Hépato-Gastro & Oncologie Digestive
MENUAdrenal insufficiency and cirrhosis Volume 19, issue 6, Juin 2012
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- Key words: cirrhosis, cortisol, adrenal insufficiency, ACTH, adrenocorticotrophic hormone, AVP, arginine vasopressine, CBG, cortisol bindingprotein, CIRCI, critical illness-related corticosteroid insufficiency, CLS, cortisol libre sérique, CRH, corticotropin-releasing hormone, CRP, protéine C réactive, HHS, hypothalamo-hypophysaire-surrénalien, ICL, index de cortisol libre, IV, intraveineux, MELD, model for end stage liver disease, NO, monoxide d’azote, iNOS, NO synthase inductible, TH, transplantation hépatique, VIH, virus de l’immunodéficience humaine
- DOI : 10.1684/hpg.2012.0736
- Page(s) : 426-36
- Published in: 2012
Adrenal insufficiency (AI) is suspected of being common in patients with cirrhosis and of worsening their prognosis. Symptoms are non-specific making the diagnosis difficult. AI diagnosis is suspected when total cortisol levels measured before and 60 minutes after i.v. injection of 250 μg synacthen are below 83 nmol/L and/or 500 nmol/L, respectively. In the setting of stress, like sepsis, AI is suspected by a delta total cortisol of < 250 nmol/L or a random total cortisol of < 276 nmol/L, and treatment with glucocorticoids is recommended for patients who respond poorly to fluid resuscitation and vasopressors. These recommendations can be applied to cirrhotic patients. More than 90 % of circulating cortisol is bound to corticosteroid-binding globulin and albumin, synthesized by the liver. The reduced serum concentrations of these two proteins in cirrhosis result in a decrease in serum total cortisol concentrations alongside the alteration of hepatic function without altering the concentrations of serum free cortisol (SFC) and salivary cortisol. The most severe cirrhotic patients have the highest levels of SFC and of salivary cortisol, probably related to the induction of an inflammatory “stress” by bacterial translocation. Although SFC is the biologically active and the most relevant hormone in the setting of cirrhosis, its routine dosage is not currently available. We suggest using instead the standard synacthen test followed by a salivary cortisol measurement in case of subnormal results. Patients with subnormal salivary cortisol should received hydrocortisone and should be referred to endocrinologists for further investigations.
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