High density lipoprotein in patients with liver failure; relation to sepsis, adrenal function and outcome of illness

Background and Aims: High density lipoprotein (HDL) plays an important role in the transport of cholesterol to the adrenal gland for steroidogenesis and may have actions that modulate response to infection and critical illness. The clinical relevance of HDL level in patients with liver failure remains poorly characterised. Methods: In 164 critically-ill patients with acute (ALF) and acute on chronic liver failure (AOCLF) we evaluated the relationship between HDL levels measured on admission to intensive care unit (ICU) and survival, predisposition to sepsis and adrenocortical function assessed through the cortisol response to short synacthen testing (SST). Results: In acute liver failure and acute on chronic liver failure, high density lipoprotein levels were significantly lower in non-survivors (P < 0.01). Levels correlated closely with biochemical markers of liver function and the duration of liver failure. However, predictive accuracy was not superior to conventional markers and on multi-variate analysis did not show independent association with survival. Low HDL concentration was not associated with an increased incidence of sepsis either precipitating or complicating ICU admission. Evidence of adrenocortical insufficiency was present in more than half of patients undergoing SST and HDL level but not other lipid parameters correlated closely with cortisol increment after SST (r = 0.364, P < 0.0001). Conclusions: High density lipoprotein levels are low in patients with liver failure and reflect its severity. Levels are lower in non-survivors but do not offer an advantage as early indicators of prognosis over conventional markers. No evidence of a major predisposing role for infection was found, but findings suggest a close link to adrenal function.