Relative adrenal insufficiency associated with severe cirrhosis (30 % to 70 % of cases).

It may only become apparent during sepsis or hypovolemia (hemorrhage), or after liver transplantation.

The pathophysiology is unknown: abnormal cholesterol metabolism, inflammation, hemodynamics ? 

Clinical signs: hyponatremia, hypoglycemia, arterial hypotension.

Diagnosis: low plasma cortisol level or at the lower limit of normal (<7 µg/dL) and/or inadequate response to an ACTH test (maximum level < 18 µg/dL or increase < 9 µg/dL at 30 min). Salivary cortisol levels appear to be more reliable than blood levels (influence of hypoproteinemia ?).

Differential diagnosis: electrolytic effect of diuretics, adrenal insufficiency secondary to corticotherapy or following adrenal infarction (hemorrhagic shock, right right adrenal artery damage during the dissection phase  of liver transplantation).

Anesthetic implications: 

keep that diagnosis in mind in case of hyponatremia and hypoglycemia, or insufficient response to vasopressors to treat vasoplegia.

References : 

-        Marik PE, Gayowski T, Starzl TE.
The hepatoadrenal syndrome: a common yet unrecognized clinical condition
Crit Care Med 2005 ; 33 : 1254-9

-        Hauser GJ, Brotzman HM,  Kaufman SS.
Hepatoadrenal syndrome in pediatric patients with end-stage liver disease.
Pediatr Crit Care Med 2012 ; 13 : e145-9

-        Elfaramawy AAM.
Hepatoadrenal syndrome in Egyptian children with liver cirrhosis with and without sepsis.
Egyptian J Medical Human Genetics 2012 ; 13 : 337-42

-         Wentworth BJ, Siragy HM.
Adrenal insufficiency in cirrhosis.
Journal of the Endocrine Society 2022 ; 6 : 1-11 doi.org/10.1210/jendso/bvac115 Advance access publication 29 July 2022

-        Wentworth BJ, Schliep M, Novicoff W, Siragy HM, Geng CX, Henry ZH.
Relative adrenal insufficiency in the non-critically ill patient with cirrhosis: A systematic review and meta-analysis.
Liver International 2023; 43:660-72.

Updated: September 2024