Adrenal Insufficiency in Cirrhosis: Don’t Forget the Hypothalamus

We read with interest the recent article reporting a very high rate of relative adrenal insufficiency (RAI) in patients cirrhosis admitted to hospital acute decompensation.1Piano S. et al.Clin Gastroenterol and Hepatol. 2020; 18: 1188-1196Abstract Full Text PDF PubMed Scopus (14) Google Scholar would like add their hypothesis that is caused by hypoperfusion impaired substrates for steroidogenesis evidenced reduced total cholesterol, high-density lipoprotein, apolipoprotein A1 RAI. Although RAI may be multifactorial, we previously showed advanced predominantly result defect hypothalamic-pituitary-adrenal axis as opposed an intrinsic gland defect. This was based on 38 nonalcoholic etiology (40% Child–Pugh C) assessed liver transplantation who underwent both insulin-induced hypoglycemia (IIH) short synacthen testing (SST). Patients had 64% reduction maximal cortisol production after indirect stimulation (with IIH) compared healthy controls, but only 39% direct SST) (both highly significant, P < .001).2McDonald J.A. al.J 1993; 8: 247-253Crossref (52) Compared SST, IIH more expensive, time consuming, potentially dangerous (and, result, rarely performed modern era), however, remains gold standard diagnosing secondary insufficiency.3Bancos I. al.Lancet Diabetes Endocrinol. 2015; 3: 216-226Abstract (165) Our cohort somewhat unique routinely. Such data supported concept, first raised 1960, hypofunction owing alteration homeostatic mechanism mediated via axis.4Peterson R.E. J Clin Invest. 1960; 39: 320-331Crossref (66) Further evidence hypothalamic-pituitary dysfunction documented hypothalamic-pituitary-gonadal axis5Handelsman D.J. 1995; 43: 331-337Crossref (51) abnormal prolactin release,6Zietz B. al.Eur 2003; 15: 495-501PubMed although IIH-induced growth hormone release normal. However, it lethal. Finally, totally agree are need randomized controlled trials evaluating corticosteroid supplementation acute-on-chronic failure, also decompensated (as suggested 1993). Including Relative Adrenal Insufficiency Definition Classification Acute-on-Chronic Liver FailureClinical Gastroenterology HepatologyVol. 18Issue 5PreviewRelative defined insufficient organ demand. observed frequently hospitalized cirrhosis, there disagreement over clinical effects these patients. evaluated prevalence cirrhosis. Full-Text