Prevalence of Adenocortical Insufficiency in Patients with Liver Cirrhosis, Liver Cirrhosis with Septic Shock and in Patients with Hepatorenal Syndrome
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- Category: Vol. 79, March 2011
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Prevalence of Adenocortical Insufficiency in Patients with Liver Cirrhosis, Liver Cirrhosis with Septic Shock and in Patients with Hepatorenal Syndrome,GAMAL HAMED, AYMAN HEIKAL, HISHAM DARWISH and MOHAMED B. MOHAMED
Abstract
Introduction: Critical illness is accompanied by the acti-vation of the hypothalamic-pituitary-adrenal (HPA) axis, which is highlighted by increased serum corticotropin and cortisol levels (27-29). In patients with severe sepsis, the integrity of the HPA axis can be impaired by a variety of mechanisms (27-30). These patients typically have an exag-gerated proinflammatory response and are considered to be relatively corticosteroid insufficient. This complex syndrome is referred to as critical illness-related corticosteroid insuffi-ciency (CIRCI) which manifests with insufficient corticosteroid mediated down regulation of inflammatory transcription factors. Similar to type II diabetes (relative insulin deficiency), CIRCI arises due to corticosteroid tissue resistance together with inadequate circulating levels of free cortisol (31). Nu-merous papers have reported a high incidence of adrenal failure in critically ill patients, including those with end stage liver disease and liver transplant recipients (10). The term hepatoadrenal syndrome e.i, Adrenocortical insufficiency in patients with liver cirrhosis has been used to describe such an association between liver disease and adrenal failure and the definition of this term extends beyond the occurrence of sepsis, which is a frequent complication of liver failure (10).
Aim of Work: It is well known that liver cirrhosis is one of the most wide spread diseases in Egypt. Aim of the present study was to assess: 1- The prevalence of hepatoadrenal syndrome (HAS) among the Egyptian cirrhotic patients. 2- The prevalence of HAS among those complicated with septic shock or hepatorenal syndrome, 3- To find significant predictors for HAS.
Patients and Methods: Our study was a cross sectional study, conducted on 45 patients admitted to the liver intensive care unit and hepatology ward of Theador Bilharz Research Institute (TBRI) in the period between November 2009 and February 2010, who were fulfilling the criteria of Child Pugh classification. Patients were divided into three groups. Group A included 15 patients with liver cirrhosis without sepsis and without hepatorenal syndrome. Group A included 15 patients with liver cirrhosis, with neither septic shock nor hepatorenal syndrome, Group B included 15 patients with liver cirrhosis and septic shock, but not associated with hepatorenal syndrome, Group C included 15 patients with hepatorenal syndrome. The adrenal function of all patients was assessed by the conventional dose, short synacthen test (250 microgram intra-venously) which was performed within the first 24h of admis-sion. Blood samples to measure plasma cartisol levels were obtained before and 30 minutes after synacthen administration.
Results: Our study revealed that adrenocortical insuffi-ciency (ACI) was found in 33 patients out of the 45 patients subjected to this study (73.3%). It was found that patients who had ACI, had a mean child score of 12.52±1.6, while those who did not have ACI, had a mean child score of 9.75±3.9 (p-value of 0.049). Regarding Model of End Stage Liver Disease (MELD) score, our study found that patients with ACI had a mean MELD score of 28.6±8 and in patients without ACI the mean MELD score was 19.2±10, (p-value: 0.008). Receiver Operating Characteristic (ROC) curve was done and showed that the MELD score may be a good predictor for ACI in liver cirrhosis patients, the area under the MELD curve was 0.76 and showed that with MELD cutoff score of 25.5 it had a sensitivity of 0.727 and specificity of 0.75, while with MELD cutoff score of 18.5, it had a sensitivity of 0.879 and specificity of 0.5. Regarding serum creatinine level, our study found that patients with ACI had a mean serum creatinine level of 3.03±1.45mg/dl, and in patients without ACI the mean level was 2±1.5mg/dl, (p-value: 0.027). Patients with ACI had a mean serum bilirubin level of 5.01±3.072mg/dl and in those without ACI the mean serum bilirubin level was 2.4±1.35mg/dl, (p-value: 0.002). ROC curve showed that the serum bilirubin may be a good predictor for ACI in liver cirrhosis patients, as the area under the curve of bilirubin was 0.811, and showed that with serum bilirubin cutoff level of 2.75mg/dl had a sensitivity of 0.909 and specificity of 0.667. When the bilirubin had a cutoff level of 2.95mg/dl, the sen-sitivity was 0.788 and specificity was 0.75.
Conclusion: Adrenocortical insufficiency is common in patients with cirrhosis and in patients complicated with hepatorenal syndrome. In patients with liver cirrhosis adrenal dysfunction is associated with renal dysfunction, it occurs more frequently in patients with more severe liver disease and correlates with diseases severity scores. According to our study MELD score and serum bilirubin level may be good predictors for Hepatoadrenal Syndrome.
Recommendation: We recommend to make further studies with greater number of patients to detect hepatoadrenal syndrome and to study its effect on the prognosis, the complication of liver cirrhosis and mortality. Further clarification is needed in terms of whether glucocorticoid supplements in this subset of patients can improve hemodynamic impairment, multiple organ dysfunction and outcomes.