Chronic Liver Disease (CLD) encompasses a broad category of liver ailments that persist over time, leading to the gradual deterioration of liver function. These conditions can range from mild fibrosis to more severe stages such as cirrhosis, liver failure, and hepatocellular carcinoma.1,2 CLD is the result of various etiologies, including viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease (NAFLD), and autoimmune liver diseases.3 The progression of CLD involves chronic inflammation and liver cell death, leading to fibrosis and, ultimately, loss of liver function. This disease process affects millions globally, imposing a significant health burden.4,5 The progression of CLD is often compounded by complications like portal hypertension, a critical factor in its pathogenesis. Additionally, CLD patients are prone to develop systemic complications, notably Hepatorenal (HRS), Hepatopulmonary (HPS), and the more recently recognized Hepato-adrenal Syndrome (HAS).6 HAS, in particular, represents a state of inadequate cortisol production in cirrhotic patients during stress conditions such as sepsis or following liver transplantation. Despite its recent identification and growing recognition, the pathophysiology of HAS, including its association with cholesterol metabolism and other factors, remains poorly understood.7–9 Moreover, the altered immune responses in CLD patients, which range from immune deficiency to paradoxical overactivation, exacerbate their vulnerability to infections, particularly severe ones. This complex immune dysregulation in CLD patients, especially in the context of severe infections and unique syndromes like HAS, underscores the necessity for in-depth research.10,11 This study aims to delve into these complexities by assessing the prevalence of HAS among CLD patients with sepsis, utilizing total basal cortisol as a measure. Our investigation seeks not only to determine HAS prevalence but also to identify practical bedside methods for recognizing affected patients. By comparing basal cortisol levels in cirrhotic patients with and without sepsis, we aim to elucidate the broader impacts of HAS within the CLD patient population. Through this comparative study, we endeavour to enhance our understanding of the intricate interplay between CLD, severe infections, immune response modifications, and specific conditions like HAS, ultimately contributing to improved patient care and therapeutic approaches.

Type of Study This research constitutes an observational comparative cross-sectional study, designed to investigate the associations between chronic liver disease (CLD) with and without sepsis on serum cortisol levels. Setting and Participants The study was conducted in a tertiary care hospital in Puducherry, involving two distinct groups of patients suffering from CLD. The total sample comprised 89 patients, with 43 in Group 1 and 46 in Group 2. Group 1 included patients evidencing CLD with concurrent sepsis, as identified by Systemic Inflammatory Response Syndrome (SIRS) criteria, the presence of Spontaneous Bacterial Peritonitis (SBP), or positive blood culture results. Conversely, Group 2 consisted of patients with stable CLD, showing no signs of sepsis. Study Period The research spanned from December 2012 to July 2014, ensuring ample time for comprehensive data collection and analysis. Study Tools and Measurements Blood samples were drawn from patients in the morning and subsequently stored at -20 degrees Celsius until batch processed at the study's conclusion. Serum total basal cortisol levels were measured utilizing electrochemiluminescence immunoassay (ECLIA) method, performed on Elescsys and Cobasee immunoassay analyzers. The patient groups underwent specific tests relevant to their conditions to facilitate the analysis. Sampling Technique and Criteria The inclusion criteria targeted all CLD patients attending the Gastroenterology Outpatient Department (OPD) or those admitted under gastroenterology care, with the diagnosis of CLD confirmed via liver function tests and ultrasonography. Relevant procedures such as blood culture and diagnostic ascitic tapping were conducted for classification into Group A (with sepsis) or Group B (without sepsis). Exclusion criteria for Group A involved patients with liver cirrhosis who had been treated with corticosteroids, whereas, for Group B, it included patients showing evidence of systemic infection. Parameters Studied For both groups, parameters such as Hemoglobin percentage (Hb%), Total Leukocyte Count (TLC), and serum cortisol were examined. Additionally, cirrhotic patients underwent assessments for Serum Bilirubin, Serum Creatinine, Serum Albumin, Total Proteins, International Normalized Ratio (INR), and High-Density Lipoprotein (HDL). Brief Procedure Upon admission, patients were evaluated against the study's criteria, including endoscopic evidence of varices, altered liver test results, ultrasonography showing CLD, ascitic fluid indicating portal hypertension, and liver biopsy results. Those meeting exclusion criteria were not considered. Informed consent was obtained from all participants. The allocation to groups was based on the defined criteria, with normal controls being attenders of patients. Sample collection occurred within the first 48 hours of admission. Statistical Analysis Data analysis included descriptive statistics (Mean, Standard Deviation, and Standard Error of Mean), prevalence rates, Pearson’s correlation coefficient, and the significance of differences assessed using Student's T-test and the Mann-Whitney test. A p-value < 0.05 was considered statistically significant. Data management and analysis were performed using MS Excel 2007 and SPSS version 16.0.

