Marik et al identified features of adrenal insufficiency in critically ill patients with severe liver disease. The authors are from Thomas Jefferson University, University of Pittsburgh and the Hepatic Cortisol Research and Adrenal Pathophysiology Study Group.


Patient selection:

(1) critically ill

(2) significant liver disease (fulminant acute, chronic, recent or remote liver transplantation)


Laboratory criteria for adrenal insufficiency:

(1) In the presence of severe physiologic stress (respiratory failure with hypoxemia, hypotension), random serum cortisol < 20 µg/dL

(2) In the absence of severe physiologic stress, one of the following:

(2a) random serum cortisol < 15 µg/dL

(2b) serum cortisol < 20 µg/dL after a 1 microgram dose of cosynotropin


The only finding predictive of adrenal insufficiency was a low serum HDL (mean 8.2 mg/dL, +/- 7.6).


Significance of adrenal status in the vasopressor-dependent patient with liver disease:

(1) A patient with normal adrenal function and vasopressor dependence has a poor prognosis (mortality rate 75%).

(2) A patient with adrenal insufficiency and vasopressor dependence will require a significant reduction in vasopressor dosage if treated with hydrocortisone (mortality rate 26% if treated with glucocorticoids and 46% if not).


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