Université Pierre et Marie Curie, Service d'hépato-gastroentérologie, Hôpital de la Pitié-Salpêtrière (AP-HP), Paris, France.
J Hepatol. 2010 Jun;52(6):839-45. doi: 10.1016/j.jhep.2010.01.026. Epub 2010 Mar 15.
BACKGROUND & AIMS: Adrenal insufficiency is a common disorder among cirrhotic patients. Adrenal function is usually assessed with serum total cortisol assays. Free cortisol (active fraction) represents only 10% of serum total cortisol, the remaining 90% being linked to cortisol-binding globulin (CBG) and albumin. In cirrhotic patients, the synthesis of these proteins is reduced, which could lead to an overestimation of the prevalence of adrenal insufficiency. Salivary cortisol assessment adequately reflects free cortisol plasma concentration. However, this method has never been validated in cirrhotic patients. The objectives of this report were to assess the following parameters by a prospective observational study: (1) correlation between salivary, serum total and free cortisol, (2) adrenal insufficiency prevalence using salivary and serum assays, (3) parameters associated with a discrepancy between both tests, and (4) adrenal insufficiency risk factors among cirrhotic patients.
Salivary and serum total cortisol were assessed before and 1h following an injection of corticotropin (250 microg) in patients hospitalized for cirrhosis complications without shock. CBG was measured and free cortisol was assessed by the Coolens formula.
Eighty-eight patients were included in the study (Child-Pugh C: 68.2%). Free cortisol was more strongly correlated with salivary than with serum total cortisol (Spearman coefficient=0.91 vs. 0.76, respectively, p<0.001). Among included patients, 9.1% had adrenal insufficiency according to salivary cortisol and 33.0% had adrenal insufficiency according to serum total cortisol (p=0.001). Hypoalbuminemia was the only factor associated with a discrepancy between the results of both tests. Adrenal insufficiency risk factors were ascites and low HDL-cholesterol plasma concentration.
Using serum total cortisol assays overstate adrenal insufficiency prevalence among cirrhotic patients, mainly because of inaccurate concentrations related to hypoalbuminemia. Salivary cortisol assays should be preferably used in these patients.
肾上腺功能不全是肝硬化患者的常见病症。通常通过血清总皮质醇检测评估肾上腺功能。游离皮质醇（活性部分）仅占血清总皮质醇的 10%，其余 90%与皮质醇结合球蛋白（CBG）和白蛋白结合。在肝硬化患者中，这些蛋白的合成减少，这可能导致对肾上腺功能不全的患病率的高估。唾液皮质醇评估充分反映了游离皮质醇的血浆浓度。然而，这种方法在肝硬化患者中从未得到验证。本报告的目的是通过前瞻性观察研究评估以下参数：（1）唾液、血清总皮质醇和游离皮质醇之间的相关性，（2）使用唾液和血清检测评估肾上腺功能不全的患病率，（3）与两种检测方法之间差异相关的参数，以及（4）肝硬化患者的肾上腺功能不全危险因素。
在因肝硬化并发症而住院且无休克的患者中，在注射促皮质素（250μg）前和 1 小时后评估唾液和血清总皮质醇。测量 CBG 并使用 Coolens 公式评估游离皮质醇。
88 例患者纳入研究（Child-Pugh C：68.2%）。游离皮质醇与唾液的相关性强于与血清总皮质醇的相关性（Spearman 系数分别为 0.91 和 0.76，p<0.001）。在所纳入的患者中，根据唾液皮质醇，9.1%的患者患有肾上腺功能不全，根据血清总皮质醇，33.0%的患者患有肾上腺功能不全（p=0.001）。低白蛋白血症是两种检测结果之间存在差异的唯一相关因素。肾上腺功能不全的危险因素是腹水和低 HDL-胆固醇血浆浓度。
使用血清总皮质醇检测会夸大肝硬化患者肾上腺功能不全的患病率，主要是因为与低白蛋白血症相关的不准确浓度。在这些患者中，应优先使用唾液皮质醇检测。
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