Effects of growth hormone administration in pediatric renal allograft recipients

Efficacy and safety of recombinant human growth hormone therapy in pediatric intestinal transplant recipients

BACKGROUND

Recombinant human growth hormone (rhGH) is widely used to treat growth retardation in children. We aimed to examine the effect of rhGH therapy on growth and its impact on allograft function in children with growth retardation after intestinal transplant (IT).

METHODS

We retrospectively included children younger than 19 years who had received an IT with or without the liver, were diagnosed with growth retardation, and have received rhGH between January 2010 and January 2021. Changes in the patient's anthropometric parameters between baseline and various time points were compared using the paired t-test or Wilcoxon signed-rank test, as appropriate.

RESULTS

Seven patients (all males and prepubertal) received rhGH for the median duration of 2.3 years. The median age at rhGH start was 9.5 years. The median growth velocity z-score improved from -0.95 before treatment to 2.3 (p = .04) and 1.9 (p = .06) after 1 and 2 years of treatment, respectively. The median height-for-age z-score significantly improved from -3.4 at rhGH start to -1.3 (p = .005) at rhGH stop and remained above baseline at the last visit (-2.4, p = .002). The change in the first-year growth velocity was negatively correlated with the change in the second-year growth velocity (r = -.90, p = .04). No serious adverse effects or worsening allograft function were observed.

CONCLUSIONS

Severely growth retarded children after IT could benefit from rhGH treatment. A larger, longitudinal study would be warranted to monitor the long-term effect and safety of rhGH and examine predictors of growth response to rhGH therapy in these pediatric IT recipients.

Glucocorticoids and the regulation of growth hormone secretion

Glucocorticoids modulate the secretion of growth hormone (GH) by various and competing effects on the hypothalamus and pituitary gland. The final effects of this modulation depend on hormone concentrations and the duration of exposure. The traditional hypothesis is that chronically raised levels of glucocorticoids suppress the secretion of GH. However, a functional impairment of the GH reserve might also be observed in patients with low levels of glucocorticoids, such as those with secondary hypoadrenalism, which is consistent with the model of biphasic dose-dependent effects of glucocorticoids on the somatotropic axis. This Review updates our current understanding of the mechanisms underlying the effects of glucocorticoids on the secretion of GH and the clinical implications of the dual action of glucocorticoids on the GH reserve in humans. This Review will also address the potential diagnostic and therapeutic implications of GH for patients with a deficiency or excess of glucocorticoids.

Management of growth retardation in pediatric recipients of renal allografts

Growth retardation frequently accompanies chronic kidney disease in children. Unfortunately, this retardation persists in magnitude despite assiduous therapeutic efforts, adequate dialytic intervention, and successful transplantation. The age of the patient at transplantation, allograft function, and corticosteroid dosage are the major factors that contribute to persistent suboptimal growth following renal transplantation. Recent data indicate that the use of recombinant human growth hormone might efficaciously improve growth velocity in the persistently growth-retarded allograft recipient. Attainment of optimum final adult height is predicated on optimum height at the time of transplantation, persistent optimum allograft function, minimization or avoidance of corticosteroid treatment, and, possibly, use of recombinant human growth hormone, especially to potentially maximize the pubertal growth spurt.

Long-term use of recombinant human growth hormone in pediatric allograft recipients: a report of the NAPRTCS Transplant Registry

Data from the NAPRTCS database were analyzed for growth, allograft function, and targeted adverse events (AE) over a 5-year period in 513 recipients who received recombinant human growth hormone (rhGH) treatment and compared with the outcome of 2,263 concurrent controls who did not receive rhGH. Recipients less than 10 years of age grew better than older recipients. Final adult height was superior in the rhGH-treated group compared with the control group. Allograft function and graft failure rate was similar in the rhGH-treated and control groups. No increased incidence of AE was noted in the rhGH-treated group. rhGH is effective and safe for use in growth-retarded pediatric renal allograft recipients.

