From the Guidelines
Adrenal insufficiency should be suspected in patients with liver cirrhosis who exhibit unexplained hypotension, have a history of sepsis, or are being treated with high-dose vasopressors for refractory shock, as these conditions are associated with a higher risk of morbidity and mortality 1.
Key Clinical Scenarios
- Patients with cirrhosis who are being tapered off corticosteroids should be monitored closely for signs of adrenal insufficiency, as they are at increased risk of developing this condition.
- Patients who have recently undergone surgery or have received etomidate for sedation should also be suspected of having adrenal insufficiency.
- In these situations, it is prudent to consider diagnostic tests such as the cosyntrropin stimulation test to evaluate adrenal function.
Management
- If adrenal insufficiency is suspected, hydrocortisone can be administered at a dose of 50-100 mg intravenously every 6-8 hours, with the dose adjusted based on clinical response and the results of diagnostic testing 1.
- Close monitoring of blood pressure, electrolytes, and overall clinical status is essential in managing these patients.
Guidance
- The AASLD practice guidance recommends considering screening for adrenal insufficiency or an empiric trial of hydrocortisone for treatment of refractory shock requiring high-dose vasopressors in patients with cirrhosis 1.
- The EASL clinical practice guidelines also support the use of hydrocortisone in patients with cirrhosis and septic shock who have relative adrenal insufficiency 1.
From the Research
Adrenal Insufficiency in Liver Cirrhosis
Adrenal insufficiency is a common condition in patients with liver cirrhosis, particularly in those with severe sepsis and septic shock 2, 3, 4. The prevalence of adrenal insufficiency in cirrhotic patients varies widely, ranging from 25% to 51.48% 2, 5.
Risk Factors
Several factors can increase the risk of adrenal insufficiency in patients with liver cirrhosis, including:
- Severe sepsis and septic shock 2, 3
- Critical illnesses such as gastrointestinal bleeding 4
- Advanced liver disease, including decompensated cirrhosis 5
- High levels of proinflammatory cytokines and circulatory endotoxin 4
Clinical Outcomes
Adrenal insufficiency in patients with liver cirrhosis is associated with:
- Poorer survival rates 2, 3
- Increased risk of complications such as bleeding and hepatorenal syndrome 3
- Hemodynamic instability and renal dysfunction 2
- Higher hospital mortality rates 2
Diagnosis
The diagnosis of adrenal insufficiency in patients with liver cirrhosis can be made using the short corticotropin stimulation test (SST) or the short synacthen test (SD-SST) 2, 5. The prevalence of adrenal insufficiency can vary depending on the diagnostic criteria and methodology used 5.
Treatment
Corticosteroid therapy may have a beneficial effect on critically ill cirrhotic patients with adrenal insufficiency, particularly in terms of hospital survival rate 3. However, the effects of corticosteroid therapy on cirrhotic patients with septic shock and adrenal insufficiency are controversial 4.