Metabolic effects of recombinant human growth hormone: isotopic studies in the postabsorptive state and during total parenteral nutrition

Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients

BACKGROUND

Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients.

METHODS

To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013.

RESULTS

Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors.

DISCUSSION

This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured.

CONCLUSIONS

GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.

Effects of growth hormone and insulin-like growth factor-1 on postoperative muscle and substrate metabolism

This study explored if a combined supplementation of GH and IGF-1 had an additive effect on whole body nitrogen economy, energy, substrate and skeletal muscle metabolism following surgical trauma. Patients were randomized to controls (C; n = 10), to GH (0.15 IU/kg/injection) (GH; n = 7) or GH combined with IGF-1 (40 μg/kg/injection) subcutaneously twice a day (GH-IGF-1; n = 9) together with standardized parenteral nutrition. Muscle amino acids, glutathione and the ribosomal pattern reflecting protein synthesis, and nitrogen balance were measured. GH- and GH-IGF-1 groups showed lower urea and higher plasma glucose concentrations. Energy expenditure increased in the GH-group. GH-IGF-1 prevented a decrease in muscle polyribosomes indicating a preserved muscle protein synthesis. In the GH group unaltered BCAA and AAA levels were seen in muscle indicating an unchanged protein breakdown, while the other groups showed increased muscle concentrations postoperatively. Without statistically difference GH marginally improved the nitrogen balance, in terms of higher values, and growth factors improved the nitrogen balance when the shift in urea was taken into account. To conclude, growth factors influences urea metabolism, protein degradation and protein synthesis. There was no clearcut additional effect when combining GH and IGF-1 but the study was probably underpowered to outrule this and effects on nitrogen balance.

Progress in prevention and cure of leakage after operation for rectal cancer

Operation is the main therapy for rectal cancer. With the deepening of knowledge of anatomy and development of surgical instruments, more anus-reserved operations have been successfully performed. Meanwhile, anastomotic leakage, which is the main complication of anus-reserved operations, is attracting more and more attentions of researchers home and abroad. Although some achievements have been acquired, many questions still remains unsolved. Inception rates, for example, are different between reports of different researchers, indicating that a unified and effective standard of operation is required. In the future, we should take prevention as the main and combine it with treatment to reduce the inception or mortality rate.

Growth hormone is a stimulating but not an essential factor in healing of colon. A study in GH-deficient dwarf rats

BACKGROUND

Growth hormone (GH) has been implicated as an important factor in the healing and previous studies showed significant strength acceleration of experimental intestinal anastomoses.

AIM

To study the healing of experimental colonic anastomoses in GH-deficient rats and to study the potential physiological effects of GH-substitution on healing parameters.

CONCLUSION

Exogenous rhGH treatment started 7 days prior to surgery and continued until day 4 postoperatively accelerates the strength development of the experimental colonic anastomoses in dwarf rats indicating a potent role of growth hormone in colonic healing. However, GH is not essential in the healing process, since anastomotic healing in GH-deficient dwarf rats is like rats with normal pituitary function.

Recovery from the hepatic acute phase response in the severely burned and the effects of long-term growth hormone treatment

BACKGROUND

Administration of growth hormone (GH) to burned children decreases acute phase proteins and increases constitutive proteins when used during the acute hospitalization. Treatment during convalescence has not been examined.

METHODS

Seventy-six children with total body surface area burned (TBSAB) >/=40% were randomized to either placebo or GH (0.05 mg/kg/day) from discharge to 1 year after burn. Subjects were followed for an additional year. Levels of constitutive proteins and acute phase proteins were measured at discharge and 6, 9, 12, 18, and 24 months. Data are expressed as mean +/- S.E.M.

RESULTS

Albumin and transferrin levels increased during convalescence to the normal range but pre-albumin and retinol binding protein (RBP) levels remained below normal for at least 24 months. Acute phase proteins alpha(1)-acid glycoprotein, C-reactive protein, and haptoglobin decreased (P < 0.05) but alpha(2)-macroglobulin increased from discharge to 6 months. C-3 complement remained elevated for at least 2 years after burn. Changes were similar in both groups with no effect for GH treatment.

CONCLUSION

Some hepatic acute phase and constitutive proteins remain abnormal even 2 years after injury. GH treatment during convalescence has no effect on hepatic acute phase protein changes.

Dangers of growth hormone therapy in critically ill patients

Prolonged length of stay is the major challenge for modern intensive care because of the associated morbidity and the impact on resource utilization. Severe trauma or infection is associated with a catabolic response, which is characterized by increased protein turnover and negative nitrogen balance. Severe catabolism leads to end-organ dysfunction and muscular weakness, prolonging the need for mechanical ventilation. Catabolism cannot be prevented with standard parenteral or enteral nutritional formulas. In order to prevent the complications of catabolism in intensive care patients, recombinant growth hormone has been applied as an experimental therapy for two decades in patients requiring parenteral nutrition and in patients with respiratory failure. Administration of recombinant growth hormone has resulted in positive nitrogen balance, and studies in mechanically ventilated patients suggest that it may shorten the need for ventilatory support. In contrast to the results of these relatively small studies, a recent multinational randomized controlled trial revealed that the administration of recombinant growth hormone (with doses 10-20 times higher than used for replacement therapy) increases mortality of critically ill patients. The excessive mortality in patients treated with recombinant growth hormone was related to infections and development of multiple organ failure, leading to the conclusion that administration of high doses of recombinant growth hormone cannot be recommended for critically ill patients. This review reinforces that conclusion.

Treatment with growth hormone and insulin-like growth factor-I in critical illness

The wider availability of recombinant human growth hormone and insulin-like growth factor-I has resulted in an investigation into the potential benefits of the pharmacological administration of these anabolic peptides in a variety of clinical conditions, characterized by an increase in catabolic rate. The initial studies were small, often uncontrolled open investigations, but investigators have more recently concentrated on larger, controlled multi-centre trials. Studies to date have included patients with cardiac failure, sepsis, burns, cancer cachexia, end-stage renal failure, trauma and AIDS, and those prior to or following major surgery. The authors have in general cautiously interpreted positive effects of treatment with growth hormone and insulin-like growth factor-I, either alone or in combination, on net protein balance, body composition, well-being and performance. Two large, randomized, placebo-controlled European multi-centre studies have recently detailed the effects of growth hormone treatment in critically ill intensive care patients. Major increases in mortality and morbidity were associated with growth hormone treatment. The mechanism(s) accounting for the increased mortality remain poorly understood. These negative findings have led to a decrease in the clinical use of growth hormone and in research activity in the area of anabolic treatment in human illness.

