Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Queensland, Australia.
J Hepatol. 2010 Nov;53(5):841-8. doi: 10.1016/j.jhep.2010.05.020. Epub 2010 Jul 17.
BACKGROUND & AIMS: Adrenal insufficiency (AI) has been reported in patients with advanced liver disease. Diagnosing AI is problematic owing to controversies in using total serum cortisol as a measure of adrenal function. No published data exist on directly measured plasma free cortisol (PFC) in patients with liver disease.
This prospective study compared serum total and measured plasma free cortisol to evaluate adrenal function in clinically stable cirrhotic patients and healthy controls. Cortisol levels were measured at baseline and following 250 μg corticotrophin. AI was defined by total cortisol increments (delta cortisol) of less than 250 nmol/L, or a peak total cortisol under 500 nmol/L after cosyntropin. We used a peak plasma free cortisol concentration of 33 nmol/L as the threshold for AI.
Forty-three consecutive patients and 10 healthy controls were studied. Cirrhotic patients had significantly lower peak (526 vs. 649 nmol/L, p=0.004) and delta total cortisol (264 vs. 397 nmol/L, p = 0.002) responses compared to healthy controls. However, basal plasma free cortisol was higher in patients (10.9 vs. 6.4 nmol/L, p = 0.03), and there were no differences in peak plasma free cortisol (p = 0.69) between the two groups. The prevalence of AI using total cortisol criteria was 58% compared to 12% using free cortisol (p<0.001).
In patients with stable severe liver disease, a significant discrepancy exists between the rates of diagnosis of AI using the total and free cortisol criteria. We would advise caution in the interpretation of adrenal function testing using total cortisol measurements in this group.
已有研究报道，晚期肝脏疾病患者可能会出现肾上腺功能不全（AI）。由于总血清皮质醇作为评估肾上腺功能的指标存在争议，因此 AI 的诊断存在问题。目前尚无关于肝脏疾病患者直接测量的血浆游离皮质醇（PFC）的发表数据。
本前瞻性研究比较了血清总皮质醇和测量的血浆游离皮质醇，以评估临床稳定的肝硬化患者和健康对照者的肾上腺功能。在基线和给予 250μg 促皮质素后测量皮质醇水平。AI 定义为总皮质醇增加量（delta 皮质醇）<250nmol/L，或促皮质素后总皮质醇峰值<500nmol/L。我们使用血浆游离皮质醇峰值 33nmol/L 作为 AI 的阈值。
连续纳入 43 例患者和 10 例健康对照者。与健康对照组相比，肝硬化患者的峰值（526 对 649nmol/L，p=0.004）和 delta 总皮质醇（264 对 397nmol/L，p=0.002）反应明显更低。然而，患者的基础血浆游离皮质醇更高（10.9 对 6.4nmol/L，p=0.03），两组间的血浆游离皮质醇峰值无差异（p=0.69）。使用总皮质醇标准诊断 AI 的患病率为 58%，而使用游离皮质醇的患病率为 12%（p<0.001）。
在稳定的严重肝脏疾病患者中，使用总皮质醇和游离皮质醇标准诊断 AI 的比率存在显著差异。我们建议在该组中使用总皮质醇测量值进行肾上腺功能测试时要谨慎解释。
