Introduction Adrenal insufficiency is noted in patients of cirrhosis, mainly in critically ill patients. Cirrhosis characterized with low synthetic functions has multiple indirect markers for severity. Methodology 100 decompensated cirrhosis patients were hospitalized to Lady Hardinge Medical College in New Delhi as part of an observational cohort research from October 2014 to June 2016. Adrenocorticotrophic hormone stimulation test was done with 250 mcg, basal cortisol, and cortisol after 60 minutes of stimulation was noted. We investigated the relationship between blood HDL levels and adrenal insufficiency. Results Insufficient adrenal function was detected in 28% of the patients. INR, serum total bilirubin, serum creatinine, low high-density lipoprotein (HDL), child score, MELD score, plasma renin activity level, and renal resistive index were all associated with patients with adrenal insufficiency on univariate analysis. Multivariate analysis showed in patients with adrenal insufficiency, MELD score had odds ratio of 1.5 with AUC 0.724 (0.622-0.825), Bilirubin with odds ratio of 5.6 and AUC of 0.676 (0.679-0.882). Serum HDL with odds ratio of 6.1 (3.3-9.2) and AUC 0.822 (0.724-0.828) with P value <0.001, cut off calculated was 26 mg/dL with sensitivity of 81% and specificity of 85% predicts adrenal insufficiency. Patients with adrenal insufficiency had higher mortality. Conclusion Cirrhosis is associated with adrenal insufficiency, more with advanced liver disease. Low HDL level in blood can be taken as an indirect marker for adrenal insufficiency.

To the editor, We read with great interest the study by Vandriel et al., "Natural History of Liver Disease in a Large International Cohort of Children with Alagille syndrome: Results from The GALA Study." In this multicentre retrospective study only 40.3% of children reach adulthood with their native liver. The study also shows bilirubin <5.0 mg/dL between 6 and 12 months of age is associated with better hepatic outcomes. [1] Furthermore, this study has the largest cohort of Alagille syndrome patients and will assist in understanding and managing patients. However certain points needs more insight.Firstly, Alagille syndrome patients have right sided heart disease and which determines the patient survival either without transplant or with transplant. The study mentions that cardiac disease is present in 91% (n = 1231/1347), but should have also elucidated more on the type of cardiac abnormality seen in these patients. More severe cardiac deformity makes them unable to undergo dobutamine stress testing, which is mandatory according to King's College guidelines for these Alagille patients. [2] Secondly, the study showed renal involvement seen in 39% (n = 500/ 1275). The study should have also illustrated the type of kidney injury, how many had renal tubular acidosis (seen with Alagille syndrome), what was the level of renal injury (stages of acute kidney injury) and whether it was reversible with therapy or not. As 4 patients underwent combined liver-kidney transplant, knowing type of acute kidney injury in these patients might help in managing them in future. [3] Thirdly, the showed that 345 patients underwent isolated liver transplant. The study should mention immunosuppression details in these patients as they are known to preserve renal function. The literature mentions early introduction of mechanistic target of rapamycin (mTOR) inhibitors. [4] Lastly, the study does not mention the growth and development of the Alagille patients as previous literature shows growth problems do not improve in these patients even after successful liver transplantation. [5]

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To the editor: We read with interest the article by Amadou et al. on the association between birth weight, preterm birth, and NAFLD in a community-based cohort. [1] The study showed that premature birth (OR = 1.23; 95% CI, 1.03-1.48 for birth between 33 and 37 vs. ≥ 37 weeks) was associated with NAFLD. This study is important given that knowing neonate risk factors would help clinicians in the management and elimination of the future risk of NAFLD. However, certain issues need consideration.First, because the study took the birth health card as the retrospective data in a selected group of patients, the investigators did not mention hospital admission and duration of hospital stay at birth. Prolonged hospital admission requires artificial feeding; whether neonates received formula feeding or breast milk was also not mentioned. Previous studies have shown that neonates who were exclusively breastfed had a lower risk of developing subsequent NAFLD. [2] Second, the study should also have discussed the weight chart in preterm, which is an important pillar of management, given that there is a tendency to overfeed at preterm, which predisposes neonates to "catch-up growth." Previous studies have shown that catch-up growth is one of the risk factors for developing obesity as well as the future risk of NAFLD in preterm patients. [3] Last, preterm neonates have an elevated risk of being born with other congenital, genetic, and metabolic disorders affecting multiple organs. The study by Amadou et al. indicates neither any genetic or metabolic risk factor nor the liver biopsy to rule out other metabolic disorders that may predispose neonates to NAFLD. [4] CONFLICT OF INTEREST Nothing to report.