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Kalafateli M, Aggeletopoulou I, Triantos C. Adrenal insufficiency in liver diseases - pathophysiology and underlying mechanisms. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09874-0. [PMID: 38305832 DOI: 10.1007/s11154-024-09874-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
Relative adrenal insufficiency (RAI) is common in critically ill patients with cirrhosis, but it has been also documented in non-critically ill patients. Its pathophysiology is complex and not well understood yet. In this review, we aimed to present potential mechanisms and causal pathways implicated in the pathogenesis of RAI in cirrhosis. There is accumulating evidence supporting a suboptimal baseline adrenal function in cirrhosis mainly due to decreased cortisol synthesis and metabolism rates from the adrenal gland. Apart from this peripheral impairment, more recent studies suggest that there is a greater defect in the central stimulation of the hypothalamic-pituitary-adrenal (HPA) axis (hypothalamus/pituitary gland). Pro-inflammatory mediators, which are elevated in cirrhosis, have been also implicated through suppression of the HPA axis, decrease in cortisol synthesis and tissue glucocorticoid resistance. All abovementioned support the hepatoadrenal syndrome hypothesis that during episodes of acute decompensation there is suboptimal adrenocortical response that leads to worse outcomes. In conclusion, the complex pathophysiology of adrenal dysfunction in cirrhosis has not been fully elucidated yet and further research is needed in order to better understand this rather common entity in cirrhosis.
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Affiliation(s)
- Maria Kalafateli
- Department of Gastroenterology, General Hospital of Patras, 26332, Patras, Greece
| | - Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504, Patras, Greece
- Laboratory of Immunohematology, Department of Internal Medicine, Medical School, University of Patras, 26504, Patras, Greece
| | - Christos Triantos
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, 26504, Patras, Greece.
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Wentworth BJ, Schliep M, Novicoff W, Siragy HM, Geng CX, Henry ZH. Relative adrenal insufficiency in the non-critically ill patient with cirrhosis: A systematic review and meta-analysis. Liver Int 2023; 43:660-672. [PMID: 36354293 PMCID: PMC9974795 DOI: 10.1111/liv.15473] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND & AIMS Characterization of relative adrenal insufficiency (RAI) in cirrhosis is heterogeneous with regard to studied patient populations and diagnostic methodology. We aimed to describe the prevalence and prognostic importance of RAI in non-critically ill patients with cirrhosis. METHODS A systematic review and meta-analysis was performed using MeSH terms and Boolean operators to search five large databases (Ovid-MEDLINE, ScienceDirect, Web of Science, Cochrane Library and ClinicalTrials.gov). The population of interest was patients with cirrhosis and without critical illness. The primary outcome was the pooled prevalence of RAI as defined by a peak total cortisol level <18 μg/dl, delta total cortisol <9 μg/dl or composite of the two thresholds in response either a standard-dose or low-dose short synacthen test. Odds ratios and standardized mean differences from random-effects models estimated important clinical outcomes and patient characteristics by adrenal functional status. RESULTS Twenty-two studies were included in final analysis, comprising 1991 patients with cirrhosis. The pooled prevalence of RAI was 37% (95% CI 33-42%). The prevalence of RAI varied by Child-Pugh classification, type of stimulation test used, specific diagnostic threshold and by severity of illness. Ninety-day mortality was significantly higher in patients with RAI (OR 2.88, 95% CI 1.69-4.92, I2 = 15%, p < 0.001). CONCLUSIONS Relative adrenal insufficiency is highly prevalent in non-critically ill patients with cirrhosis and associated with increased mortality. Despite the proposed multifactorial pathogenesis, no studies to date have investigated therapeutic interventions in this specific population.
