Delayed puberty in uremia: pituitary-gonadal function during short-term pulsatile luteinizing hormone-releasing hormone administration

Sexual maturity of children on regular hemodialysis: Role of testosterone and estradiol, a tertiary multicenter experience

A big problem is the delayed growth and sexual maturity in children with chronic kidney disease (CKD) with the consequent reduction in adults' height. Testosterone and estradiol have significant physiologic changes in children suffering from CKD, resulting in delayed puberty. We aim to assess blood levels of these hormones in patients with CKD-5 on regular hemodialysis.One hundred-six participants were enrolled in the current study, 56 of whom had CKD on hemodialysis 3 times a week 4 hours per session, and 60 healthy age- and gender-matched children acted as controls. Full history was taken, and a clinical review was performed on both patients and controls. The pubertal assessment was performed according to Tanner's classification and laboratory investigations of total and free serum (s.) testosterone in boys and s.estradiol in girls.Patients' weight and height were considerably lower than controls. The free and total s.testosterone of patients were significantly reduced. The same applies to s.estradiol levels which were substantially reduced in comparison to controls. In both patients and controls, Tanner staging & male total s.testosterone levels and female s.estradiol levels had significant positive associations. There was a negative association between the sex hormones levels and the disease's and dialysis duration in the patients' group.S.testosterone and s.estradiol levels were significantly low in CKD patients on dialysis and were positively correlated with delayed pubertal growth observed in those patients.

Serum leptin levels in males with delayed puberty during short-term pulsatile GnRH administration

Leptin may be a possible trigger for puberty. In normal males, it has been shown that leptin increases from the pre-pubertal to the early pubertal stage, and then declines in the late pubertal stage. We examined leptin levels in six male adolescents (mean age 16.3+/-0.6 yr; range 14.2-17.6 yr) with delayed puberty (constitutional delay of puberty no.=2; idiopathic hypogonadotropic hypogonadism no.=4) during 120 days of subcutaneous pulsatile GnRH administration. A group of subjects in pre-puberty (no.=11), early-puberty (n=10) and mid-puberty (no.=7) were evaluated as controls. Morning blood samples were taken for determination of leptin, testosterone, LH and FSH levels. In delayed puberty subjects blood samples were taken every 30 days after the start of GnRH administration. At each examination BMI and testicular volume were evaluated. A follow-up examination was performed in the 6 patients 1.3-7.5 yr after the end of the 120 days of GnRH therapy. At baseline evaluation in delayed puberty mean leptin levels were 11.3+/-2.0 microg/l (median 11.3 microg/l; range 4.7-17.3 microg/l) and were higher than those found in pre-puberty (p=0.04) and mid-puberty (p=0.001). During GnRH administration there was no change in BMI and leptin levels but there was an increase in gonadotrophin levels, testosterone and testicular volume. One hundred and twenty days after, mean serum leptin were 10.1+/-2.1 microg/l (median 9.1 microg/l; range 3.4-16.8 microg/l). At the end of the study, leptin levels were higher in delayed puberty than in mid-puberty (p=0.002). At the follow-up examination leptin levels were 4.3+/-1.3 microg/l (median 3.4 microg/l; range 1.4-9.1 microg/l) (p=0.03 vs end of 120 days GnRH therapy) while testosterone and BMI were not changed. In conclusion 120-day pulsatile GnRH administration induced in males with delayed puberty physiological-like pubertal changes but not the decline in leptin levels reported during the progression of puberty. Therefore, in males with delayed puberty an impairment in the phenomenon of leptin decline associated with progression of puberty could be suggested. However after retrospective diagnosis of pubertal delay and long-term therapy in subjects with idiopathic hypogonadotropic hypogonadism leptin levels declined. These data seem to indicate that time more than increase in testosterone levels and testicular volume is the determinant of leptin decline at puberty.

Androgen therapy in chronic renal failure

Chronic renal failure, dialysis and transplantation have major effects on male reproductive health because of the impairment of spermatogenesis, steroidogenesis and sexual function. Hypothalamo-pituitary testicular dysfunction in uraemia is manifest clinically as delayed growth and puberty, sexual dysfunction, androgen deficiency, impaired spermatogenesis and infertility. Apart from renal anaemia, there are at present no proven indications for androgen therapy in chronic renal failure. This chapter reviews the basis and scope for various clinical applications of gonadotropin and androgen therapy as an adjunct to the standard medical care of chronic renal failure. The therapeutic possibilities implied by experimental and clinical findings suggesting that uraemic hypogonadism may be a functional state of gonadotropin deficiency are emphasized.

Central precocious puberty and chronic renal failure: a reversible condition post renal transplantation

A 3 year-old boy with chronic renal failure associated with prune belly syndrome who developed central precocious puberty is described. He had been maintained on cyclic peritoneal dialysis from age 13 months with creatinine levels of 400-600 mumol/l. Increased linear growth rate probably began at 18 months, and by 38 months of age he had testicular enlargement and pubic hair consistent with Tanner stage 2. Elevated levels of serum testosterone (3.6 nmol/l; normal < 0.7 nmol/l) and luteinizing hormone (LH) (2.8 IU/l; normal < 1.0 IU/l) were demonstrated with a pubertal response to luteinizing hormone-releasing hormone (LHRH) stimulation (peak LH 43.5 IU/l). Other endocrine tests demonstrated hyperprolactinemia (170 micrograms/l; normal 3.4-22 micrograms/l), but normal pituitary-thyroid and pituitary-adrenal functions and normal cranial MR imaging. Despite LHRH-agonist therapy with leuprolide over the next 8 months, he showed an incomplete response with only partial inhibition of basal LH and testosterone levels, and continued significant increments in height standard deviation scores (Ht-SDS) and bone age estimates. However, the sexual precocity appeared fully reversible following a successful living-related renal transplant at age 50 months. Despite discontinuation of leuprolide treatment post-operatively, there was a full reversal of his serum LH and testosterone to a prepubertal profile as well as normalization of the serum prolactin levels. Whereas most boys with chronic renal failure show delayed pubertal development and suppressed linear growth, our patient presents a unique phenomenon of reversible central precocious puberty. The effects of leuprolide therapy in the presence of a uremic milieu and the outcome of successful renal transplantation on sexual precocity are described.