Management of catabolism in metabolically stressed patients: a literature survey about growth hormone application

In the effort to improve the long-term outcome in critically ill patients, the utilization of anabolic agents, such as human recombinant growth hormone, has been proposed in order to reduce catabolism and improve nutritional status. A recent multicentre study regarding the use of human recombinant growth hormone in intensive care unit patients showed an unexpected increase in the mortality rate in human recombinant growth hormone-treated patients. This finding is in contrast with previous literature data reporting either no differences or an even lower mortality rate with the administration of human recombinant growth hormone. This review evaluates the possible reasons for this dramatic difference in outcomes between the multicentre study and the existing literature. Articles dealing with human recombinant growth hormone administration either in intensive care unit patients (n=26) or in postoperative patients (n=16) have been reviewed. Our analysis suggests that the low caloric intake given to patients enrolled in the multicentre study might have been inadequate to compensate for the hypermetabolism of these patients, and could not support the prolonged and delayed administration of high doses of human recombinant growth hormone. Whether the beneficial metabolic effects of human recombinant growth hormone translate into better clinical outcomes deserves further investigation. In addition, the careful selection of patients to be treated, and close monitoring of both the adequacy of caloric support and modality of human recombinant growth hormone administration would favour the safety of human recombinant growth hormone utilization in critical care settings.

Stimulation of human albumin synthesis and gene expression by growth hormone treatment

BACKGROUND AND AIMS

In this study the effects of acute (5 h) and short-term (5 days) GH treatment on albumin synthesis rates in man were investigated and related to changes in the availability of hepatic albumin mRNA.

METHODS

30 patients undergoing elective laparoscopic cholecystectomy were randomized into controls (n=10) or GH-treatment (12 U/dose) for 5 h or 5 days (n=10 in each group). Albumin mRNA levels (in liver biopsy specimens) were measured employing a quantitative polymerase chain reaction assay developed specifically for this purpose, whereas albumin synthesis was measured using [(2)H(5)]phenylalanine.

RESULTS

The fractional synthesis rate of albumin was 6.0+/-0.9 %/day in the control group and 8.0+/-1.8 %/day and 8.3+/-1.7 %/day in the GH-treated groups, respectively (P<0.05 vs controls in both cases). The corresponding values for the concentration of albumin mRNA were 2.6+/-1.1 ng/microg total RNA, 2.9+/-0.8 ng/microg total RNA (NS) and 4.7+/-1.8 ng/microg total RNA in the "GH 5" group (P<0.01 vs controls). The changes in albumin synthesis were only partly explained by the differences in hepatic albumin mRNA levels (r=0.5, P<0.01).

CONCLUSION

These results suggest that GH may induce a quick, gene expression-independent increase in albumin synthesis, which is sustained by a later-occurring increase in albumin gene expression.

Clinical applications of recombinant human growth hormone in adults

The main function of growth hormone (GH) is to promote linear growth during childhood; however, GH secretion persists throughout life after cessation of skeletal growth. This hormone has important physiological functions apart from growth stimulation. Many aspects of the physiological and pharmacological actions of GH have been recently clarified. Accordingly, in the last years, especially since the introduction of recombinant human GH (rhGH), GH therapeutical applications have increased. In the last years, the main clinical application of rhGH has been to stimulate growth of growth-retarded GH deficient (GHD) children. More recently, rhGH therapy has been approved for other conditions associated with short stature, including Turner syndrome and end stage renal disease. In adults, the only therapeutic indications approved are the adult GHD syndrome and the AIDS-associated wasting. This review outlines the present knowledge of the physiological effects, clinical applications, therapeutic perspectives, side effects, precautions and contraindications of rhGH therapy in adults.

Depression of liver protein synthesis during surgery is prevented by growth hormone

This study was undertaken to elucidate the specific effects of growth hormone (GH) on liver protein metabolism in humans during surgery. Otherwise healthy patients scheduled for elective laparoscopic cholecystectomy were randomized into controls (n = 9) or pretreatment with 12 units of GH for 1 day (GH 1, n = 9) or daily for 5 days (GH 5, n = 10). The fractional synthesis rate of liver proteins, as assessed by flooding with [2H5]phenylalanine, was higher in the GH 5 group (22.0 +/- 6.9%/day, mean +/- SD, P < 0.05) than in the control (16.1 +/- 3.1%/day) and GH 1 (16.5 +/- 5.5%/day) groups. During surgery, the fraction of polyribosomes in the liver, as assessed by ribosome analysis, decreased in the control group by approximately 12% (P < 0.01) but did not decrease in the GH-treated groups. In addition, the concentrations of the essential amino acids and aspartate in the liver decreased in response to GH treatment. In conclusion, GH pretreatment decreases hepatic free amino acid concentrations and preserves liver protein synthesis during surgery.

Perioperative growth hormone treatment and functional outcome after major abdominal surgery: a randomized, double-blind, controlled study

OBJECTIVE

To evaluate short- and long-term effects of perioperative human growth hormone (hGH) treatment on physical performance and fatigue in younger patients undergoing a major abdominal operation in a normal postoperative regimen with oral nutrition.

SUMMARY BACKGROUND DATA

Muscle wasting and functional impairment follow major abdominal surgery.

METHODS

Twenty-four patients with ulcerative colitis undergoing ileoanal J-pouch surgery were randomized to hGH (12 IU/day) or placebo treatment from 2 days before to 7 days after surgery. Measurements were performed 2 days before and 10, 30, and 90 days after surgery.

RESULTS

The total muscle strength of four limb muscle groups was reduced by 7.6% in the hGH group and by 17.1% in the placebo group at postoperative day 10 compared with baseline values. There was also a significant difference between treatment groups in total muscle strength at day 30, and at the 90-day follow-up total muscle strength was equal to baseline values in the hGH group, but still significantly 5.9% below in the placebo group. The work capacity decreased by approximately 20% at day 10 after surgery, with no significant difference between treatment groups. Both groups were equally fatigued at day 10 after surgery, but at day 30 and 90 the hGH patients were less fatigued than the placebo patients. During the treatment period, patients receiving hGH had reduced loss of limb lean tissue mass, and 3 months after surgery the hGH patients had regained more lean tissue mass than placebo patients.

