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World J Gastroenterol. Jan 28, 2013; 19(4): 445-456
Published online Jan 28, 2013. doi: 10.3748/wjg.v19.i4.445
Update on adrenal insufficiency in patients with liver cirrhosis
Anca Trifan, Stefan Chiriac, Carol Stanciu
Anca Trifan, Stefan Chiriac, Carol Stanciu, “Gr. T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iaşi, Romania
Author contributions: Trifan A prepared the first draft, revised the article critically for important intellectual content, and performed the final edit of the paper; Chiriac S performed the literature research, wrote and edited the paper; Stanciu C contributed in the conception, design and drafting of this paper, revised and gave the final approval for the version to be published.
Correspondence to: Carol Stanciu, MD, PhD, FRCP, Professor, “Gr. T. Popa” University of Medicine and Pharmacy, Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, Independenţei 1, 700111 Iaşi, Romania. stanciucarol@yahoo.com
Telephone: +40-72-2306020 Fax: +40-23-2264411
Received: November 5, 2012
Revised: December 3, 2012
Accepted: December 20, 2012
Published online: January 28, 2013
Processing time: 56 Days and 16.9 Hours
Abstract

Liver cirrhosis is a major cause of mortality worldwide, often with severe sepsis as the terminal event. Over the last two decades, several studies have reported that in septic patients the adrenal glands respond inappropriately to stimulation, and that the treatment with corticosteroids decreases mortality in such patients. Both cirrhosis and septic shock share many hemodynamic abnormalities such as hyperdynamic circulatory failure, decreased peripheral vascular resistance, increased cardiac output, hypo-responsiveness to vasopressors, increased levels of proinflammatory cytokines [interleukine(IL)-1, IL-6, tumor necrosis factor-alpha] and it has, consequently, been reported that adrenal insufficiency (AI) is common in critically ill cirrhotic patients. AI may also be present in patients with stable cirrhosis without sepsis and in those undergoing liver transplantation. The term hepato-adrenal syndrome defines AI in patients with advanced liver disease with sepsis and/or other complications, and it suggests that it could be a feature of liver disease per se, with a different pathogenesis from that of septic shock. Relative AI is the term given to inadequate cortisol response to stress. More recently, another term is used, namely “critical illness related corticosteroid insufficiency” to define “an inadequate cellular corticosteroid activity for the severity of the patient’s illness”. The mechanisms of AI in liver cirrhosis are not completely understood, although decreased levels of high-density lipoprotein cholesterol and high levels of proinflammatory cytokines and circulatory endotoxin have been suggested. The prevalence of AI in cirrhotic patients varies widely according to the stage of the liver disease (compensated or decompensated, with or without sepsis), the diagnostic criteria defining AI and the methodology used. The effects of corticosteroid therapy on cirrhotic patients with septic shock and AI are controversial. This review aims to summarize the existing published information regarding AI in patients with liver cirrhosis.

Keywords: Liver cirrhosis; Adrenal insufficiency; Septic shock; Corticosteroid therapy