Growth hormone can reverse glucocorticoid-induced low bone turnover on cortical but not on cancellous bone surfaces in adult Wistar rats

We evaluated the effect of glucocorticoids (GC) and growth hormone (GH) on cortical and cancellous bone turnover in adult rats using random vertical sections giving valid measurements of bone surfaces and bone formation parameters. GH administration could reverse GC-induced osteopenia and low bone turnover of cortical bone. However, GH could not reverse the GC-induced low bone turnover of cancellous bone.

METHODS

Seventy female Wistar rats, 7 months of age, were divided into five groups: (1) start control, (2) saline, (3) GC 9 mg/kg/day (Solu Medrol), (4) GH 5 mg/kg/day, and (5) GC 9 mg/kg/day + GH 5 mg/kg/day, and injected for 3 months. The vertebral body was examined using dynamic histomorphometry and biomechanical tests. Nonparametric methods were used.

RESULTS

Glucocorticoid administration induced a low bone turnover state of both the cortical and cancellous bone of the vertebral body, without altering the absolute amount of bone or the biomechanical competence of the vertebral body. GH administration induced a small increase in longitudinal bone growth and ventral modeling drift. This growth increased the total amount of cortical, endocortical, and cancellous bone in the vertebra. The biomechanical competence of a 3.5-mm-high cylinder of the central vertebral body was also increased due to an increase in the amount of cortical bone, whereas the total amount of cancellous bone in the cylinder was unaltered. The cancellous bone density (CBV) was, however, increased due to thicker trabeculae probably induced by an accelerated mineral appositional rate (MAR) induced by GH. GH also increased longitudinal and ventral modeling drifts in the GC-injected animals. GH increased the amount of cortical bone and also the amount of cancellous bone close to the epiphyseal growth plate, whereas the cancellous bone volume of the central vertebral cylinder was unaffected by GH administration in GC-injected animals. GH could also increase parameters of bone formation (bone mineralizing surface (MS) and MAR) on cortical bone surfaces in GC-injected animals, whereas parameters of bone formation [MS and bone formation rates (BFR)] on cancellous bone surfaces were even lower than those of animals injected with GC alone.

CONCLUSION

GH can reverse GC-induced low bone turnover on cortical but not on cancellous bone surfaces.

Current status of kidney transplant: update 2003

Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.

Recombinant human growth hormone post-renal transplantation in children: a randomized controlled study of the NAPRTCS

BACKGROUND

Growth retardation persists in renal allograft recipients despite successful transplantation. The etiology is multi-factorial including the adverse effects of corticosteroids, suboptimal allograft function, and perturbations of the GH/GF axis. Recombinant human growth hormone (rhGH) has been effective in improving growth velocity; however, allograft dysfunction has been reported. Therefore, a randomized controlled study was undertaken.

METHODS

Sixty-eight growth retarded pediatric renal allograft recipients were enrolled in a one-year randomized controlled study to determine the efficacy and safety of rhGH. A protocol biopsy was performed prior to enrollment.

RESULTS

After one year, the delta SDS (standardized height) was +0.49 +/- 0.10 in the treatment group (N = 30) compared to -0.10 +/- 0.08 in the control group (N = 22; P < 0.001). During the first year, there were no rejection episodes in the treatment group and three in the control group. After the first year, when all recipients were receiving rhGH, there were three patients in the treatment group and two patients in the control group who experienced an acute rejection episode. Prior to enrollment, more than one acute rejection episode was predictive of a subsequent rejection following enrollment. There was no difference in adverse events between the two groups.

CONCLUSION

In conclusion, rhGH is effective in improving the growth velocity of pediatric renal allograft recipients and is not associated with an increase in adverse events.