CONCLUSIONS

Perioperative hGH treatment of younger patients undergoing major abdominal surgery preserved limb lean tissue mass, increased postoperative muscular strength, and reduced long-term postoperative fatigue.

Does growth hormone augment brain edema caused by brain injury? A study with a freeze brain injury model in the rat

OBJECTIVE

Because of the known sodium and water retention associated with growth hormone (GH) therapy, it is crucial to evaluate the safety of GH after brain injury. To clarify this issue, we investigated whether GH affects brain edema in a rat brain freeze-injury model.

METHODS

Male Wistar rats (n = 29) were divided into four groups according to the substance injected (GH vs. normal saline) and whether the brain was injured or not. The subcutaneous injections of GH (0.8 IU/kg) or saline were given 24 hours apart. In the injury groups, after the second injection, an aluminum rod (4-mm diameter) cooled to -50 degrees C was placed on the exposed dura mater in the right parietal region for 4 minutes, under anesthesia. At 4 hours after the insult, brain and skeletal muscle were excised and their water content was measured by drying.

RESULTS

Freeze injury of the brain caused an increase in water and sodium content in skeletal muscle. GH injection augmented this edema in skeletal muscle. Freeze injury of the brain also caused an increase in water and sodium content in the injured hemisphere of the brain. GH injection did not exacerbate this edema in injured brain tissue. Neither freeze injury nor GH injection caused brain edema in the noninjured hemisphere or in the cerebellum.

CONCLUSION

GH administration did not augment brain edema caused by brain injury in our model.

Transgenic rabbits overexpressing growth hormone develop acromegaly and diabetes mellitus

Transgenic rabbits expressing the bovine growth hormone (bGH) gene in liver and kidney were obtained to study the long-term effects of chronic exposure to GH in nonrodent animals. These rabbits presented high levels of bGH and insulin-like growth factor I in serum. In spite of chronic exposure to bGH, transgenic rabbits had similar body weight to controls. However, enlargement of the head and limbs and reduction of visceral fat were observed in these animals. They also showed marked hyperinsulinemia, hyperglycemia, and hypertriglyceridemia, indicating that they developed insulin resistance. Furthermore, serious histopathological alterations, including marked fibrosis, were observed in liver, kidney, and skeletal muscle. These anatomical, metabolic, and histological alterations closely resemble those found in patients with acromegaly. Thus, transgenic rabbits overexpressing GH may be a good model of the human disease.

Growth hormone treatment in pediatric burns: a safe therapeutic approach

OBJECTIVE

To determine the safety and efficacy of recombinant human growth hormone (rhGH) in the treatment of children who are severely burned.

SUMMARY BACKGROUND DATA

During the last decade, we have used recombinant human growth hormone (rhGH; 0.2 mg/kg/day s.q.) to successfully treat 130 children with more than 40% total body surface area (TBSA) burns to enhance wound healing and decrease protein loss. A significant increase in the mortality of adult patients in the intensive care unit who were given rhGH has recently been reported in two large European trials which questions the therapeutic safety of rhGH.

METHODS

The records of 263 children who were burned were reviewed. Patients receiving either rhGH at 0.2 mg/kg/day subcutaneously as part of a randomized clinical trial (n = 48) or therapeutically (n = 82) were compared with randomized placebo-administered controls (n = 54), contiguous matched controls (n = 48), and matched patients admitted after August 1997, after which no patients were treated with rhGH (n = 31). Morbidity and mortality, which might be altered by rhGH therapy, were considered with specific attention to organ function or failure, infection, hemodynamics, and calcium, phosphorous, and albumin balance.

RESULTS

A 2% mortality was observed in both rhGH and saline placebo groups in the controlled studies, with no differences in septic complications, organ dysfunction, or heart rate pressure product identified. In addition, no difference in mortality could be shown for those given rhGH therapeutically versus their controls. No patient deaths were attributed to rhGH in autopsies reviewed by observers blinded to treatment. Hyperglycemic episodes and exogenous insulin requirements were higher among rhGH recipients, whereas exogenous albumin requirements and the development of hypocalcemia was reduced.

CONCLUSIONS

Data indicate that rhGH used in the treatment of children who were severely burned is safe and efficacious.

Metabolic effects of adjuvant recombinant human growth hormone in patients with continuing sepsis receiving parenteral nutrition

BACKGROUND

Adjuvant growth hormone is advocated for treating the catabolism of prolonged sepsis not corrected by parenteral nutrition alone.

METHODS

An open study was performed in which eight patients whose postabsorptive resting energy expenditure was persistently elevated by a mean of 19% as a result of continuing sepsis were randomized to receive 0.03 or 0.06 mg/kg recombinant human growth hormone (rhGH) each evening for 7 days adjuvant to total parenteral nutrition. Plasma concentrations of growth hormone, insulin, insulin-like growth factors 1 and 2 (IGF-1 and -2) and their binding proteins IGFBP-1 and -3 were measured before and after rhGH, and their relationship with rates of whole-body protein turnover was determined in the morning in the postabsorptive state by using L-[1-13C]leucine.

RESULTS AND CONCLUSIONS

Before rhGH, the patients were hyperinsulinemic (mean, 44.4 mU/L) but had growth hormone levels within the normal range (< 10 mU/L). After the seventh dose of rhGH, nocturnal growth hormone concentrations rose to a mean of 35.3 +/- 26.1 and 61.3 +/- 21.05 mU/L for the low and higher dose groups, respectively. Morning IGF-1 concentrations showed a small increase during treatment, rising from a mean of 241.3 +/- 99.0 to 301.7 +/- 167.3 ng/mL for the low-dose group and from 214.5 +/- 74.6 to 294.1 +/- 116.9 ng/mL for the higher-dose group. IGF-2 increased slightly by 89 +/- 39 and 75 +/- 49 ng/mL for the low and higher doses, respectively. IGFBP-1 and -3 and insulin did not change. The balance between nitrogen input and urinary urea nitrogen increased after rhGH by a mean of 5.3 g/d with no differences between the two dosage groups (4.74 +/- 1.56 g/d for the higher dose, 5.94 +/- 3.70 g/d for the lower). No significant changes were observed in whole-body protein turnover after a 1-week course of rhGH.