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Affiliation(s)
- Brian J Wentworth
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Matthew Schliep
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Wendy Novicoff
- Departments of Public Health Sciences and Orthopaedic Surgery, School of Medicine, University of Virginia Charlottesville, VA
| | - Helmy M Siragy
- Division of Endocrinology & Metabolism, School of Medicine, University of Virginia, Charlottesville, VA
| | - Calvin X Geng
- Department of Medicine, School of Medicine, University of Virginia, Charlottesville, VA
| | - Zachary H Henry
- Division of Gastroenterology & Hepatology, School of Medicine, University of Virginia, Charlottesville, VA
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Assessment of adrenal response in patients with stable cirrhosis and ascites using different short Synacthen tests and definitions. Eur J Gastroenterol Hepatol 2021; 33:e540-e547. [PMID: 33905212 DOI: 10.1097/meg.0000000000002153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS The definition of relative adrenal insufficiency (RAI) in patients with cirrhosis remains controversial. We investigated the serum and salivary cortisol (SalC) response after low-dose and standard-dose Synacthen test in patients with stable cirrhosis and ascites. METHODS Ninety-five cirrhotic patients with ascites were prospectively evaluated from January 2014 to January 2018. Low-dose [adrenocorticotrophic hormone (ACTH): 1 μg] and standard-dose (ACTH: 250 μg) Synacthen test were successively performed. Paired serum total and saliva cortisol were taken at baseline, 30 min (low-dose test) and 60 min (standard-dose test). Salivary and Δserum total cortisol criteria included post-ACTH SalC < 12.7 ng/ml and/or SalC increase <3 ng/ml and serum total cortisol increase <9 μg/dl, respectively. RESULTS The prevalence of RAI varied according to the definition used. SalC-defined RAI was significantly more common after low-dose than standard-dose test (54.7% vs. 20%; P < 0.001). Δserum total cortisol-defined RAI was also significantly more frequent after low-dose than standard-dose test (66.3% vs. 24.2%; P < 0.001). Considering low-dose test/SalC criteria as reference diagnostic criteria, standard-dose/salivary and Δserum total cortisol criteria showed low specificity for RAI diagnosis (43.9% and 52.7%, respectively). Survival probability was significantly lower in patients with low-dose test/SalC-defined RAI compared to those without (53.8% vs. 79.1%; P = 0.01). SalC-defined RAI after low-dose test was significantly more common than that defined after standard-dose test (72.7% vs. 30.3%; P < 0.001) among patients who died. CONCLUSION Low-dose test/SalC definition can identify RAI in about half of patients with stable cirrhosis and ascites and is associated with increased mortality.
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Scicali R, Di Pino A, Ferrara V, Rabuazzo AM, Purrello F, Piro S. Effect of PCSK9 inhibitors on pulse wave velocity and monocyte-to-HDL-cholesterol ratio in familial hypercholesterolemia subjects: results from a single-lipid-unit real-life setting. Acta Diabetol 2021; 58:949-957. [PMID: 33745063 PMCID: PMC8187232 DOI: 10.1007/s00592-021-01703-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/03/2021] [Indexed: 02/08/2023]
Abstract
AIMS Subjects with familial hypercholesterolemia (FH) are characterized by an increased amount of low-density lipoprotein cholesterol (LDL-C) that promotes a continuous inflammatory stimulus. Our aim was to evaluate the effect of PCSK9-i on inflammatory biomarkers, neutrophil-to-lymphocyte ratio, monocyte-to-high-density lipoprotein ratio (MHR), and on early atherosclerosis damage analyzed by pulse wave velocity (PWV) in a cohort of FH subjects. METHODS In this prospective observational study, we evaluated 56 FH subjects on high-intensity statins plus ezetimibe and with an off-target LDL-C. All subjects were placed on PCSK9-i therapy and obtained biochemical analysis as well as PWV evaluation at baseline and after six months of PCSK9-i therapy. RESULTS After six months of add-on PCSK9-i therapy, only 42.9% of FH subjects attained LDL-C targets. As expected, a significant reduction of LDL-C (- 49.61%, p < 0.001) was observed after PCSK9-i therapy. Neutrophil count (NC) and MHR were reduced by PCSK9-i (-13.82% and -10.47%, respectively, p value for both < 0.05) and PWV significantly decreased after PCSK9-i therapy (- 20.4%, p < 0.05). Finally, simple regression analyses showed that ∆ PWV was significantly associated with ∆ LDL-C (p < 0.01), ∆ NC and ∆ MHR (p value for both < 0.05). CONCLUSIONS In conclusion, PCSK9-i therapy significantly improved lipid and inflammatory profiles and PWV values in FH subjects; our results support the positive effect of PCSK9-i in clinical practice.
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Affiliation(s)
- Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy
| | - Viviana Ferrara
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy
| | - Agata Maria Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy.