Linear growth after pediatric liver transplantation

To determine growth patterns in a large cohort of unselected children undergoing liver transplantation, the outcomes of 294 orthotopic liver transplantations performed in 221 children at The University of Chicago between October 1984 and October 1992 were retrospectively reviewed; 66% were alive at the time of this analysis. The mean age at transplantation was 4.1 +/- 5.0 years; 44% of the children were male and 16% of the transplants were from living-related donors. The mean height z score at the time of transplantation was -1.6 +/- 1.8, and 39% of children had height z scores of < -2.0 at transplantation. When children with growth retardation at the time of transplantation (height z scores of < -2. 0) were compared with children with more normal growth, there were no significant differences in gender or re-transplantation rates, although children with growth retardation at transplantation were significantly younger than those with more appropriate growth (2.8 +/- 4.1 years vs 4.7 +/- 5.1 years, P <.05). The height z score of all children with biliary atresia at the time of transplantation was -1.9 +/- 1.7 compared with -1.2 +/- 2.0 in those children with underlying diseases other than biliary atresia. Catch-up growth was seen in 37% to 47% of children at any given time point after transplantation. Children with evidence of catch-up growth (growth velocity z score >0) 2 years after transplantation were more likely to be first-time transplant recipients, had more growth retardation at the time of transplantation, and were receiving lower doses of prednisone at 2 years after transplantation. Younger children were most likely to demonstrate catch-up growth after transplantation. In summary, a large proportion of children have growth retardation at the time of liver transplantation. This growth retardation is inversely correlated with age. Before transplantation, children with biliary atresia grow less well than children with other forms of liver disease. Up to one half of children demonstrate catch-up growth after liver transplantation. Growth after transplantation is proportional to the degree of growth retardation at transplantation and inversely correlated to age at transplantation. Children with poor growth after transplantation are more likely to be receiving higher doses of corticosteroid.

Randomised controlled trial of recombinant human growth hormone in prepubertal and pubertal renal transplant recipients. British Association for Pediatric Nephrology

AIMS

To evaluate the efficacy (height velocity (HV), change in height standard deviation score (delta HSDS)), and safety (glomerular filtration rate (GFR), incidence of rejection, and calcium and glucose metabolism) of recombinant human growth hormone (rhGH) treatment after renal transplantation.

DESIGN

A two year randomised controlled trial.

SUBJECTS

Fifteen prepubertal and seven pubertal children: mean (SD) age, 13.0 (2.6) and 15.2 (2.4) years, respectively; mean (SD) GFR, 51 (30) and 48 (17) ml/min/1.73 m2, respectively. Six prepubertal and three pubertal children were controls during the first year; all received rhGH in the second year.

RESULTS

In the first year, mean (SE) HV and delta HSDS in the prepubertal treated group increased compared with controls: 8.1 (0.9) v 3.7 (0.6) cm/year and 0.6 (0.1) v -0.3 (0.2), respectively. In the pubertal treated group, mean (SE) HV and delta HSDS were also greater: 10.1 (0.6) v 3.9 (1.3) cm/year and 0.6 (0.1) v -0.1 (0.2), respectively. Comparing all treated and control children, there was no significant change in GFR: treated group, mean (SE) 9.9 (5.4) ml/min/1.73 m2 v control group, -1.6 (7.6) ml/min/1.73 m2. There were also no differences in the incidence of rejection in the first year: eight episodes in 13 patients v five episodes in nine patients, respectively. Phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and fasting insulin concentrations rose during the first year of treatment, but not thereafter. In the second year of treatment, HV remained above baseline.

CONCLUSION

Treatment with rhGH improves growth in prepubertal and pubertal children with renal transplants, with no significant change in GFR or the incidence of rejection. Phosphate, ALP, PTH, and insulin increased during the first year of treatment.

Treatment of peripubertal children after renal transplantation (RTX) with recombinant human growth hormone: auxological data and effects on insulin-like growth factor-I (IGF-I) and IGF-binding protein-3 (IGFBP-3) during 24 months

OBJECTIVE

To evaluate growth and endocrine parameters in RTX children with GH treatment during 24 months.

