Thread by @ebtapper

HepatoADrenal syndrome

Say WHAT?!

⌚️It's #tweetorial o'clock

Be prepared to:
1⃣Define adrenal insufficiency of critical illness
2⃣never look @ a lipid panel the same
3⃣respect how sick ppl w/#cirrhosis get

#MedTwitter #meded #livertwitter
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First, what is AI (adrenal insufficiency)?

1⃣Critical illness can make the HPA axis😢
Fig1
⬇️Cortisol release
⬇️ACTH response
⬇️Tissue response to cort

2⃣Definition
Fig2-3
➡️Random cort <10➡️AI!
➡️Random cort >9➡️ACTH stim
➡️Cort⬆️<9➡️AI!

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Second: adrenal insufficiency(AI) is real, common & matters

1⃣Fig1:People who die from sepsis have:
⬆️baseline cort
⬇️ACTH response

2⃣Fig2:This time: correlation is causation
➡️norepi🚫work in AI
➡️give steroids, norepi work

3⃣Fig2: steroids (may) help for AI

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Adrenal insufficiency(AI) in #cirrhosis

1⃣1/3 stable outpatients have some AI
2⃣>1/2 noncritical decompensated inpatients
➡️Risk⬆️Sepsis,HRS,death
3⃣AI⬆️risk of death as much as ACLF
4⃣Super common in ICU
➡️⬆️mortality

Associated with low cholesterol...WHAT?

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Let's step back

Where does cortisol come from?

Cholesterol!

Check out this cool 1967 study using radiolabeled cholesterol infusions to prove that it is necessary for cortisol production

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And who makes cholesterol?

The liver! (Fig1)

Fig2: Sick liver, low cholesterol

Fig3: Patients with #cirrhosis & adrenal insufficiency often have HDLs <10!

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Does treating hepatoADrenal syndrome help?

I dont know!

One trial in @cmaj was stopped for futility

Steroids for adrenal insufficiency critical illness is controversial overall

What do you think? @Jakob_McSparron @PulmCrit @laxswamy @HalliePrescott

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HepatoADrenal syndrome

⭐️Common in #Cirrhosis
⭐️Cortisol ⬆️<9 in stim test
⭐️Associated (caused by?) with low cholesterol
⭐️Deadly
⭐️Think of it like an ACLF organ failure

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This concludes a #tweetorial on hepatoadrenal syndrome

I hope you enjoyed

I remember stumbling upon this concept in medical school. It blew my mind. It is very humbling what #cirrhosis does to a person while teaching us so much about the body.

Fin