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Internal Medicine, Garibaldi Hospital, Via Palermo 636, 95122, Catania, Italy
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A Predictive Risk Score to Diagnose Adrenal Insufficiency in Outpatients: A 7 Year Retrospective Cohort Study. MEDICINES 2021; 8:medicines8030013. [PMID: 33801854 PMCID: PMC7998205 DOI: 10.3390/medicines8030013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
Background: The diagnosis of adrenal insufficiency (AI) requires dynamic tests which may not be available in some institutions. This study aimed to develop a predictive risk score to help diagnose AI in outpatients with indeterminate serum cortisol levels. Methods: Five hundred and seven patients with intermediate serum cortisol levels (3–17.9 µg/dL) who had undergone ACTH (adrenocorticotropin) stimulation tests were included in the study. A predictive risk score was created using significant predictive factors identified by multivariable analysis using Poisson regression clustered by ACTH dose. Results: The seven predictive factors used in the development of a predictive model with their assigned scores are as follows: chronic kidney disease (9.0), Cushingoid appearance in exogenous steroid use (12.0), nausea and/or vomiting (6.0), fatigue (2.0), basal cortisol <9 µg/dL (12.5), cholesterol <150 mg/dL (2.5) and sodium <135 mEq/L (1.0). Predictive risk scores range from 0–50.0. A high risk level (scores of 19.5–50.0) indicates a higher possibility of having AI (positive likelihood ratio (LR+) = 11.75), while a low risk level (scores of <19.0) indicates a lower chance of having AI (LR+ = 0.09). The predictive performance of the scoring system was 0.82 based on the area under the curve. Conclusions: This predictive risk score can help to determine the probability of AI and can be used as a guide to determine which patients need treatment for AI and which require dynamic tests to confirm AI.
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Scicali R, Giral P, D'Erasmo L, Cluzel P, Redheuil A, Di Pino A, Rabuazzo AM, Piro S, Arca M, Béliard S, Purrello F, Bruckert E, Gallo A. High TG to HDL ratio plays a significant role on atherosclerosis extension in prediabetes and newly diagnosed type 2 diabetes subjects. Diabetes Metab Res Rev 2021; 37:e3367. [PMID: 32558162 DOI: 10.1002/dmrr.3367] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022]
Abstract
AIMS We investigated the role of TG to HDL ratio (TG/HDL) on atherosclerosis extension, defined as presence of coronary artery calcium (CAC), carotid and femoral plaque, in prediabetes or newly diagnosed type 2 diabetes (T2D). METHODS We performed a retrospective, cross-sectional, single centre study involving 440 prediabetes or newly diagnosed controlled T2D subjects. Participants underwent CAC analysis by computed tomography and carotid and femoral plaque evaluation by ultrasonography and were stratified in high TG/HDL (H-TG/HDL) or low TG/HDL (L-TG/HDL) group according to TG/HDL median value. We estimated atherosclerosis extension according to the number of involved vascular districts. RESULTS CAC was higher in the H-TG/HDL group than L-TG/HDL group (29.15 [0.0-95.68] vs 0.0 [0.0-53.97] AU, P < .01) and CAC > 0 was more prevalent in the H-TG/HDL group than L-TG/HDL group (64.5% vs 45%, P < .001). Femoral atherosclerosis was higher in the H-TG/HDL group than L-TG/HDL group (57.3% vs 43.6%, P < .01). H-TG/HDL group exhibited a lower prevalence of subjects with 0-TWP compared to L-TG/HDL group (21.8% vs 38.6%, P < .01) and higher percentages of subjects with 2-TWP or 3-TWP than L-TG/HDL group (for 2-TWP 29.5% vs 21.5%, P < .05; for 3-TWP 32.7% vs 20.9%, P < .01). Multiple logistic regression analysis showed that a H-TG/HDL was inversely associated to 0-TWP (P < .05) and positively associated with 2-TWP (P < .05) and 3-TWP (P < .01). CONCLUSIONS Our data suggest that TG/HDL is a marker of increased atherosclerotic extension in prediabetes and newly diagnosed T2D and may be useful to identify subjects with a higher cardiovascular risk profile.