SUBJECTS

18 children (13 boys), age 13.1 yr (8.0-16.6), bone age 10.1 yr (5.4-15.3). Patients were 2.8 yr (0.5-7.5) after RTX and had immunosuppressive therapy, prednisone 0.16 mg/kg/d (0.08-0.68).

METHODS

GH (4 IU/m2/day s.c.) was given and patients were seen every 3 months for evaluation of height, height velocity, bone age, and hormone parameters. Serum IGF-I was determined by RIA, IGFBP-3 by RIA and Western ligand blotting (WLB). Renal function and adverse effects (GFR, glucose tolerance, rejection episodes) were monitored.

RESULTS

Height (+1 SDS) and height velocity (+2.2 SDS) increased significantly during 24 months GH treatment, but delta BA/delta CA was 1.7 and 1.5 during the first and second treatment year, respectively, and all patients entered puberty during the treatment period. GFR decreased slightly during 2 yr (p = 0.048), two patients had chronic rejection and GH therapy was terminated in one patient because of glucose intolerance. The ratio IGF-I/IGFBP-3 rose during the first year (p = 0.002) indicating more bioavailable IGF-I. IGFBP-3 determined by WLB was decreased, but IGFBP-1, -2 and -4 were elevated as compared to a standard.

CONCLUSIONS

GH treatment increased height and growth rate in children after RTX. This may be due to significant changes in IGF-I and IGFBP-3 relationship. However, bone maturation was also accelerated thus diminishing height potential. From month 12 to 24 a continuous decrease of IGF-I was observed. There was a slight but significant deterioration of graft function. Adverse events that led to termination of GH therapy were observed in 3 of 18 patients.

Body composition in children receiving recombinant human growth hormone after renal transplantation

BACKGROUND

Recombinant human growth hormone (rhGH) is an anabolic hormone promoting protein synthesis in various tissues. Therefore, changes in body composition may be expected during rhGH treatment.

METHODS

We studied changes in body composition during two years of rhGH treatment in 21 children after at least one year with a functioning renal transplant. The mean +/- SD age was 12.9+/-2.5 years at the start of rhGH therapy. A whole body, dual energy X-ray absorptiometry (DEXA) exam was performed before the initiation of rhGH therapy (T0), and was repeated at one and two year intervals after initiation of the therapy (T1 and T2, respectively).

RESULTS

Lean body mass increased by a median of 0.48 SDS during the first year of treatment (P = 0.022), and the median increase during two years of therapy was 0.36 SDS (P = 0.061). On the contrary, the median fat body mass decreased by 2.17 SDS during the T0 to T1 period (P = 0.04) and by 1.99 SDS during the T0 to T2 period (P = 0.055). The index for fat body mass/lean body mass (FBM/LBM) decreased by a median of 5.3% during T0 to T1 (P < 0.001), however, a slower but still significant decrease by a median of 4.2% was noted at T2 (P < 0.05). Bone mass content did not change significantly during rhGH treatment. The medians in caloric and protein intakes were stable during rhGH treatment.

CONCLUSION

A significant increase of lean body mass and a decrease of fat body mass was noted during rhGH therapy in children after renal transplantation.

[Graft function following renal transplantation in children]

BACKGROUND

Since renal transplantation is known to be the best choice for the growing child with end-stage renal failure, we prospectively evaluated early and late graft function in transplanted children.

POPULATION AND METHODS

The study included 78 children (32 girls, 46 boys) 10.4 +/- 0.6 years at the time of transplantation. Renal investigations were performed at 3, 6 and 12 months post-transplantation and yearly thereafter. Inulin clearance was used to evaluate the glomerular filtration rate (GFR), and the reabsorption rates of Na, P and Ca were measured concomitantly.

RESULTS

The overall adjusted GFR was approximately 70 mL/min/1.73 m2 and remained unchanged during the first 5 years post-transplantation. In the mean time the absolute GFR increased significantly, suggesting a remaining capacity for compensatory hypertrophy of the transplanted kidney. Renal function was significantly influenced by the number of rejection episodes during the first 2 years post-transplantation but no correlation was found between GFR and the number of HLA mismatches or the use of preemptive transplantation.