Effect of growth hormone treatment on the healing of left colonic anastomoses in protein-malnourished rats

BACKGROUND

Malnutrition is known to affect wound healing but it is not known with certainty whether or not postoperative hyperalimentation can reverse this defect. The present study was designed to examine the effects of recombinant human growth hormone (hGH) on left colonic anastomoses in malnourished rats.

METHODS

Experimental animals were allocated randomly into four groups. In groups 1 and 2 animals were fed with normal diet for 10 days before surgery. In groups 3 and 4 animals were fed with a low-protein diet. Left colonic anastomoses were performed in all animals. Following surgery, rats in groups 1 and 3 received hGH whereas rats in groups 2 and 4 were injected with saline as control. Bursting pressure and hydroxyproline levels on day 4 after operation were used to determine anastomotic healing.

RESULTS

Bursting pressure was lower in the malnourished rats than those fed with normal diet (P< 0.05). Bursting pressure was higher in normally fed rats which were given hGH. No significant differences could be noted between malnourished control rats and those receiving hGH.

CONCLUSION

These results suggest that hGH strengthened the left colonic anastomoses in rats fed a normal diet, but could not reverse the negative effects of malnutrition on colonic anastomoses.

Growth hormone and insulinlike growth factor 1 promote intestinal uptake and hepatic release of glutamine in sepsis

OBJECTIVE

To study the effects of growth hormone (GH) and insulinlike growth factor 1 (IGF-1) on whole body and gastrointestinal (GI), hepatic, femoral, and renal glutamine (GLN) uptake and release in septic piglets.

SUMMARY BACKGROUND DATA

The GI metabolism of GLN is impaired during sepsis, and this may contribute to a breakdown of the gut's mucosal barrier. GH treatment has produced increased GI GLN uptake in surgical stress. Little is known about the effects of GH and IGF-1 in sepsis.

METHODS

Twenty-four piglets were randomized to three groups of eight each: a GH group received a bolus of 16 IU of Genotropin; an IGF-1 group received a continuous infusion of 1.3 mg/hour of IGF-1; and a control group received saline. After surgical preparation, sepsis was induced with live Escherichia coli bacteria. Using isotope technique, whole body turnover and organ-specific absolute uptake and release were measured before and 4 hours after sepsis.

RESULTS

After sepsis, both GH and IGF-1 treatment increased GI GLN uptake compared with controls and induced hepatic release of GLN. GLN release from skeletal muscle was diminished in all groups after sepsis. Whole body GLN turnover was increased in the GH and IGF-1 groups compared with the controls, before and after sepsis.

CONCLUSIONS

GH and IGF-1 treatment induced increased GI net uptake of GLN. GH and IGF-1 treatment also promoted absolute and net release of GLN from the liver. This release might facilitate increased GI uptake despite reduced hindleg release in the early phase of sepsis.

Acquired growth hormone resistance in adults

Acquired growth hormone resistance (AGHR) may be defined as the combination of a raised serum growth hormone (GH) concentration, low serum insulin-like growth factor-1 (IGF-1) concentration and a reduced anabolic response to exogenous GH. A wide range of conditions exhibit the syndrome to a variable degree, including sepsis, trauma, burns, AIDS, cancer, and renal or liver failure. The primary defect seems to be a reduction in IGF-1 concentration which then leads to increased GH concentration by a loss of negative feedback. It is not clear whether IGF-1 concentration falls because of decreased production or increased clearance from the circulation, or both. Treatment to reverse the biochemical defect by restoring IGF-1 levels, either by the administration of GH or IGF-1, has resulted in improvements in a wide range of metabolic parameters and, more recently, to definite clinical benefit in well-defined groups, such as patients with AIDS. These results cannot be extrapolated to other groups with AGHR as a recent unpublished report suggested increased mortality in critically ill patients treated with GH. Research needs to focus on the molecular basis of AGHR if we are to develop therapies for catabolism.

Hyperglucagonemia and the immediate fate of dietary leucine: a kinetic study in humans

The possible role of glucagon in determining the fate of dietary absorbed amino acids within the splanchnic bed was investigated in five healthy male volunteers. A kinetic study was performed involving a continuous 240-minute infusion of L-[5,5,5-2H3]leucine and D-[6,6-2H2]glucose by vein, while L-[1-13C]leucine was infused by a feeding tube into the duodenum (intragut [i.g.]) along with a constant intravenous (i.v.) infusion of somatotropin release-inhibitory factor (SRIF) combined with insulin, growth hormone, and glucagon. In random order, glucagon was infused at a rate of 0.4 ng x kg(-1) x min(-1) in one experiment and 1.2 ng x kg(-1) x min(-1) in the other experiment, while insulin and growth hormone were kept at constant serum levels, respectively, 37+/-13 pmol x L(-1) and 5+/-0.2 microg x L(-1). The diet was provided as an L-amino acid solution including 60 micromol x kg(-1) x h(-1) leucine without fat and carbohydrate. During the higher rate of glucagon infusion, there was an increase in plasma glucagon and glucose concentrations, glucose flux, and net dietary leucine release into the periphery from the splanchnic bed. Splanchnic removal and uptake of leucine were decreased with increased glucagon infusion. There were no statistical differences in the plasma leucine level and i.v. and i.g. leucine fluxes at the two glucagon levels, although leucine metabolic clearance increased (0.74 v 0.85 L x kg(-1) x h(-1), P=.08) in the case of glucagon excess. Plasma glucose increased with glucagon excess and was negatively correlated (P < .05) with the plasma leucine level (r=-.348) and i.v. (r=-.459) or i.g. (r=-.359) leucine fluxes. The negative correlation between plasma glucagon and leucine levels was also significant (r=-.684). No significant correlation was found between dietary leucine splanchnic removal and glucose, glucagon, or leucine plasma concentrations. We conclude that glucagon in excess has only a small quantitative effect on the overall handling of dietary leucine, and hypothesize that more leucine is exported to the peripheral tissues under these hormonal conditions.

