals. Cirrhosis is a predisposing condition for AI in cirrhotics as well. Both stable cirrhotics and liver transplant patients (early and later after transplantation) have been reported to present AI. The mechanisms leading to reduced cortisol production in cirrhotics are the combination of low cholesterol levels (the primary source of cortisol), the increased cytokines production that overstimulate and exhaust HPA axis and the destruction of adrenal glands due to coagulopathy. AI has been recorded in 10%-82% cirrhotics depending on the test used to evaluate adrenal function and in 9%-83% stable cirrhotics. The similarity of those proportions support the assumption that AI is an endogenous characteristic of liver disease. However, the lack of a gold standard method for AI assessment and the limitation of precise thresholds in cirrhotics make difficult the recording of the real prevalence of AI. This review aims to summarize the present data over AI in stable, critically ill cirrhotics and liver transplant recipients. Moreover, it provides information about the current knowledge in the used diagnostic tools and the possible effectiveness of corticosteroids administration in critically ill cirrhotics with AI.
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