RESUMO
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.
Assuntos
Testes de Função do Córtex Suprarrenal , Córtex Suprarrenal/metabolismo , Insuficiência Adrenal/diagnóstico , Taxa de Filtração Glomerular , Síndrome Hepatorrenal/diagnóstico , Hidrocortisona/sangue , Rim/fisiopatologia , Cirrose Hepática/diagnóstico , Insuficiência Adrenal/sangue , Insuficiência Adrenal/epidemiologia , Insuficiência Adrenal/fisiopatologia , Adulto , Idoso , Biomarcadores/sangue , Feminino , Grécia/epidemiologia , Cardiopatias/diagnóstico , Cardiopatias/epidemiologia , Cardiopatias/fisiopatologia , Síndrome Hepatorrenal/sangue , Síndrome Hepatorrenal/epidemiologia , Síndrome Hepatorrenal/fisiopatologia , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/epidemiologia , Cirrose Hepática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Prognóstico , Reprodutibilidade dos Testes , Adulto JovemRESUMO
Relative adrenal insufficiency (RAI) was demonstrated in patients with cirrhosis and liver failure. A relationship appears to exist between the severity of the liver disease and the presence of RAI. Neither the mechanism nor the exact prevalence of RAI is fully understood. There is though a hypothesis that low high-density lipoprotein (HDL) levels in this group of patients may be responsible for the insufficiency of cortisol. Several questions also arise about the way and the kind of cortisol (total cortisol, free cortisol, or even salivary cortisol) that should be measured. The presence of RAI in patients with cirrhosis is unquestionable, but still several studies should come up in order to properly define it and fully understand it.