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Affiliation(s)
- Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Philippe Giral
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Paris Hospital Public Assistance, Pitié-Salpêtrière Hospital Group - Sorbonne University, Paris, France
- Dyslipoproteinemia and Atherosclerosis Research Unit, National Institute for Health and Medical Research (INSERM) and Pierre et Marie Curie University (UPMC - Paris VI), Paris, France
| | - Laura D'Erasmo
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Paris Hospital Public Assistance, Pitié-Salpêtrière Hospital Group - Sorbonne University, Paris, France
- Department of Translational and Precision Medicine, Sapienza Università di Roma, Rome, Italy
| | - Philippe Cluzel
- Laboratoire d'imagerie Biomédicale, INSERM 1146, - CNRS 7371, Sorbonne University, Paris, France
- Département d'imagerie cardiovasculaire et de radiologie interventionnelle, Pôle Imagerie-Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alban Redheuil
- Laboratoire d'imagerie Biomédicale, INSERM 1146, - CNRS 7371, Sorbonne University, Paris, France
- Département d'imagerie cardiovasculaire et de radiologie interventionnelle, Pôle Imagerie-Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Agata Maria Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza Università di Roma, Rome, Italy
| | - Sophie Béliard
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Eric Bruckert
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Paris Hospital Public Assistance, Pitié-Salpêtrière Hospital Group - Sorbonne University, Paris, France
- Dyslipoproteinemia and Atherosclerosis Research Unit, National Institute for Health and Medical Research (INSERM) and Pierre et Marie Curie University (UPMC - Paris VI), Paris, France
| | - Antonio Gallo
- Cardiovascular Prevention Unit, Department of Endocrinology and Metabolism, Paris Hospital Public Assistance, Pitié-Salpêtrière Hospital Group - Sorbonne University, Paris, France
- Laboratoire d'imagerie Biomédicale, INSERM 1146, - CNRS 7371, Sorbonne University, Paris, France
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Xu Y, Li Y, Jadhav K, Pan X, Zhu Y, Hu S, Chen S, Chen L, Tang Y, Wang HH, Yang L, Wang DQH, Yin L, Zhang Y. Hepatocyte ATF3 protects against atherosclerosis by regulating HDL and bile acid metabolism. Nat Metab 2021; 3:59-74. [PMID: 33462514 PMCID: PMC7856821 DOI: 10.1038/s42255-020-00331-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/09/2020] [Indexed: 12/13/2022]
Abstract
Activating transcription factor (ATF)3 is known to have an anti-inflammatory function, yet the role of hepatic ATF3 in lipoprotein metabolism or atherosclerosis remains unknown. Here we show that overexpression of human ATF3 in hepatocytes reduces the development of atherosclerosis in Western-diet-fed Ldlr-/- or Apoe-/- mice, whereas hepatocyte-specific ablation of Atf3 has the opposite effect. We further show that hepatic ATF3 expression is inhibited by hydrocortisone. Mechanistically, hepatocyte ATF3 enhances high-density lipoprotein (HDL) uptake, inhibits intestinal fat and cholesterol absorption and promotes macrophage reverse cholesterol transport by inducing scavenger receptor group B type 1 (SR-BI) and repressing cholesterol 12α-hydroxylase (CYP8B1) in the liver through its interaction with p53 and hepatocyte nuclear factor 4α, respectively. Our data demonstrate that hepatocyte ATF3 is a key regulator of HDL and bile acid metabolism and atherosclerosis.
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Affiliation(s)
- Yanyong Xu
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Yuanyuan Li
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
- Zhongshan Institute for Drug Discovery, the Institutes of Drug Discovery and Development, Chinese Academy of Sciences, Zhongshan, China
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Kavita Jadhav
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Xiaoli Pan
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
- Divison of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingdong Zhu
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Shuwei Hu
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Shaoru Chen
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Liuying Chen
- Divison of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Tang
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Helen H Wang
- Department of Medicine and Genetics, Marion Bessin Liver Research Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ling Yang
- Divison of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - David Q-H Wang
- Department of Medicine and Genetics, Marion Bessin Liver Research Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Liya Yin
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Yanqiao Zhang
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH, USA.
