Is Adrenal Insufficiency Under-diagnosed in Hospitalized Cirrhosis Patients?

Study Overview
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Brief Summary
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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.

Official Title
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Is Adrenal Insufficiency Under-diagnosed in Hospitalized Cirrhosis Patients?

Conditions
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Cirrhosis, Adrenal Insufficiency, Spur Cell Anemia, Lecithin Acyltransferase Deficiency

Intervention / Treatment
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* Drug: Cosyntropin


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 110 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Hospitalized cirrhosis patients<br>Administration of cortisol stimulation test to assess for presence or absence of adrenal insufficiency | Drug: Cosyntropin<br>* Administer 250mcg cosyntropin to hospitalized cirrhosis patients to assess for the presence of adrenal insufficiency<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With Cholesterol Esterification Deficiency | A percent quantification of serum cholesterol esterification will be measured via blood draw. Low values represent deficiency in esterification, which is a surrogate measure of lecthicin-cholesterol acetyltransferase (LCAT) enzymatic deficiency. | 24 hours | 
| Number of Participants With Spur Cell Anemia | A peripheral blood smear will be obtained and assessed for presence of acanthocytes (spur cells). Spur cell anemia is defined as a serum hemoglobin < 10g/dL and the presence of >= 5% spur cells on blood smear. | 24 hours | 
| Participant Transplant-Free Survival | Transplant and Death are considered equivalent outcomes | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With Relative Adrenal Insufficiency (RAI) | A baseline total cortisol level will be obtained and then patients will receive a standard-dose synthetic ACTH (250mcg of Cosyntropin) stimulation test to assess for the presence of adrenal insufficiency. RAI is defined as a change in the total cortisol level in response to the stimulation test of <9mcg/dL when measured 60 minutes after the Cosyntropin is administered. | 24 hours | 
| Number of Participants With Low Free Cortisol | Patients will have their free cortisol levels measured to assess for deficiency. | 24 hours | 
| Number of Participants Who Received Liver Transplantation at 90 Days | Patients who received a liver transplant within 90 days of enrollment | 90 days | 
| Number of Participants Who Received Liver Transplantation at 6 Months | Patients who received a liver transplant within 6 months of enrollment | 6 months | 
| Number of Participants Who Died Within Index Hospitalization | Patients who died within the same hospitalization as enrollment | Within Hospitalization | 
| Number of Participants Who Died at 30 Days | Patients who died within 30 days of enrollment | 30 days | 
| Number of Participants Who Died at 90 Days | Patients who died within 90 days of enrollment | 90 days | 
| Number of Participants Who Died at 6 Months | Patients who died within 6 months of enrollment | 6 months |