Growth-hormone treatment of renal transplant recipients: the National Cooperative Growth Study experience--a report of the National Cooperative Growth Study and the North American Pediatric Renal Transplant Cooperative Study

OBJECTIVE

To evaluate growth response and renal allograft measures after recombinant human growth-hormone (GH) treatment in pediatric renal transplant recipients.

STUDY DESIGN

Data on GH-treated children in the National Cooperative Growth Study (NCGS) database were linked to the database of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Data were analyzed for growth rate, graft survival, graft function, acute rejection, and adverse events. Data on 2390 transplant recipients in the NAPRTCS who had at least 24 months of graft function were used in the comparisons.

RESULTS

Fifty-nine patients were treated with GH after renal transplantation. One-year growth data were available for 42 of these; 2-year, for 31; and 3-year, for 13. Growth velocity increased from 2.47 +/- 1.83 cm/yr to 7.17 +/- 2.97 cm/yr after 1 year. Year-2 and -3 growth rates were 5.93 +/- 2.29 cm/yr and 6.31 +/- 2.32 cm/yr. Height standard deviation score immediately after transplantation was -3.26 +/- 1.44 and at the initiation of GH was -3.59 +/- 1.15; it increased to -3.18 +/- 1.06 at year 1 and to -3.16 +/- 0.92 at year 2 and was -3.31 +/- 1.00 at year 3. Five-year graft survival was 80% in the GH cohort and 85% in the NAPRTCS cohort. Acute rejection ratio was 1.44 and 1.43 episodes per patient in the GH and NAPRTCS cohorts, respectively. Calculated creatinine clearance at 6 years was 68 and 63 ml/min per 1.73 m2, respectively.

CONCLUSIONS

Growth hormone increase growth velocity for up to 3 years without an apparent decrease in graft survival or renal function, and no relation between GH therapy and acute rejection is seen. A randomized, prospective study to evaluate further the safety and efficacy of this promising therapy is required.

Growth hormone is safe in children after renal transplantation

With the availability of an easily produced and safely administered form of recombinant human growth hormone (GH), the clinical indications for its use have increased. Recent studies have shown that GH therapy is both safe and effective in the treatment of growth failure in children with chronic renal insufficiency. Similarly, GH has been used to treat growth failure in children after renal transplantation. GH therapy increases growth in these patients, but in some of them increased organ rejection or worsening of kidney function occurs. GH is a neuroendocrine peptide that is important to somatic growth, but it has also been shown to have pleiotropic effects on many cells and organ systems including the immune system. We have shown that GH in vitro augments the responses during a mixed leukocyte culture in normal adult volunteers. GH also augments the responses to donor-specific alloantigens in some patients. We conclude that if in vitro assays such as these can successfully identify those patients who are at risk for organ rejection and worsening kidney function, then GH therapy is safe in children with growth failure after renal transplantation.

Growth hormone treatment of children with chronic renal insufficiency, end-stage renal disease and following renal transplantation--update 1997