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Scicali R, Russo GI, Di Mauro M, Manuele F, Di Marco G, Di Pino A, Ferrara V, Rabuazzo AM, Piro S, Morgia G, Purrello F. Analysis of Arterial Stiffness and Sexual Function after Adding on PCSK9 Inhibitor Treatment in Male Patients with Familial Hypercholesterolemia: A Single Lipid Center Real-World Experience. J Clin Med 2020; 9:jcm9113597. [PMID: 33171638 PMCID: PMC7695132 DOI: 10.3390/jcm9113597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022] Open
Abstract
Familial hypercholesterolemia (FH) subjects have high low-density lipoprotein cholesterol (LDL-C) and may be at high risk of erectile dysfunction and atherosclerotic cardiovascular diseases. We evaluated the effect of PCSK9-i on sexual function evaluated by the Male Sexual Health Questionnaire (MSHQ) and the International Index of Erectile Function (IIEF-5) questionnaire and on pulse wave velocity (PWV) in FH male subjects. In this prospective observational study, we evaluated 30 FH male patients on high-intensity statins plus ezetimibe and with an LDL-C off-target. All patients added PCSK9-i treatment and obtained clinical assessment at baseline and after six months of PCSK9-i. As expected, LDL-C significantly decreased after adding-on PCSK9-i (-48.73%, p < 0.001). MSHQ and PWV significantly improved after adding-on PCSK9-i (for MSHQ 93.63 ± 6.28 vs. 105.41 ± 5.86, p < 0.05; for PWV 9.86 ± 1.51 vs. 7.7 ± 1.42, p < 0.05); no significant change of IIEF-5 was found. Finally, a simple regression showed that ∆ MSHQ was significantly associated with ∆ LDL-C and ∆ PWV (p value for both <0.05). In conclusion, PCSK9-i therapy significantly improves lipid profile, PWV, and sexual function in FH male patients; our results support the favorable function of PCSK9-i on these parameters.
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Affiliation(s)
- Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
- Correspondence: ; Tel.: +39-0957598401; Fax: +39-0957598421
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, 95100 Catania, Italy; (G.I.R.); (M.D.M.); (G.M.)
| | - Marina Di Mauro
- Urology Section, Department of Surgery, University of Catania, 95100 Catania, Italy; (G.I.R.); (M.D.M.); (G.M.)
| | - Flavia Manuele
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Grazia Di Marco
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Viviana Ferrara
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Agata Maria Rabuazzo
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
| | - Giuseppe Morgia
- Urology Section, Department of Surgery, University of Catania, 95100 Catania, Italy; (G.I.R.); (M.D.M.); (G.M.)
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, 95100 Catania, Italy; (F.M.); (G.D.M.); (A.D.P.); (V.F.); (A.M.R.); (S.P.); (F.P.)
- Internal Medicine, Garibaldi Hospital, 95122 Catania, Italy
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Manosroi W, Kosachunhanan N, Atthakomol P. Clinical and biochemical factors to predict biochemical adrenal insufficiency in hospitalized patients with indeterminate cortisol levels: a retrospective study. BMC Endocr Disord 2020; 20:24. [PMID: 32075632 PMCID: PMC7031969 DOI: 10.1186/s12902-020-0508-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 02/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adrenal insufficiency (AI) in hospitalized patients is a fatal condition if left undiagnosed. Most patients may require an adrenocorticotropic hormone (ACTH) stimulation test to facilitate AI diagnosis. We aim to identify simple biochemical and clinical factors and derive a predictive model to help identify hospitalized patients with biochemical AI who have indeterminate 0800 h serum cortisol levels. METHODS A seven-year retrospective study was performed in a tertiary care medical center. We identified 128 inpatients who had undergone low-dose or high-dose ACTH stimulation tests. The association between biochemical AI and other factors was evaluated using a logistic regression model clustering by ACTH dose. Stepwise regression analysis was used to demonstrate the predictive model. Diagnostic performance was evaluated using ROC analysis. RESULTS Of the 128 patients, 28.1% had biochemical AI. The factors associated with biochemical AI were serum random cortisol < 10 μg/dL (OR = 8.69, p < 0.001), cholesterol < 150 mg/dL (OR = 2.64, p = 0.003), sodium < 140 mmol/L (OR = 1.73, p = 0.004)). Among clinical factors, cirrhosis (OR = 9.05, p < 0.001), Cushingoid appearance in those with exogenous steroid use (OR = 8.56, p < 0.001), and chronic kidney disease (OR = 2.21, p < 0.001) were significantly linked to biochemical AI. The AUC-ROC of the final model incorporating all factors was 83%. CONCLUSIONS These easy-to-perform biochemical tests and easy-to-assess clinical factors could help predict biochemical AI in hospitalized patients with high accuracy. The physician should therefore have a high index of suspicion to perform dynamic tests for AI diagnosis in those who meet the proposed model criteria.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chiang Mai University Hospital, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand.
