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World J Hepatol. May 18, 2015; 7(8): 1112-1124
Published online May 18, 2015. doi: 10.4254/wjh.v7.i8.1112
Adrenal insufficiency in patients with decompensated cirrhosis
Apostolos KA Karagiannis, Theodora Nakouti, Chrysoula Pipili, Evangelos Cholongitas
Apostolos KA Karagiannis, Department of Endocrinology, Diabetes and Metabolism, Korgialeneio Mpenakeio Hospital, 11526 Athens, Greece
Theodora Nakouti, Evangelos Cholongitas, 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, 54642 Thessaloniki, Greece
Chrysoula Pipili, Division of Nephrology, Royal Infirmary of Edinburgh, Scotland EH16 4SA, United Kingdom
Author contributions: Karagiannis AKA and Nakouti T contributed equally in writing and editing of the article; Pipili C edited the article at the end; Cholongitas E supervised the article.
Conflict-of-interest: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Evangelos Cholongitas, MD, PhD, 4th Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece. cholongitas@yahoo.gr
Telephone: +30-6936-378903 Fax: +30-2310-992940
Received: October 7, 2014
Peer-review started: October 7, 2014
First decision: December 17, 2014
Revised: January 12, 2015
Accepted: February 9, 2015
Article in press: February 11, 2015
Published online: May 18, 2015
Processing time: 224 Days and 5.8 Hours
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.

Keywords: Critically ill; Cirrhosis; Adrenal insufficiency; Corticosteroid

Core tip: Adrenal insufficiency is present in both critically ill and stable cirrhotics and in liver transplant recipients early or later after transplantation. Due to certain difficulties in determining cortisol levels and lack of gold standard method, the incidence of adrenal failure varies and depends on each test used for assessment of adrenal function. Corticosteroid administration has not been elucidated whether it leads to beneficial outcome in critically ill cirrhotics.