Table 1: Sex Distribution of patients attending the Gastroenterology Department in a tertiary care Hospital in Puducherry. Sex CLD with Severe Infection Count (%) Stable CLD Without Infection Count (%) Female 4 (80%) 1 (20%) Male 39 (46.4%) 45 (53.6%) Among females, 80% had CLD with severe infection, 20% had stable CLD without infection. Among males, 46.4% had CLD with severe infection, while 53.6% had stable CLD without infection. Table 2: Comparison of Various Tests by CLD with and without Severe Infection of patients attending the Gastroenterology Department in a tertiary care Hospital in Puducherry. Category Test CLD with Severe Infection (Mean ± SD) Stable CLD Without Infection (Mean ± SD) P-Value (t-test) Biochemical parameters INR 1.89 ± 0.90 1.48 ± 0.39 0.006 Alb 2.49 ± 0.43 2.78 ± 0.48 0.003 Urea 53.58 ± 36.65 32.28 ± 20.38 0.001 Creatinine 1.66 ± 1.98 0.90 ± 0.68 0.016 HDL 20.02 ± 9.22 20.80 ± 7.96 0.669 Liver Function Tests TLC 16,269.77 ± 6,128.49 7,826.09 ± 2,700.57 <0.001 Prot 6.30 ± 0.90 6.34 ± 0.88 0.818 Glob 3.81 ± 0.94 3.57 ± 0.76 0.174 Total Bilirubin 7.59 ± 5.97 6.16 ± 7.01 0.303 Direct Bilirubin 6.03 ± 4.86 4.79 ± 6.60 0.320 Other Parameters Age 49.44 ± 13.02 49.13 ± 9.40 0.897 Serum Cortisol 30.17 ± 19.04 21.59 ± 9.95 0.009 MELD 22.54 ± 7.73 17.83 ± 4.78 0.001 Table 2 Patients with severe infection exhibited higher International Normalized Ratio (INR), urea, and creatinine levels, indicating impaired liver function and kidney stress. These patients also had higher total leukocyte counts (TLC), signalling increased inflammation. Lower albumin levels in the severe infection group suggested a risk of fluid imbalance and poor nutritional status. Additionally, higher serum cortisol and Model for End-Stage Liver Disease (MELD) scores in this group pointed to a higher stress response and a worse prognosis. The differences between the two groups was statistically significant. Conversely, parameters like HDL cholesterol, total proteins, globulins, and bilirubin levels showed no significant difference between the groups, indicating these aspects were not as impacted by infection status. Table:3 Child-Pugh Score and Class Distribution by CLD with and without Severe Infection of patients attending the Gastroenterology Department in a tertiary care Hospital in Puducherry. Condition N Mean ± Std. Deviation P-Value Child-Pugh Class Count (CLD with Severe Infection) Count (Stable CLD Without Infection) Total OR (95% CI) P-Value CLD with Severe Infection 43 11.47 ± 1.67 <0.001 C 39 30 69 5.2 (1.5 to 17.1) 0.004 Stable CLD Without Infection 46 9.74 ± 1.02 B 4 16 20 Table 4: Serum Cortisol Category Distribution in CLD with Severe Infection Serum Cortisol Count Column N % <17.5 mcg/dl 16 37.2% >17.5 mcg/dl 27 62.8% Table 3 and 4 shows in-patients with Chronic Liver Disease (CLD), those with severe infection have significantly higher Child-Pugh scores (mean 11.47 ± 1.67) compared to those without infection (mean 9.74 ± 1.02), with a P-value of <0.001. Additionally, the distribution of Child-Pugh classes shows a higher prevalence of Class C among patients with severe infection (39 out of 43) compared to stable patients (30 out of 46). This yields an odds ratio of 5.2 (95% CI: 1.5 to 17.1) and a significant P-value of 0.004. Conversely, fewer patients with severe infection are in Class B (4 out of 43) compared to stable patients (16 out of 46). This indicates that severe infection in CLD patients is associated with worse liver function and prognosis. Furthermore, among CLD patients with severe infection, serum cortisol levels are elevated in the majority, with 62.8% having levels above 17.5 mcg/dl and 37.2% below this threshold. So, the prevalence of Hepato-adrenal syndrome is 37.2%. Table 5: Correlations of various parameters with Serum Cortisol Parameter Pearson Correlation P-Value Total Lymphocyte Count (TLC) 0.452** <0.001 International Normalized Ratio (INR) 0.047 0.660 Protein (Prot) 0.146 0.174 Albumin (Alb) -0.060 0.576 Globulin (Glob) 0.184 0.084 Urea 0.245* 0.021 Creatinine 0.175 0.102 Total Bilirubin 0.051 0.634 Direct Bilirubin 0.055 0.610 High-Density Lipoprotein (HDL) 0.082 0.446 Table 5 shows Total Lymphocyte Count (TLC) shows a moderate positive