1. Long-term (> 5 years) hGH treatment in children with CRI produces sustained improvement in standardized height. 2. hGH treatment of infants (< 2 1/2 years of age) with CRI is as effective at improving growth velocity as in older children with CRI. 3. Once target height (50th percentile for midparental height) is reached the optimal approach is to pause hGH treatment and observe the patient. If standardized height declines significantly, hGH is effective when re-initiated. 4. Neither short-term nor long-term hGH treatment in children with CRI or in pediatric allograft recipients adversely impacts on carbohydrate tolerance; however, hyperinsulinemia develops which has not been associated with any clinical consequences to date. 5. The presence of renal osteodystrophy may blunt the impact of hGH and predispose to development of slipped capital femoral epiphysis and/or avascular necrosis in children with CRI. Pre-treatment radiologic evaluation and radiologic surveillance with clinical symptoms is indicated. 6. hGH is effective during the initial year of treatment; however the response may be blunted during subsequent years of treatment. The precise mechanism of the latter has not been delineated. 7. hGH has been shown to improve growth velocity in patients undergoing both peritoneal and hemodialysis; however, long-term data are lacking and the response may be less than that achieved in patients with CRI. 8. Growth velocity is uniformly improved in growth retarded pediatric renal allograft recipients receiving hGH. 9. Allograft dysfunction occurs following hGH treatment; however, the relationship to hGH treatment requires delineation. 10. The mechanism responsible for early allograft dysfunction which is usually reversible upon discontinuation of hGH is unknown. 11. Risk factors for the development of an acute rejection episode during the course of hGH treatment are > 1 prior rejection episode and the use of alternate day corticosteroid therapy. 12. The potential exists for an accelerated decline in allograft function following hGH treatment in recipients with chronic rejection. 13. The salutary effect of hGH in this patient population is probably related to increasing the bioavailability of ("free") IGF-I.

Growth hormone is not safe for children with renal transplants

Growth failure is an important problem in children with renal failure. Even after renal transplantation their growth rates may be lower than normal, and "catch-up" growth does not occur. Therefore there is great interest in giving growth hormone (GH) after transplantation. Clinical observations and theoretic considerations call into question whether GH after transplantation is safe. Studies have shown a more rapid than normal decline in renal function after the initiation of GH therapy. This result could be explained by the effects of GH on the immune response. Growth hormone is known to modulate (usually upregulate) the immune response and could be a reason for the increased loss of renal function caused by rejection. It could also be explained by the long-term effects of GH on the injured kidney. Experimental data (generally not in the transplantation model) suggest that exogenous GH given after renal injury or reduced renal mass leads to a more rapid development of glomerular sclerosis and reduced renal function. GH should not be administered to children after renal transplantation until all safety questions have been answered in prospective clinical trials.

Effects of recombinant human growth hormone on renal function in children with renal transplants

OBJECTIVE

To provide accurate measurement of renal function during treatment with recombinant human growth hormone (rhGH).

METHODS

We measured glomerular filtration rate and effective renal plasma flow by clearance of inulin and para-aminohippuric acid before rhGH therapy, after 1 week, and then at 6-month intervals for up to 2 years of treatment in 16 children (mean (SD) age = 13.1 (2.2) years; glomerular filtration rate = 52 (27) ml/min per 1.73 m2). The mean (SD) time from transplantation was 6.5 (3.6) years.

RESULTS

Linear growth velocity during rhGH therapy increased from 4.0 (1.8) to 8.8 (2.6) cm/yr (p < 0.0001). One child was withdrawn after 9 months because of abnormal glucose tolerance, and another child received a second renal transplant after 18 months. Glomerular filtration rate increased to 57 (29) ml/min per 1.73 m2 at 1 week (p = 0.004), remained improved at 6 months (63 (30); p = 0.013), but was not significantly better at 1 year (59 (33)). Effective renal plasma flow on day 1 was 237 (127) ml/min per 1.73 m2 and was unchanged on day 8 (244 (123)), at 6 months (271 (149)), and after 1 year (269 (157)). During the study there was no significant change in filtration fraction, blood pressure, or kidney volume, and excretion of microalbumin and N-acetylglucosaminidase was unaltered. There was one rejection episode per 14.8 patient-months in the year before treatment, 1 per 18.9 patient-months during the first year of treatment, and 1 per 13 patient-months during the second year of rhGH therapy.

CONCLUSION

Treatment with rhGH improves growth in children with renal transplants. Glomerular filtration rate was increased after 1 week and 6 months of rhGH therapy but returned to baseline values thereafter. The data indicate the need for long-term follow-up of children with renal transplants who are receiving rhGH.