| | - Natapong Kosachunhanan
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chiang Mai University Hospital, 110 Intrawarorot Road Soi 2, Si Phum, Amphoe Mueang Chiang Mai, Chiang Mai, 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University Hospital, Chiang Mai, Thailand
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Mandraffino G, Scicali R, Rodríguez-Carrio J, Savarino F, Mamone F, Scuruchi M, Cinquegrani M, Imbalzano E, Di Pino A, Piro S, Rabuazzo AM, Squadrito G, Purrello F, Saitta A. Arterial stiffness improvement after adding on PCSK9 inhibitors or ezetimibe to high-intensity statins in patients with familial hypercholesterolemia: A Two-Lipid Center Real-World Experience. J Clin Lipidol 2020; 14:231-240. [PMID: 32111581 DOI: 10.1016/j.jacl.2020.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/29/2019] [Accepted: 01/28/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is characterized by increased cardiovascular risk; despite-high intensity statins, only few patients with FH achieve the recommended low-density lipoprotein cholesterol (LDL-C) targets. OBJECTIVE We aimed to evaluate the effectiveness of six-month add-on therapy with proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9-i) or ezetimibe on lipid profile and pulse wave velocity (PWV) in patients with FH. METHODS In this observational study, we evaluated 98 genetically confirmed patients with FH with an LDL-C off-target despite high-intensity statins with or without ezetimibe; of these, 53 patients (statin plus ezetimibe) added PCSK9-i (PCSK9-i group) and 45 (statin only) added ezetimibe (EZE group) per applicable guidelines and reimbursement rules. All patients obtained biochemical analysis and PWV evaluation at baseline and after six months of optimized treatment. RESULTS After 6 months of add-on therapy, most patients achieving LDL-C targets were in the PCSK9-i group (77.3% PCSK9-i group vs 37.8% EZE group, P < .001). The PCSK9-i group achieved both a greater LDL-C and PWV reduction than the EZE group [-51% vs -22.8%, P < .001 and -15% vs -8.5%, P < .01, respectively]. In a linear regression analysis, we showed a coefficient (r) of 0.334 for the relationship between ΔPWV and ΔLDL (P < .05); moreover, in an exploratory analysis, the relationship appeared to be stronger in patients with FH without cardiovascular events (r = 0.422, P < .01). CONCLUSIONS Lipid and PWV profiles in patients with FH significantly improved after addition of PCSK9-i or ezetimibe to high-intensity statin therapy; moreover, ΔPWV was associated with ΔLDL. Our results are consistent with a beneficial role of these novel therapies in FH subjects.
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Affiliation(s)
| | - Roberto Scicali
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Javier Rodríguez-Carrio
- Department of Functional Biology, Area of Immunology, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Area of Metabolism, Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Oviedo, Spain; Bone and Mineral Research Unit, Instituto Reina Sofía de Investigación Nefrológica, RED in REN Del ISCIII, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Francesca Savarino
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Federica Mamone
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Michele Scuruchi
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Maria Cinquegrani
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | | | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Antonino Saitta
- Department of Clinical and Experimental Medicine, University of Messina, Italy
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11
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Manosroi W, Phimphilai M, Khorana J, Atthakomol P, Pipanmekaporn T. Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study. ACTA ACUST UNITED AC 2020; 56:medicina56010023. [PMID: 31936335 PMCID: PMC7022503 DOI: 10.3390/medicina56010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
| | - Jiraporn Khorana
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Tanyong Pipanmekaporn
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
- Correspondence: ; Tel.: +66-53-936453
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12
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Analysis of HDL-microRNA panel in heterozygous familial hypercholesterolemia subjects with LDL receptor null or defective mutation. Sci Rep 2019; 9:20354. [PMID: 31889114 PMCID: PMC6937253 DOI: 10.1038/s41598-019-56857-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/06/2019] [Indexed: 12/18/2022] Open
Abstract
In the last years increasing attention has been given to the connection between genotype/phenotype and cardiovascular events in subjects with familial hypercholesterolemia (FH). MicroRNAs (miRs) bound to high-density lipoprotein (HDL) may contribute to better discriminate the cardiovascular risk of FH subjects. Our aim was to evaluate the HDL-miR panel in heterozygous FH (HeFH) patients with an LDLR null or defective mutation and its association with pulse wave velocity (PWV). We evaluated lipid panel, HDL-miR panel and PWV in 32 LDLR null mutation (LDLR-null group) and 35 LDLR defective variant (LDLR-defective group) HeFH patients. HDL-miR-486 and HDL-miR-92a levels were more expressed in the LDLR-null group than the LDLR-defective group. When we further stratified the study population into three groups according to both the LDLR genotype and history of ASCVD (LDLR-null/not-ASCVD, LDLR-defective/not-ASCVD and LDLR/ASCVD groups), both the LDLR/ASCVD and the LDLR-null/not-ASCVD groups had a higher expression of HDL-miR-486 and HDL-miR-92a than the LDLR-defective/not-ASCVD group. Finally, HDL-miR-486 and HDL-miR-92a were independently associated with PWV. In conclusion, the LDLR-null group exhibited HDL-miR-486 and HDL-miR-92a levels more expressed than the LDLR-defective group. Further studies are needed to evaluate these HDL-miRs as predictive biomarkers of cardiovascular events in FH.
