Is Adrenal Insufficiency Under-diagnosed in Hospitalized Cirrhosis Patients?
Condition: Adrenal Insufficiency; Cirrhosis; Spur Cell Anemia; Lecithin Acyltransferase Deficiency
MeSH terms: Liver Cirrhosis; Lecithin Cholesterol Acyltransferase Deficiency; Adrenal Insufficiency; Fibrosis
Intervention: Cosyntropin
Intervention description: Administer 250mcg cosyntropin to hospitalized cirrhosis patients to assess for the presence of adrenal insufficiency
Intervention MeSH terms: Cosyntropin
Phase: Phase 3
Study type: Interventional
Primary purpose: Diagnostic
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 100.0
Sex: All
Minimum age: 18 Years
Maximum age: 110 Years
Healthy volunteers: No

Summary:

      The hepatoadrenal syndrome has been well described in the literature and is known to be
      associated with poorer outcomes in both stable and critically ill cirrhotic patients. In
      chronic liver disease, adrenal (and more specifically cortisol) insufficiency is thought to
      be a byproduct of altered lipid metabolism that results in decreased HDL production and thus
      decreased delivery of cholesterol to the adrenal for subsequent corticosteroid production.
      Studies to date have implicated lecithin-cholesterol acetyltransferase (LCAT) as the key
      enzyme which is deficient in some cirrhotic patients, leading to an impaired ability to
      esterify cholesterol and thus a loss of normal cellular functioning and membrane stability.
      The investigators seek to quantify this LCAT deficiency in a cohort of cirrhotic patients and
      demonstrate its association with various abnormal physiologies associated with chronic liver
      disease, including spur cell anemia, low HDL levels, and adrenal insufficiency.

      Hospitalized cirrhotic patients at UVA that meet study eligibility criteria will be
      approached by a member of the study team to obtain consent for participation. If a patient
      agrees to become a study subject, they will have an approximate total of 35ml of blood drawn
      the following morning. Lab tests to be performed include: peripheral blood smear, lipid
      panel, free cortisol, cortisol binding globulin, serum cholesterol esters (surrogate for LCAT
      enzyme activity), and a standard-dose cortisol stimulation test. The latter involves blood
      drawn with the initial collection, administration of an intravenous 250mcg dose of synthetic
      ACTH, and then repeat small-volume blood draws at 30 minutes and 60 minutes later.

      Subjects will be classified as adrenally sufficient or insufficient on the basis of as
      standard-dose cortisol stimulation test. Variables of interest for comparison between the
      groups include MELD score, Child-Turcotte-Pugh (CTP) classification, high-density lipoprotein
      (HDL) levels, presence of spur cell anemia, serum cholesterol ester percentage (surrogate for
      LCAT enzymatic activity), cortisol binding globulin levels, and free cortisol levels.
      Student's t-test and Chi Square tests will be utilized to determine significance; a p <0.05
      value will be used as our threshold for significance. If multiple factors are found to be
      significantly different in a univariate fashion between classification groups, a multivariate
      logistic regression analysis will be performed for adjusted analysis. The investigators will
      also seek to define any correlations between variables. Furthermore, the investigators will
      assess correlation between MELD score and serum cholesterol ester percentage, spur cell
      anemia, HDL levels, cortisol binding globulin levels, and free cortisol levels; similar
      correlate analysis will be done using CTP classification instead of MELD score.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Age >=18 years

          -  Diagnosis of cirrhosis

          -  Admission to hospital

        Exclusion Criteria:

          -  Age < 18 years

          -  Prior enrollment in study (i.e. readmission)

          -  Prisoner

          -  Pregnancy

          -  Prednisone or Hydrocortisone use in last 24 hours