Twenty-four-hour profile of growth hormone in cyclic nocturnal total parenteral nutrition

OBJECTIVE

To detect the effect of the loss of alimentation rhythmicity on a circadian rhythm of human growth hormone (HGH) secretion, a 24-hour profile of HGH was studied in a growing child on cyclic nocturnal total parenteral nutrition (TPN). Twenty-four-hour profiles of substrates and metabolic hormones were also studied to evaluate the efficiency of cyclic nocturnal TPN on childhood growth.

STUDY DESIGN

Periodic blood samples from a child with megacystis-microcolon-intestinal-hypoperistalsis syndrome were obtained on five occasions, at ages 6, 7, 8, 9, and 11, when she was on cyclic nocturnal TPN.

RESULTS

Peak HGH secretion appeared with the onset of deep sleep despite the concomitant hyperglycemia and hyperinsulinemia induced by TPN at night. Smaller peaks of HGH were also observed during the noninfusion period during the day. Twenty-four-hour profiles of substrates and metabolic hormones indicated a switch from glucose use during the infusion phase to an oxidation of lipids during the noninfusion period.

CONCLUSION

The fact that the patient's growth curve remains within normal limits suggests that cyclic nocturnal TPN would be an efficient method of nutritional support. During cyclic nocturnal TPN, regular rhythm of HGH secretion occurs, and normal childhood growth is achieved.

The role of IGFs in catabolism

The hypercatabolic response to trauma, extensive surgery and sepsis is characterized by an increased metabolic rate, severe muscle wasting and a negative nitrogen balance. This process of 'autocannibalism' may be in part a consequence of a disordered growth hormone (GH)/insulin-like growth factor (IGF) axis. In this chapter the normal physiology of the GH/IGF axis is first briefly reviewed. This is followed by a discussion of the changes that accompany fasting and catabolic illness, the effects of IGF-1 administration in health and disease and a comparison of the effects of IGF-1, GH and insulin on catabolism. Although initial investigations of IGF-1 administration in animals and human volunteers have often been encouraging, studies in catabolic patients have so far proved disappointing. Combined treatment with GH, IGF-1 (and insulin) or with IGF-1 and its major binding protein, may prove more effective, especially when used in conjunction with nutritional supplements such as glutamine.

Responsiveness of muscle protein synthesis to growth hormone administration in HIV-infected individuals declines with severity of disease

This study was undertaken to determine if human recombinant growth hormone (hrGH, 6 mg/d for 2 wk) would stimulate muscle protein synthesis in AIDS wasting. Healthy controls were compared with patients who were HIV+, had AIDS without weight loss, and had AIDS with > 10% weight loss. Before hrGH, rates of skeletal muscle protein synthesis, measured with l-[2H5]phenylalanine, were the same in controls and in all stages of disease. Rates of myofibrillar protein degradation, however, assessed from urinary excretion of 3-methyl histidine, were higher in AIDS and AIDS wasting than in HIV+ or healthy individuals. The group with weight loss had significantly higher TNFalpha levels but not higher HIV viral loads. Muscle function, as determined by isokinetic knee extension and shoulder flexion, was significantly higher in controls than all infected individuals. After GH, rates of protein synthesis were stimulated 27% in controls, with a smaller increase (11%) in HIV+, and a significant depression (42%) in AIDS with weight loss, despite fourfold elevation in insulin-like growth factor-I in all groups. There was a significant correlation of hrGH-induced changes in muscle protein synthesis with severity of disease (P = 0.002). The results indicate increased basal muscle protein degradation and decreased responsiveness of muscle protein synthesis to GH in the later stages of disease.

Administration of human recombinant insulin-like growth factor-I in critically ill patients

OBJECTIVES

To study the pharmacokinetics of a single subcutaneous dose of recombinant human insulin-like growth factor-I (IGF-I) in patients with systemic inflammatory response syndrome in the intensive care unit (ICU). To evaluate the effects of exogenous recombinant human IGF-I on circulating concentrations of IGF-I binding protein-1 (IGFBP-1), IGF-I binding protein-3 (IGFBP-3), and growth hormone in the critically ill patient; to assess the safety of the subcutaneous administration of 40 microg/kg of recombinant human IGF-I in these patients; and to investigate any effect this dose might have on nitrogen balance, creatinine clearance, and serum electrolyte and lipid concentrations.

DESIGN

Open-labeled, noncontrolled, prospective, single-dose study of eight fully evaluable ICU patients with systemic inflammatory response syndrome.

SETTING

ICUs in a teaching hospital and a linked district general hospital in England.

PATIENTS

Nine patients were examined, eight of whom were fully evaluable.

INTERVENTIONS

Subcutaneous administration of 40 microg/kg of recombinant human IGF-I.

MEASUREMENTS AND MAIN RESULTS

Blood samples were taken 24 hrs before the subcutaneous injection of 40 microg/kg of recombinant human IGF-I, and for 48 hrs thereafter. Urine was collected throughout this period. Serum concentrations of IGF-I, IGFBP-1, IGFBP-3, growth hormone, and insulin were measured by radioimmunoassay. IGF-I concentrations (median and range) increased significantly above baseline values (35 ng/mL [20 to 144]) from 15 mins (p < .02) until 10 hrs (p < .02) after injection of recombinant human IGF-I. Peak IGF-I concentrations were sustained from 2 hrs (90.5 ng/mL [23 to 228]) to 5 hrs (88.5 ng/mL [29 to 300]). By 24 hrs, circulating IGF-I concentrations had returned to baseline values. Baseline IGF-I concentrations were extremely low, and although peak values were three times greater, these values only approached the fifth percentile of defined reference ranges for normal values. Compared with values in less seriously ill patients, maximum IGF-I concentrations were reached earlier, the elimination half-life was shorter, clearance was more rapid, and the apparent volume of distribution was similar. IGFBP-3 concentrations also increased after recombinant human IGF-I injection, and at 3 to 4 hrs were significantly elevated, from 30 mins (p = .04) to 8 hrs (p = .04). There was marked between-patient variability in changes in circulating IGF-I, and IGFBP-1, and IGFBP-3 concentrations. More severely ill patients had the lowest circulating IGF-I concentrations and the least response to exogenous recombinant human IGF-I. Elevated baseline circulating growth hormone concentrations (2.3 ng/mL, range 0.8 to 4 [5.1 mU/L, 1.5 to 8]) were significantly depressed from 4 hrs (0.5 ng/mL, 0.5 to 1.5 [1 mU/L, 1 to 3], p = .01) to 6 hrs (0.8 ng/mL, 0.5 to 4 [1.5 mU/L, 1 to 8], p = .02) after recombinant human IGF-I administration.

