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Category: Volume 08 Issue 10 October 2020
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Title: Relative Adrenal Insufficiency as a Predictive Factor of Development of Decompensation in Cirrhotic Ascites

Authors: Anvin Thomas, R. Murali, K Prem Kumar

 DOI: https://dx.doi.org/10.18535/jmscr/v8i10.45

Abstract

Introduction: Relative adrenal insufficiency is a  feature of liver dysfunction where adrenal cortex cannot synthesize enough cortisol at times of  pathological stress and  which may not manifest  during normal periods.

Aim: To assess the prevalence of Relative Adrenal Insufficiency (RAI) in stable cirrhotic ascites and its relationship with further occurrence of infective and non-infective complications.

Methodology: In this prospective study, out of all cirrhotic patients presenting with ascites to our department, those with SBP, HRS, jaundice, sepsis, ARDS, previous steroid use, other complications/ comorbidities were excluded at the time of admission and 60 patients were selected. In these patients LDSST was done and RAI was diagnosed on the basis of low post stimulation cortisol and low delta cortisol. These 60 patients were divided into two cohorts, those with RAI and those without RAI and followed up over a period of 6 months for the development of infective (SBP, HRS, Sepsis) and non-infective complications (encephalopathy, coagulopathy, jaundice, bleeding ) to know whether the two groups had any significant difference in the occurrence of these complications.

Results: Infective complications like SBP (63 %;p value 0.018),HRS(55.6 %;p value 0.017), Sepsis (44 %,p value 0.046) were significantly increased in RAI group. With respect to non-infective complications and other infections there were no significant differences.

Conclusion: In those patients with RAI selective interventions like corticosteroids or albumin could be tried to prevent infective complications.

Keywords: RAI-Relative Adrenal Insufficiency, SBP – spontaneous bacterial peritonitis, HRS- hepatorenal syndrome.

References

  1. Thevenot T, Borot S, Remy-Martin A, Sapin R, Cervoni JP, in cirrhotic patients using concentration of serum-free and salivary cortisol. Liver Int 2011; 31: 425-433 [PMID: 21281437 DOI: 10.1111/j.1478-3231.2010.02431.x]
  2. Fede G, Spadaro L, Tomaselli T, Privitera G. Assessment of adrenocortical reserve in stable patients with cirrhosis. J Hepatol 2011; 54: 243-250 [PMID: 21056503 DOI: 10.1016/j.jhep.2010.06.034]
  3. Tan T, Chang L, Woodward A, McWhinney B, Galligan JCharacterising adrenal function using directly measured plasma free cortisol in stable severe liver disease. J Hepatol 2010; 53: 841-848 [PMID: 20739086 DOI: 10.1016/j.jhep.2010.05.020]
  4. Gui D, Spada PL, De Gaetano A, Pacelli F. Hypocholesterolemia and risk of death in the critically ill surgical patient. Intensive Care Med 1996; 22: 790-794 [PMID: 8880248 DOI: 10.1007/ BF01709522]
  5. Marik PE. Adrenal-exhaustion syndrome in patients with liver disease. Intensive Care Med 2006; 32: 275-280 [PMID: 16432671 DOI: 10.1007/s00134-005-0005-5]
  6. Soares JB, Pimentel-Nunes P, The role of lipopolysaccharide/toll-like receptor 4 signaling in chronic liver diseases. Hepatol Int 2010; 4: 659-672[PMID:21286336 DOI:10.1007/s12072-010-9219-x]
  7. Sekiyama KD, Yoshiba M,. Circulating proinflammatory cytokines (IL-1 beta, TNF-alpha, and IL-6) and IL-1 receptor antagonist (IL-1Ra) in fulminant hepatic failure and acute hepatitis. Clin Exp Immunol 1994; 98: 71-77 [PMID: 7923888]
  8. Marik PE. Adrenal-exhaustion syndrome in patients with liver disease. Intensive Care Med 2006; 32: 275-280 [PMID: 16432671 DOI: 10.1007/s00134-005-0005-5]
  9. Hebbar KB, Stockwell JA, Leong T, Fortenberry JD. Incidence of adrenal insufficiency and impact of corticosteroid supplementation in critically ill children with systemic inflammatory syndrome. Crit Care Med 2011; 39: 1145-1150 [PMID: 21336126 DOI: 10.1097/CCM.0b013e31820eb4e4]
  10. Montagnese S, Middleton B, Mani AR, Skene DJ, Morgan MY. Hepatoadrenal syndrome: doesdoes cortisol sample time matter? J Hepatol. 2009;50(84):206
  11. Kazlauskaite R, Evans AT, Consortium for Evaluation of Corticotropin Test in Hypothalamic-Pituitary Adrenal Insufficiency. Corticotropin tests for hypothalamic—pituitary—adrenal insufficiency: a meta-analysis. J Clin Endocrinol Metab. 2008;93:4245–4253
  12. Coolens JL, Van Baelen H, Heyns W. Clinical use of unbound plasma cortisol as calculated from total cortisol and corticosteroid-binding globulin. J Steroid Biochem 1987;26:197-202
  13. Kim WR, Biggins SW, Kremers WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list.NEJM, 2008 ;359 :1018-1026.
  14. Beishuizen A, Thijs LG. Relative adrenal insufficiency in intensive care: an identifiable problem requiring treatment? Best Pract Res Clin Endocrinol Metab 2001;15:513-531
  15. Shilov JI, Orlova EG. Role of adrenergic mechanisms in regulation of phagocytic cell functions in acute stress response. Immunol Lett 2003; 86:229-233.
  16. Moreau R, Gine`s P, Jalan R et al. Acute-on-chronic liver failure is a distinct syndrome developing in patients with acute decompensation of cirrosis. Gastroenterology 2013.
  17. eu/publications/clinical-practice-guidelines
  18. Surviving_Sepsis_Campaign_International_Guidelines

Corresponding Author

Anvin Thomas

Institute of Medical Gastroenterology, Madras Medical College, The Tamil Nadu Dr. M.G.R Medical University, Chennai, India