Recombinant human growth hormone for children with renal failure

The pathogenesis of growth retardation in children with chronic renal failure (CRF) is clearly multifactorial. A major breakthrough in the understanding of the pathogenesis of uremic growth failure was achieved only recently by a more detailed analysis of the growth hormone (GH)/insulinlike growth factor (IGF) axis. Uremia is characterized by an insensitivity to the somatotropic action of GH. The mechanisms that account for this insensitivity include reduced hepatic GH receptor expression, decreased production of IGF-I, and inhibition of IGF bioactivity by increased binding of IGFs to their specific binding proteins. Recombinant human growth hormone (rhGH) in supraphysiological doses is able to overcome the partial GH resistance and to stimulate longitudinal growth under both experimental and clinical conditions. One possible mechanism of action of rhGH in uremia is the restoration of circulating IGF bioactivity, which results from the differential regulatory effect of rhGH on circulating IGF-I and IGFBP-3 concentrations. RhGH has proven to be an effective, safe, and well-tolerated new treatment modality for growth-retarded children at all stages of CRF. There is strong evidence that final height will increase in these children. Other than a modest chronic stimulation of insulin secretion, no frequent side effects have been observed; in particular, no acceleration in loss of residual renal function has been seen in children treated before the onset of end-stage renal failure. In children after transplantation, rhGH is also effective, but the potential risk of interference with graft function is not yet sufficiently defined.

Glucocorticoids and growth in asthmatic children

The effects of asthma and oral and inhaled glucocorticoid therapy on growth in children are reviewed. Previous reports have shown that asthma itself may delay the onset of puberty, an effect which may masquerade as growth suppression. Oral glucocorticoids appear to impair growth; however, lower doses and alternate-day therapy may have less risk of this effect. While a controversial topic, inhaled glucocorticoids in lower doses appear to be associated with a small risk of adverse effects on growth. Minimal data are available for higher doses. Knemometry, a relatively new technique used for measuring small changes in growth, has detected short-term effects with both oral and inhaled glucocorticoids therapy. However, a number of limitations are associated with short-term growth studies. Clinicians should be aware of the potential for growth impairment with glucocorticoid therapy so adequate monitoring can be undertaken and appropriate intervention introduced when deemed necessary.

Effects of growth hormone on kidney function in pediatric transplant recipients

Recent evidence suggests that treatment with recombinant human growth hormone (rhGH) after a successful kidney transplant improves the growth rate of children with short stature. We prospectively investigated eight children (6 boys, 2 girls), focusing on acute rejection episodes and changes in serum creatinine levels during rhGH treatment. The children (mean age 11.6 +/- 3.4 years) received rhGH daily (0.04-0.05 mg/kg subcutaneously). Seven patients completed at least 12 months (20 +/- 8 months) of rhGH treatment. Their mean serum creatinine level was 1.3 +/- 0.7 mg/dl 12 months before, and increased to 3.4 +/- 4.2 mg/dl after 12 months of rhGH treatment, but did not achieve statistical significance (P = 0.06). Their mean calculated glomerular filtration rate was 58 +/- 20 ml/min per 1.73 m2 12 months before, and decreased to 38 +/- 21 ml/min per 1.73 m2 after 12 months of rhGH treatment, but did not achieve statistical significance (P = 0.08). Of the seven patients, two developed acute rejection after 5 and 6 rejection-free years; three lost their grafts and returned to dialysis. These preliminary observations describe untoward renal events in children receiving rhGH treatment after a kidney transplant.

An analytical review of growth hormone studies in children after renal transplantation

With steady improvement in 1- and 5-year patient and graft survivals in the last decade, rehabilitation of the child is the major focus of the transplant physician. The notion that the elimination of the uremic milieu should enable children to grow has not been born out over time, and growth retardation continues to be a serious morbidity in many children despite a well-functioning renal allograft. In children with chronic renal failure prior to renal transplantation, recombinant human growth hormone (rhGH) has been recently shown in controlled trials to improve growth. The use of rhGH in children after renal transplantation is controversial, since uncontrolled studies have questioned its safety. Acute rejection and graft loss have been reported in children after the initiation of rhGH. This study analyzes the data regarding the safety and efficacy of rhGH in children after renal transplantation as presented in seven current published reports. The demographic characteristics of the patients, the dose and duration of rhGH therapy, the "growth" rates of the patients before and after rhGH therapy, renal function before and after rhGH therapy, and other possible complications are reviewed. Based on this analysis, suggestions for future studies are made.