correlation with serum cortisol (r = 0.452, P < 0.001), indicating that as cortisol levels increase, TLC tends to increase as well. This correlation is statistically significant, suggesting a meaningful relationship between stress or inflammation and lymphocyte counts. Urea also shows a significant weak positive correlation with serum cortisol (r = 0.245, P = 0.021), suggesting that higher cortisol levels might be associated with increased urea levels, which could indicate stress-related increases in metabolic rate or renal stress. Other parameters, such as INR, Protein (Prot), Albumin (Alb), Globulin (Glob), Creatinine, Total Bilirubin, Direct Bilirubin, and High-Density Lipoprotein (HDL), show no significant correlation with serum cortisol, as indicated by their P-values (ranging from 0.084 to 0.660). This suggests that these parameters are not directly related to cortisol levels in a statistically significant manner within the studied population. Notably, Globulin (Glob) shows a somewhat positive correlation (r = 0.184), but this is not statistically significant (P = 0.084), indicating a potential but not definitively established relationship with cortisol levels.

The objective of this study was to assess the clinical outcomes and immune responses in patients with chronic liver disease (CLD), comparing those with severe infections to those without. The rationale behind this comparison lies in the need to understand how severe infections impact the progression and prognosis of CLD. By examining key parameters such as Child-Pugh scores, serum cortisol levels, and other clinical markers, this study aims to elucidate the differences between these two patient groups and provide insights that could inform better management strategies for CLD patients, particularly in preventing and treating severe infections. The study revealed significant differences between CLD patients with severe infections and those without. Key findings include: • Child-Pugh Scores: Patients with severe infection had significantly higher Child-Pugh scores (mean 11.47 ± 1.67) compared to those without infection (mean 9.74 ± 1.02), with a P-value of <0.001. This indicates worse liver function among the infected group. • Child-Pugh Class Distribution: A higher prevalence of Class C was observed among patients with severe infection (39 out of 43) compared to stable patients without infection (30 out of 46), yielding an odds ratio (OR) of 5.2 (95% CI: 1.5 to 17.1) and a significant P-value of 0.004. Conversely, fewer patients with severe infection were in Class B (4 out of 43) compared to stable patients (16 out of 46). • Serum Cortisol Levels: Elevated serum cortisol levels were more common in patients with severe infection, with 62.8% having levels above 17.5 mcg/dl, indicating a heightened stress response. • Gender Differences: Among females, 80% had CLD with severe infection, while 20% had stable CLD without infection. Among males, 46.4% had CLD with severe infection, while 53.6% had stable CLD without infection. The OR of 4.6 suggests that females with CLD are more likely to develop severe infections, though this was not statistically significant. • Clinical Parameters: Patients with severe infection had higher INR, urea, and creatinine levels, indicating impaired liver function and kidney stress. They also had higher total leukocyte counts (TLC), suggesting increased inflammation, and lower albumin levels, indicating a risk of fluid imbalance and poor nutritional status. • Correlations with Serum Cortisol: TLC showed a moderate positive correlation with serum cortisol (r = 0.452, P < 0.001), suggesting a relationship between stress or inflammation and lymphocyte counts. Urea also showed a significant positive correlation with serum cortisol (r = 0.245, P = 0.021), indicating potential stress-related increases in metabolic rate or renal stress. In our study, the prevalence of hepato-adrenal syndrome was found to be 37% among chronic liver disease (CLD) patients with severe infections. This prevalence aligns closely with the findings of Wentworth et al., who reported a 37% prevalence of relative adrenal insufficiency (RAI) in non-critically ill cirrhotic patients.12 Similarly, Marik et al. found a 