CONCLUSION

We observed no adverse effects (e.g., hypoglycemia) that could be attributed to recombinant human IGF-I therapy.

Effects of growth hormone treatment in children with cystic fibrosis: the National Cooperative Growth Study experience

Poor longitudinal growth and low body weight affect many persons with cystic fibrosis (CF). The Cystic Fibrosis Foundation reports that 28% of all persons with CF are below the 10th percentile for height and that 34% are below the 10th percentile for weight. Intensive nutritional supplementation has not resulted in sustained improvement in the poor linear growth and low weight in CF. Because of the significant impact of nutrition in CF, the anabolic effects of growth hormone (GH) may make the agent useful as adjunctive treatment for malnutrition and poor linear growth. To date, 24 patients with CF (16 boys; 87% Tanner stage 1) have been enrolled in the National Cooperative Growth Study. The average age at enrollment was 10.3 years, and there was significant delay in height in all patients (mean height age, 7.1 years). Bone age was also significantly delayed (mean delay, 3.0 years). The mean maximum stimulated GH level was 12.3 micrograms/L and the mean GH dose given was 0.291 +/- 0.038 mg/kg per week. After 1 and 2 years of treatment with GH the growth rate increased in all patients with available growth rate data. The growth rates in these children were slightly lower than in children who were treated with GH for idiopathic GH deficiency. The weight-for-height standard deviation scores improved significantly after 2 years of GH treatment. There were adverse reactions (glucose intolerance) to GH in only two patients; treatment was suspended in one of these patients but was continued in the other. National Cooperative Growth Study data indicate that treatment with GH increases linear growth and weight in prepubertal patients with CF. These data suggest that GH may be useful for treating malnutrition in CF.

Effects of growth hormone and insulin-like growth factor-1 on protein metabolism, gut morphology, and cell-mediated immunity in burned rats

The effects of recombinant human growth hormone (GH) and insulin-like growth factor-1 (IGF-1) were investigated in burned rats. Sprague-Dawley rats were fed exclusively by total parenteral nutrition and were subjected to 20% third-degree scald burns. The rats were then divided into the following three groups: (1) the GH group received GH at a dose of 1 IU.kg-1.d-1 for 2d (n = 10); (2) the IGF group received IGF-1 at a dose of 4 mg.kg-1.d-1 for 2d (n = 19); and (3) the control group received saline (n = 17). Cumulative nitrogen balance increased significantly in the GH (P < 0.01) and IGF (P < 0.01) groups as compared with the control group. There were no differences in nitrogen balance between the GH and IGF groups. Blood glucose was decreased in the IGF group (P < 0.01) and increased in the GH group (P < 0.05) as compared with the control group. The intestinal villus height and wall thickness of the GH and IGF groups were significantly greater than those of the control group. Delayed-type hypersensitivity was enhanced in both the GH and the IGF groups as compared with the control group (both P < 0.01). Furthermore, the increase in the IGF group was significantly greater than that in the GH group (P < 0.05). It was concluded that both GH and IGF-1 improve protein metabolism and immune responsiveness, as well as promote proliferation of the intestinal mucosa.

Growth hormone modulates amino acid oxidation in the surgical patient: leucine kinetics during the fasted and fed state using moderate nitrogenous and caloric diet and recombinant human growth hormone

Twelve patients (aged 70 +/- 9 years) who were scheduled for resection of rectosigmoid colon adenocarcinoma but were otherwise healthy were randomly allocated after surgery to receive either peripheral parenteral nutrition alone ([PPN] n = 6) or in combination with recombinant human growth hormone (rGH) at a daily dose of 0.15 U x kg(-1) x d(-1)(PPN + rGH, n = 6). The daily nutritional regimen was 0.1 g nitrogen x kg(-1) x d(-1) and 20 kcal x kg(-1) x d(-1) (nonprotein energy was supplied as 60% lipid and 40% carbohydrate), and it was maintained for 6 days before and 6 days after surgery. Protein kinetics were studied in all 12 patients during the fasted and fed states before and 6 days after surgery using an 8-hour 13C-leucine tracer infusion. Daily urinary nitrogen, gaseous exchange, and plasma insulin, growth hormone, and insulin-like growth factor-I (IGF-I) were determined before and after surgery. Surgery was responsible for significant increases in postabsorptive whole-body protein flux and synthesis and leucine oxidation (P < .01). Supplementation of PPN with rGH contributed to a significant attenuation of the postoperative increase in leucine oxidation (P = .02), with a significant increase in whole-body protein synthesis (P = .02) and no effect on protein breakdown (P = .40). During the fed state, leucine oxidation increased significantly (P = .005), with the greatest change occurring in the PPN group. Feeding was associated with a significant decrease in whole-body protein breakdown before and after surgery in both groups (P = .001). Postoperative urinary nitrogen excretion was lower but was not statistically significant in the PPN + rGH group compared with the PPN group. There was a significant increase in oxygen consumption (VO2) and carbon dioxide production (VCO2) as a result of feeding and surgery (P < .01). Supplementation with rGH caused a decrease in the respiratory quotient (RQ) (P = .04), particularly after surgery, indicating a direct effect of rGH on fatty acid oxidation. Circulating plasma insulin increased significantly in both groups with feeding and rGH supplementation (P < .05). This was enhanced after surgery, particularly in the rGH group (P < .05). Plasma growth hormone decreased after surgery in the PPN group (P < .05), but did not change as a result of feeding. The circulating levels increased in the PPN + rGH group following subcutaneous administration before or after surgery. Plasma IGF-I decreased after surgery in the PPN group (P < .05), and no changes occurred in the PPN + rGH group with feeding. The present findings suggest a distinct positive effect of rGH on protein synthesis in catabolic patients receiving a moderate intake of nitrogen and calories. This is achieved by modulation of amino acid oxidation. The acute effect of intravenous (IV) nutrients on protein metabolism during the catabolic phase of surgical stress caused a direct decrease in protein breakdown with no effect on protein synthesis.