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13
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van der Geest R, van der Sluis RJ, Groen AK, Van Eck M, Hoekstra M. Cholestasis-associated glucocorticoid overexposure does not increase atherogenesis. J Endocrinol 2019; 242:1-12. [PMID: 31035252 DOI: 10.1530/joe-19-0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 12/15/2022]
Abstract
Chronic glucocorticoid overexposure predisposes to the development of atherosclerotic cardiovascular disease in humans. Cholestatic liver disease is associated with increased plasma glucocorticoid levels. Here, we determined - in a preclinical setting - whether the chronic presence of cholestatic liver disease also induces a concomitant negative impact on atherosclerosis susceptibility. Hereto, regular chow diet-fed atherosclerosis-susceptible hypercholesterolemic apolipoprotein E (APOE)-knockout mice were treated with the bile duct toxicant alpha-naphthylisothiocyanate (ANIT) for 8 weeks. ANIT exposure induced the development of fibrotic cholestatic liver disease as evident from collagen deposits and compensatory bile duct hyperproliferation within the liver and the rise in plasma levels of bilirubin (+60%; P < 0.01) and bile acids (10-fold higher; P < 0.01). Adrenal weights (+22%; P < 0.01) and plasma corticosterone levels (+72%; P < 0.01) were increased in ANIT-treated mice. In contrast, atherosclerosis susceptibility was not increased in response to ANIT feeding, despite the concomitant increase in plasma free cholesterol (+30%; P < 0.01) and cholesteryl ester (+42%; P < 0.001) levels. The ANIT-induced hypercorticosteronemia coincided with marked immunosuppression as judged from the 50% reduction (P < 0.001) in circulating lymphocyte numbers. However, hepatic glucocorticoid signaling was not enhanced after ANIT treatment. It thus appears that the immunosuppressive effect of glucocorticoids is uncoupled from their metabolic effect under cholestatic disease conditions. In conclusion, we have shown that cholestatic liver disease-associated endogenous glucocorticoid overexposure does not increase atherosclerosis susceptibility in APOE-knockout mice. Our studies provide novel preclinical evidence for the observations that the hypercholesterolemia seen in cholestatic human subjects does not translate into a higher risk for atherosclerotic cardiovascular disease.