Prednisone dose limitation of growth hormone treatment of steroid-induced growth failure

Seven children with prednisone-induced growth failure were treated with recombinant growth hormone to improve linear growth. Six of seven patients had an increase in linear growth during therapy with recombinant growth hormone. The response to recombinant growth hormone was found to be related to the prednisone dose. When the prednisone dose was greater than 0.35 mg/kg per day, recombinant growth hormone did not increase the linear growth rate. At lower doses the response was inversely related to the amount of prednisone taken.

The use of recombinant human growth hormone in short children with chronic renal failure

Regulation of the somatotropic axis is altered in chronic renal failure (CRF) resulting in a secondary syndrome of growth hormone (GH) insensitivity. Secretion of growth hormone estimated by deconvolution analysis is low normal in prepubertal patients and reduced in late pubertal children with CRF. Basal and integrated GH serum concentration measured by RIA is increased due to reduced renal metabolic clearance, whereas the fractional urinary excretion is increased due to damage of renal tubular cells. GH receptor mRNA is decreased (rat) and the serum concentration of GH binding protein (BP) activity is low (man). Insulin-like growth factor (IGF)-1 production rate is reduced, whereas serum concentrations of IGFBPs are increased secondary to reduced renal metabolic clearance. This results in a reduction of free, active IGF-1. Treatment with GH induces a rise in serum IGF-1 concentration and normalizes IGF bioactivity. Clinical studies in prepubertal children demonstrated a dramatic rise in height velocity during the first treatment year and to a lesser extent during the following years. In children on conservative treatment prior to dialysis, mean height SDS improved by 1.5 within two years and by 2.0 within four years. Patients with renal allografts responded in a similar way. Age and pretreatment height velocity SDS are confounding variables for the response to GH. Renal function seems not be altered by recombinant human (rh) GH in patients with CRF, and the number of renal allograft rejection crises seems not to be substantially increased under rhGH treatment in allograft recipients.

Triple immunosuppression with subsequent prednisolone withdrawal: 6 years' experience in paediatric renal allograft recipients

Thirty-four children (< or = 15 years of age) with end-stage renal failure received 39 renal allografts between 1985 and 1991 and were treated with cyclosporin A (CyA), azathioprine and low-dose prednisolone (PNL). We aimed to withdraw PNL by 6 months after transplantation. Median duration of follow-up was 2 years 4 months (range 0.1 month to 6 years 4 months). There were no deaths. Crude graft survival for living-related grafts (n = 9) was 100%, although only 1 patient has been followed for > 2 years. For cadaveric grafts (n = 30), 1- and 5-year actuarial graft survivals were 90% and 79% respectively. At 12 months posttransplant, the median (range) glomerular filtration rate for all patients was 63 (19-109) ml/min per 1.73 m2 (n = 25) and at 5 years was 48 (17-64) ml/min per 1.73 m2 (n = 9). Complications observed included rejection episodes which occurred after discontinuation of PNL. Long-term (after 12 months), 28% of patients remain on PNL. Hypertension was present in more than 50% of patients. Severe CyA nephrotoxicity was not seen. Catch-up growth as determined by the change (delta) in mean height standard deviation score (Ht-SDS) was noted at 1 year [delta SDS/year = +0.60; P < 0.001 (n = 18)] and at 2 years [delta SDS/year = +0.27; P < 0.01 (n = 16)] in pre-pubertal patients. The median Ht-SDS at 2 years for pre-pubertal children was -0.71 SD and growth velocity did not improve thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)