Relative adrenal insufficiency in a patient with liver disease

Patients with established cirrhosis are at increased risk of sepsis. Bacterial infections are a frequent cause of morbidity and mortality in patients with advanced liver disease. Mortality for patients admitted to hospital with bacterial infection is approximately 30%, whereas the development of septic shock and multiorgan failure is associated with a mortality of 70-100%. Activation of the hypothalamic-pituitary-adrenal axis is an important feature of a patient's response to severe sepsis and major trauma. An inadequate adrenal response with suboptimal cortisol production has been recognized in patients with septic shock. Patients with septic shock and adrenal insufficiency have reduced response to vasoconstrictor agents, higher rates of refractory shock and high mortality rates. An improvement in survival with administration of hydrocortisone in patients with septic shock and an inadequate adrenal response has been demonstrated. In a more recent study, however, there was no survival benefit in septic shock though reversal of shock was faster with hydrocortisone administration. Recently, adrenal insufficiency has been demonstrated in patients with severe liver disease such as acute liver failure, acute on chronic liver failure, recent liver transplantation and cirrhosis irrespective of the presence of sepsis. Nevertheless survival benefit with administration of hydrocortisone has only been demonstrated in patients with cirrhosis and septic shock. A case report of a patient with cirrhosis and adrenal insufficiency is presented with a review of the literature.