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Affiliation(s)
- Rick van der Geest
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Gorlaeus Laboratories, Leiden, The Netherlands
| | - Ronald J van der Sluis
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Gorlaeus Laboratories, Leiden, The Netherlands
| | - Albert K Groen
- Departments of Pediatrics and Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Miranda Van Eck
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Gorlaeus Laboratories, Leiden, The Netherlands
| | - Menno Hoekstra
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Gorlaeus Laboratories, Leiden, The Netherlands
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Theiler-Schwetz V, Zaufel A, Schlager H, Obermayer-Pietsch B, Fickert P, Zollner G. Bile acids and glucocorticoid metabolism in health and disease. Biochim Biophys Acta Mol Basis Dis 2019; 1865:243-251. [DOI: 10.1016/j.bbadis.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/18/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
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Park SH, Joo MS, Kim BH, Yoo HN, Kim SE, Kim JB, Jang MK, Kim DJ, Lee MS. Clinical characteristics and prevalence of adrenal insufficiency in hemodynamically stable patients with cirrhosis. Medicine (Baltimore) 2018; 97:e11046. [PMID: 29952944 PMCID: PMC6039635 DOI: 10.1097/md.0000000000011046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
It is well known that adrenal insufficiency is common in septic shock or hemodynamically unstable patients. But, there is as yet no sufficient clinically significant data about the exact prevalence or differences in the cause of cirrhosis with adrenal insufficiency. To investigate adrenal insufficiency prevalence in hemodynamically stable patients with cirrhosis and determine differences based on cirrhosis severity or etiology.From July 2011 to December 2012, 69 hemodynamically stable patients with cirrhosis without infection admitted at Hallym University Medical Center were enrolled. Adrenal insufficiency was defined as a peak cortisol level < 18 μg/dL, 30 or 60 minutes after 250 μg Synacthen injection.The study included 55 male patients (79.7%), and the mean age was 57.9 ± 12.9 years. Cirrhosis etiology was alcohol consumption, HBV, HCV, both viral and alcohol related, and cryptogenic in 49, 15, 7, 11, 9 patients, respectively. Adrenal insufficiency occurred in 24 patients (34.8%). No differences were found in age, sex, mean arterial pressure, heart rate, HDL, cirrhosis etiology, degree of alcohol consumption, encephalopathy, variceal bleeding history, or hepatocellular carcinoma between patients with or without adrenal insufficiency. Serum albumin level was lower (P < .05), and INR was higher (P < .05) in patients with than in those without adrenal insufficiency. However, multivariate analysis revealed no independent adrenal insufficiency predictor. Significant negative correlations were found between Child-Pugh score and peak cortisol levels (γ=-0.365, P = .008).Adrenal insufficiency was frequent even in hemodynamically stable patients with cirrhosis and tended to be associated with only liver disease severity, being unrelated to cirrhosis etiology.
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16
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Abnormalities of Lipoprotein Levels in Liver Cirrhosis: Clinical Relevance. Dig Dis Sci 2018; 63:16-26. [PMID: 29177578 DOI: 10.1007/s10620-017-4862-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 11/19/2017] [Indexed: 12/17/2022]
Abstract
Progressive lipoprotein impairment occurs in liver cirrhosis and is associated with increased morbidity and mortality. The present review aims to summarize the current evidence regarding the prognostic value of lipoprotein abnormalities in liver cirrhosis and to address the need of a better prognostic stratification of patients, including lipoprotein profile assessment. Low levels of lipoproteins are usual in cirrhosis. Much evidence supports the prognostic role of hypolipidemia in cirrhotic patients. In particular, hypocholesterolemia represents an independent predictor of survival in cirrhosis. In cirrhotic patients, lipoprotein impairment is associated with several complications: infections, malnutrition, adrenal function, and spur cell anemia. Alterations of liver function are associated with modifications of circulating lipids. Decreased levels of lipoproteins significantly impact the survival of cirrhotic patients and play an important role in the pathogenesis of some cirrhosis-related complications.
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17
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Bertino G, Privitera G, Purrello F, Demma S, Crisafulli E, Spadaro L, Koukias N, Tsochatzis EA. Emerging hepatic syndromes: pathophysiology, diagnosis and treatment. Intern Emerg Med 2016; 11:905-16. [PMID: 27273018 DOI: 10.1007/s11739-016-1478-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide, mainly due to complications of portal hypertension. In this article, we review the current understanding on the pathophysiology, the diagnostic criteria and the available therapeutic options for patients with emerging hepatic syndromes in cirrhosis, namely the hepatorenal, hepato-adrenal and hepatopulmonary syndrome. The hepatorenal syndrome is a well-recognized complication of advanced cirrhosis and is usually associated with an accelerated course to death unless liver transplantation is performed. The hepatopulmonary syndrome is often missed in the evaluation of patients with cirrhosis; however, early recognition is essential for the efficient management of individual patients. The hepato-adrenal syndrome, although not fully characterized, offers an exciting field for research and potential therapeutic interventions.
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Affiliation(s)
- Gaetano Bertino
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Graziella Privitera
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Francesco Purrello
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Shirin Demma
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Emanuele Crisafulli
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Luisa Spadaro
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Nikolaos Koukias
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
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