Combined insulin-like growth factor-1 and growth hormone improves weight loss and wound healing in burned rats

The anabolic effects of growth hormone (GH) in burned patients appear to act both directly and through insulin-like growth factor-1 (IGF-1). We, therefore, hypothesize that exogenous GH plus IGF-1 will attenuate increases in metabolism and lean muscle wasting while promoting wound healing.

MATERIALS AND METHODS

Rats, each weighing 440-470 g, were given a 35% total body surface area, full-thickness scald burn and divided into four groups to receive placebo (burned controls), bovine GH (2.5 mg/kg/day), IGF-1 (2.0 mg/kg/day), or bovine GH plus rhIGF-1 (2.5 + 2.0 mg/kg/day), respectively, for 8 weeks.

RESULTS

Total body weight gain after 8 weeks averaged 110 g for GH plus IGF-1 compared with gains of 49 and 11 g for GH or IGF-1 alone, respectively. Burned controls lost 24 g. Metabolic rates were significantly reduced in all groups receiving growth hormones. Gastrocnemius muscle dry weight was significantly increased in those receiving GH plus IGF-1 compared with GH and IGF-1 alone or burned controls (p < .01).

CONCLUSIONS

Data show that GH plus IGF-1 synergistically increased lean muscle weight, total body weight, and was more effective in re-epithelialization of the burn wound than either GH or IGF-1 alone.

Anabolic and cardiovascular effects of recombinant human growth hormone in surgical patients with sepsis

The clinical and metabolic effects of 7 days of recombinant human growth hormone (rhGH) and total parenteral nutrition (TPN) in surgical patients with sepsis were determined in a randomized controlled trial. In patients with a mean(s.e.m.) pretreatment rate of net protein catabolism (NPC) of 1.5 g per kg per day or less rhGH treatment decreased NPC from 0.93(0.14) to -0.20(0.24) g per kg per day (n = 5; P < 0.0005) and rendered these patients anabolic. TPN alone decreased NPC from 1.12(0.11) to 0.61(0.11) g per kg per day (n = 5; P < 0.001). In patients with an initial NPC of more than 1.5 g per kg per day rhGH treatment decreased NPC from 2.72(0.12) to 1.08(0.24) g per kg per day (n = 5; P < 0.001) while TPN alone decreased it from 2.41(0.32) to 1.28(0.28) g per kg per day (n = 5; P < 0.005). Use of rhGH was not associated with any adverse effects or improvement in clinical course but did decrease the mean systolic and diastolic pressures during the study period. Thus rhGH is a useful anabolic agent and may have a role in the haemodynamic management of the catabolic patient with sepsis.

Growth hormone and IGF-I therapy in the hypercatabolic patient

The use of exogenous GH to increase its circulating concentration, may benefit critically ill patients by increasing their nitrogen retention and promoting the wound healing process. GH also changes protein production in wounds, causes higher levels of insulin and changes substrate utilization. Its effects are anabolic, diabetogenic and lipolytic, acting through both direct and indirect mechanisms. The effects on carbohydrate and fat metabolism are directly mediated through specific GH receptors, while its effect on protein is mediated through IGF-I. Its effects on IGF-I production and the induction of IGF binding proteins are currently being studied in an effort to better understand the mechanism of GH actions during stress.

Insulin-like growth factor-I but not growth hormone attenuates dexamethasone-induced catabolism in parenterally fed rats

BACKGROUND

We demonstrated that recombinant human insulin-like growth factor-I (rhIGF-I) or growth hormone (rhGH) produces identical body weight gain during total parenteral nutrition (TPN) in surgically-stressed rats. Our current objective was to evaluate the relative anabolic and metabolic effects associated with administration of rhIGF-I and/or rhGH during hypocaloric TPN in rats with dexamethasone (DEX)-induced catabolism.

METHODS

Male Sprague-Dawley rats (approximately 270 g) given TPN and DEX were treated with IGF-I and/or GH for 6 days. Two control groups, TPN and DEX, were included. Anabolic response was assessed by change in body protein content and nitrogen balance. Metabolic response was assessed by determination of serum concentrations of IGF-I, IGF binding proteins (IGFBPs), insulin, glucose, triacylglycerol, glycerol, and free fatty acids.

RESULTS

Compared with GH, IGF-I attenuated DEX-induced loss of body protein and decreased serum concentrations of glucose, free fatty acids, glycerol, and triglycerol. Treatment with IGF-I plus GH showed an anabolic response similar to IGF-I alone. IGF-I and/or GH increased serum concentrations of IGF-I and IGFBP-3. IGF-I alone increased serum level of IGFBP-5.

CONCLUSION

Administration of IGF-I, but not GH, attenuates DEX-induced protein catabolism in association with increased insulin sensitivity in rats. Glucocorticoid excess may limit the response to GH therapy during TPN.

Insulin-like growth factor I accelerates protein synthesis in skeletal muscle during sepsis

Sepsis causes an inhibition of protein synthesis in gastrocnemius that is resistant to the anabolic effects of insulin. The purpose of the present studies was to investigate the effect of recombinant human insulin-like growth factor I (IGF-I) on protein synthesis during a 30-min perfusion of the isolated rat hindlimb from septic rats. Inclusion of IGF-I (1 or 10 nM) in the perfusate stimulated protein synthesis in gastrocnemius of septic rats 2.5-fold and restored rates of protein synthesis to those observed in control rats. The stimulation of protein synthesis did not result from an increase in the RNA content but was correlated with a 2.5-fold increase in the translational efficiency. The enhanced translational efficiency was accompanied by a 33 and 55% decrease in the abundance of free 40S and 60S ribosomal subunits, respectively, indicating that IGF-I accelerated peptide-chain initiation relative to elongation/termination. These studies provide evidence that IGF-I can accelerate protein synthesis in gastrocnemius during chronic sepsis by reversing the sepsis-induced inhibition of peptide-chain initiation.

