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Adrenal Insufficiency, “Relative Adrenal Insufficiency,” or None of the Above?

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Management of Patients with Pseudo-Endocrine Disorders

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Abstract

Assessing adrenal function during acute illness or in patients who are chronically ill with an acute decompensation in their health status can be extremely challenging and complex. It is suggested that serum total cortisol levels and the response of total cortisol to a cosyntropin stimulation test are not reliable markers of adrenal function in severe illness due to multiple factors, including hypoalbuminemia, low serum cortisol binding globulin (CBG) levels, and altered CBG affinity. The same notion applies to patients with liver disease and advanced cirrhosis. In this chapter, we will review the effect of critical illness on the HPA axis and cortisol secretion and present the challenges in the interpretation of an ACTH (cosyntropin) stimulation test in this patient population. Direct measurement of serum free cortisol (SFC), which is the biologically active free fraction of cortisol, can potentially address many of the challenges that we face in the evaluation of the hypothalamic-pituitary-adrenal (HPA) axis in the abovementioned patient population. One of the limiting factors is the lack of specific criteria for diagnosis of adrenal insufficiency using SFC levels. Thus, it is of paramount importance that baseline and post-ACTH stimulation reference ranges be established for serum free cortisol.

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Authors and Affiliations

  1. Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Maria Vamvini & James V. Hennessey

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  1. Maria Vamvini
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  2. James V. Hennessey
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Correspondence to Maria Vamvini .

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Editors and Affiliations

  1. University of Colorado Hospital, Aurora, CO, USA

    Michael T. McDermott

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Vamvini, M., Hennessey, J.V. (2019). Adrenal Insufficiency, “Relative Adrenal Insufficiency,” or None of the Above?. In: McDermott, M. (eds) Management of Patients with Pseudo-Endocrine Disorders. Springer, Cham. https://doi.org/10.1007/978-3-030-22720-3_12

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  • DOI: https://doi.org/10.1007/978-3-030-22720-3_12

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-22719-7

  • Online ISBN: 978-3-030-22720-3

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