72% prevalence of adrenal insufficiency in liver disease patients, particularly those with chronic liver failure and post-liver transplantation, while Vasu et al. identified a 62.5% prevalence of hepatoadrenal syndrome in critically ill cirrhotic patients.13,14 Nandish et al. reported a 60% prevalence of RAI in decompensated cirrhotic patients without infection.15 our findings indicate that elevated serum cortisol levels and higher Child-Pugh scores in patients with severe infections complicate the management of CLD patients. This is consistent with Wentworth et al.'s observation that RAI is associated with significantly higher 90-day mortality (OR 2.88), suggesting the need for early identification and management.12 Marik et al. emphasized the pathophysiological relationship between low HDL levels and adrenal insufficiency, highlighting the importance of monitoring and treating adrenal insufficiency to improve outcomes.13 Similarly, Vasu et al. reported longer ICU stays and higher in-hospital mortality in patients with hepato-adrenal syndrome, underscoring the clinical impact of adrenal dysfunction.14 Although Nandish et al. did not find a significant difference in 3-month mortality, they noted the need for further investigation into the clinical utility of routine adrenal function testing in non-infected cirrhotic patients. Given the clinical implications of our findings, regular monitoring of serum cortisol levels and Child-Pugh scores in CLD patients, particularly those with severe infections, is crucial. Early intervention with stress doses of hydrocortisone may be beneficial, as suggested by Marik et al., who recommended treating adrenal insufficiency with hydrocortisone to reduce mortality and improve outcomes.13 Wentworth et al. called for further research into therapeutic interventions for RAI in non-critically ill cirrhotic patients, and Vasu et al. advocated for more extensive studies to confirm the benefits of managing hepatoadrenal syndrome in critically ill patients.12,14 Nandish et al. indicated the need for more research to determine the clinical significance of RAI in cirrhotic patients without infection.15 Child-Pugh Scores and Class Distribution: our study's findings of higher Child-Pugh scores and a greater prevalence of Class C among patients with severe infections are consistent with existing literature. Wentworth et al. identified variations in RAI prevalence by Child-Pugh classification, while Marik et al. found high rates of adrenal insufficiency in patients with chronic liver failure.12,13 Vasu et al. also reported a higher prevalence of hepatoadrenal syndrome in patients with advanced liver disease (Child-Pugh Class C).14 Serum Cortisol Levels: The elevated serum cortisol levels observed in our study's patients with severe infections suggest a heightened stress response, correlating with increased inflammation and renal stress. This finding is comparable to Wentworth et al.'s use of serum cortisol levels to diagnose RAI, associating higher levels with worse outcomes.12 Marik et al. reported high baseline serum cortisol levels in nonsurvivors, indicating disease severity, while Vasu et al. observed elevated cortisol levels in critically ill patients, reflecting stress and adrenal insufficiency.13,14 Nandish et al. also noted cortisol level differences in decompensated cirrhotic patients, highlighting the role of adrenal function in disease progression.15

Overall, our study contributes to the existing literature by emphasizing the impact of severe infections on clinical outcomes and immune responses in chronic liver disease patients. The higher Child-Pugh scores, elevated serum cortisol levels, and impaired liver and kidney function in infected patients highlight the need for careful monitoring and targeted interventions. Additionally, the observed gender differences and correlations with serum cortisol levels provide new insights into the complex interplay between infection severity and adrenal function in chronic liver disease. These findings underscore the importance of early identification and management of adrenal insufficiency to improve clinical outcomes in this patient population.

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