Somatostatin prevents the postoperative increases in plasma amino acid clearance and urea synthesis after elective cholecystectomy

The importance of glucagon on postoperative changes in hepatic amino-nitrogen conversion were investigated in six patients undergoing elective cholecystectomy for uncomplicated gall stones. Patients were given infusions of somatostatin (bolus of 6 micrograms/kg followed by continuous infusion of 6 micrograms/kg/h) from induction of anaesthesia to the end of investigation, the first postoperative day (30 hours). Controls were 16 patients undergoing the same procedures omitting the somatostatin infusion. In all patients blood concentration and plasma clearance of total alpha-amino-nitrogen, and amino acid stimulated rate of urea synthesis were measured. Elective cholecystectomy decreased blood alpha-amino-nitrogen concentration from mean (SEM) 2.9 (0.2) to 2.4 (0.1) mmol/l (p < 0.05), increased the clearance of total alpha-amino-nitrogen from 5.2 (0.3) to 6.6 (0.3) ml/s (p < 0.05), and increased the rate of amino acid stimulated urea synthesis from 27 (1) to 37 (2) mumol/s (p < 0.05) pointing to increased hepatic removal of amino-nitrogen at expense of plasma amino-nitrogen. Infusion of somatostatin prevented increase of glucagon for 24 hours after surgery, and prevented the negative changes in postoperative nitrogen homeostasis resulting from the postoperative changes in hepatic nitrogen conversion, suggesting glucagon as mediator. The exact mechanism remains in doubt, however, because of the multiple effects of somatostatin.

Effects of human growth hormone in critically ill nonseptic patients: results from a prospective, randomized, placebo-controlled trial

OBJECTIVES

To study the effects of growth hormone administration on insulin-like growth factor I concentration, nitrogen balance, and fuel utilization, and to study its safety in critically ill nonseptic patients.

DESIGN

Prospective, randomized, placebo-controlled trial.

SETTING

Medical intensive care unit of a university hospital.

PATIENTS

Eighteen critically ill nonseptic patients were studied for 8 days after admission.

INTERVENTIONS

Growth hormone (0.1 mg/kg/day) or placebo was administered as a continuous intravenous infusion on the second, third, and fourth days after admission. The study period was 8 days.

MEASUREMENTS AND MAIN RESULTS

Plasma hormone concentrations were measured every 6 hrs and average daily values were calculated. The 24-hr urinary nitrogen and 3-methylhistidine excretion were measured. Indirect calorimetry was used to calculate fuel utilization. Insulin-like growth factor I concentrations increased in the treatment group from subnormal to normal values and remained increased despite discontinuation of growth hormone treatment (p = .02). Nitrogen balance differed between the groups upon admission: growth hormone group (3.9 +/- 4.1 g/day) vs. controls (13.8 +/- 5.4 g/day), but improved with growth hormone. This finding appeared independent of the imbalance between the groups. The 3-methylhistidine excretion was not different between the groups and did not change during growth hormone administration. Free fatty acids and glycerol concentrations increased during growth hormone treatment, but calculated fuel utilization did not change. During growth hormone treatment, insulin concentrations increased, due to the increased administration of insulin necessary for glycemic control. Side effects other than hyperglycemia were not observed.

CONCLUSIONS

Growth hormone administration in a heterogeneous group of critically ill nonseptic patients resulted in normalization of insulin-like growth factor I levels, even after cessation of growth hormone treatment. Nitrogen balance improved, but this change was transient. Hence, growth hormone affects nitrogen balance, probably partly independent of insulin-like growth factor I.

Effect of growth hormone and protein intake on tumor growth and host cachexia

BACKGROUND

Growth hormone supplementation has been shown to stimulate muscle protein synthesis and to improve nitrogen balance in a variety of catabolic states. The role of growth hormone to support the tumor-bearing host is complicated by the risk that growth hormone or its intermediaries may stimulate tumor growth. The purpose of this study is to examine the effect of growth hormone supplementation in tumor-bearing rats. This is studied in the protein-fed and protein-starved state in an attempt to isolate a selective benefit for the host over the tumor.

METHODS

Forty Lewis rats bearing a metastatic mammary adenocarcinoma (MAC-33) were divided into four groups: one receiving a regular diet plus saline solution, one receiving a regular diet plus growth hormone (1 IU/kg/day), one receiving protein-depleted diet plus saline solution, and one receiving a protein-depleted diet plus growth hormone. After 25 days of growth hormone treatment, animals were killed to determine primary tumor size, tumor/carcass ratio, host organ composition, pulmonary metastasis, and serum amino acid levels.

RESULTS

The tumor/carcass ratio was decreased as a result of growth hormone treatment in both the protein-fed and protein-starved groups. Growth hormone supplementation resulted in increased carcass weight, muscle weight, and muscle protein content in the protein-fed, tumor-bearing animals (p < 0.05). In the protein-starved, tumor-bearing rats growth hormone supplementation resulted in a significant decrease in tumor volume and tumor protein content. Amino acid analysis suggests that the amino acid tyrosine is a rate-limiting substrate for tumor cell proliferation in this model.

CONCLUSIONS

Growth hormone has a differential effect on tumor and host growth in the protein-fed and protein-starved state. Growth hormone supplementation inhibited tumor growth in protein-deprived animals. This is most likely accomplished indirectly by limiting amino acid substrate availability to the tumor.

[Role of anabolic hormonal factors in surgery in adults]

Hormonal agents with anabolic effect are virtually able to limit or even to counteract the adverse effects of stress and to act in synergy with nutritional support. Hormones with a high theoretic anabolic power include recombinant human growth hormone (rGH), insulin, insulin-like growth factor and testosterone. Other molecules favour anabolism in modifying the catabolic effect of diseases (anti-cytokines, beta-adrenoceptor agonists), in promoting intestinal absorption of substrates or in stimulating epithelial growth (EGF). The results of preliminary studies cannot be transferred into routine clinical practice. The rGH favours the preservation of body mass integrity and various functions. Therefore it could improve postoperative outcome and decrease the duration of hospital stay. A study in severely burnt children showed the metabolic benefits of rGH as well as a shortening of hospital stay because of a decrease of cicatrisation delay after skin grafting. Finally it demonstrated that rGH allows major financial savings in severe burns. The IGF-1 stimulates host defences and decreases the rate of wound infections. The rGH potentiates nitrogen sparing effect of IGF-1 and decreases hypoglycaemia induced by IGF-1. However a study on patients in stress is yet lacking. A combination of growth factors could be virtually efficient, however the cost seems exorbitant. An unquestionable evidence of their clinical efficiency is required before a clinical use in routine can be considered. The postoperative protein catabolism could be decreased by nandrolone decanoate or its derivatives. On the other hand, it has not been proven that protein synthesis, the muscle function or clinical prognosis can be improved by such a treatment.(ABSTRACT TRUNCATED AT 250 WORDS)