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Inoue-Lima TH, Vasques GA, Nakaguma M, Brito LP, Mendonça BB, Arnhold IJP, Jorge AAL. A Bayesian Approach to Diagnose Growth Hormone Deficiency in Children: Insulin-Like Growth Factor Type 1 Is Valuable for Screening and IGF-Binding Protein Type 3 for Confirmation. Horm Res Paediatr 2021; 93:197-205. [PMID: 32799208 DOI: 10.1159/000509840] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The utility of insulin-like growth factor type 1 (IGF-1) is well established in the diagnosis of growth hormone deficiency (GHD), whereas IGF-binding protein type 3 (IGFBP-3) has a more controversial role. Most studies evaluated the value of these peptides by assessing their sensitivity and specificity but not considering the low prevalence of GHD among short children (<2%). OBJECTIVE To evaluate the utility of basal IGF-1 and IGFBP-3 values in the GHD diagnosis process with a Bayesian approach, based on pre- and post-test probability. METHODS We determined ROC curves, sensitivity, specificity, and positive and negative predictive values for IGF-1 and IGFBP-3 obtained from patients with GHD (n = 48) and GH-sufficient children (n = 175). The data were also analyzed by classifying the children into early childhood and late childhood (girls and boys younger and older than 8 and 9 years, respectively). RESULTS The area under the curve (AUC) of the receiver operating characteristic curve of IGF-1-SDS (standard deviation score) was greater than that of IGFBP-3-SDS (AUC 0.886 and 0.786, respectively, p = 0.001). In early childhood, the AUC of IGFBP-3-SDS was significantly improved (0.866) and similar to IGF-1-SDS (0.898). IGF-1-SDS, in comparison to IGFBP-3-SDS, had a greater sensitivity (92 vs. 45.8%, respectively), lower specificity (69 vs. 93.8%, respectively), and lower positive predictive value (5.7 vs. 13.1%, respectively), with similar negative predictive values. CONCLUSION IGF-1-SDS is a useful screening tool in the diagnosis of GHD. Although IGFBP-3-SDS lacks sensitivity, its high specificity supports the role to confirm GHD in short children, especially in early childhood. This strategy could simplify and reduce the necessity of a second laborious and expensive GH stimulation test to confirm the diagnosis of GHD.
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Affiliation(s)
- Thais H Inoue-Lima
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Gabriela A Vasques
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil.,Unidade de Endocrinologia Genetica (LIM/25), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Marilena Nakaguma
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Luciana Pinto Brito
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Berenice B Mendonça
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Ivo J P Arnhold
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil
| | - Alexander A L Jorge
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular (LIM/42), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil, .,Unidade de Endocrinologia Genetica (LIM/25), Hospital das Clinicas da Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, Brazil,
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Ibba A, Corrias F, Guzzetti C, Casula L, Salerno M, di Iorgi N, Tornese G, Patti G, Radetti G, Maghnie M, Cappa M, Loche S. IGF1 for the diagnosis of growth hormone deficiency in children and adolescents: a reappraisal. Endocr Connect 2020; 9:1095-1102. [PMID: 33112822 PMCID: PMC7774770 DOI: 10.1530/ec-20-0347] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/22/2020] [Indexed: 01/26/2023]
Abstract
A number of studies have evaluated the role of IGF1 measurement in the diagnosis of growth hormone deficiency (GHD). This study aimed to evaluate the accuracy and the best cut-off of IGF1 SDS in the diagnosis of GHD in a large cohort of short children and adolescents. One-hundred and forty-two children and adolescents with GHD ((63 organic/genetic (OGHD), 79 idiopathic (IGHD)) and 658 short non-GHD children (median age 10.4 years) were included in the analysis. The two groups were subdivided according to age (G1 <6, G2 6 <9, G3 9 <12, G4 ≥12) and to pubertal status. Serum IGFI was measured by the same chemiluminescence assay in all samples and expressed as age- and sex-based SDS. Receiver operating characteristic (ROC) analysis was used to evaluate the optimal IGF1 SDS cut-off and the diagnostic accuracy. Median IGF1 SDS was significantly lower in the GHD than in non-GHD patients. The area under the curve (AUC) was 0.69, with the best IGF1 cut-off of -1.5 SDS (sensitivity 67.61%, specificity 62.62%). The AUC was 0.75 for OGHD and 0.63 for IGHD. The accuracy was better in the pubertal (AUC = 0.81) than the prepubertal group (AUC = 0.64). In our cohort, IGF1 measurement has poor accuracy in discriminating GHD from non-GHD. Our findings confirm and reinforce the belief that IGF1 values should not be used alone in the diagnosis of GHD but should be interpreted in combination with other clinical and biochemical parameters.
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Affiliation(s)
- Anastasia Ibba
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Francesca Corrias
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Chiara Guzzetti
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Letizia Casula
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | | | - Natascia di Iorgi
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Gianluca Tornese
- SSD Endocrinologia Pediatrica, Clinica Pediatrica, IRCCS Materno-infantile Burlo Garofolo, Trieste, Italy
| | - Giuseppa Patti
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Giorgio Radetti
- Dipartimento di Pediatria, Ospedale Generale Regionale, Bolzano, Italy
| | - Mohamad Maghnie
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Marco Cappa
- UOC di Endocrinologia, Dipartimento Universitario Ospedaliero, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
- Correspondence should be addressed to S Loche:
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Chesover AD, Dattani MT. Evaluation of growth hormone stimulation testing in children. Clin Endocrinol (Oxf) 2016; 84:708-14. [PMID: 26840536 DOI: 10.1111/cen.13035] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/30/2015] [Accepted: 01/28/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the use and interpretation of growth hormone (GH) stimulation tests used across the UK for diagnosing GH deficiency. BACKGROUND Previous studies show poor consensus on the use of GH stimulation tests. Sex steroid priming and retesting in the transition period are areas not previously surveyed. DESIGN Data were collected from tertiary paediatric endocrinologists, paediatricians with a specialist interest in endocrinology and biochemists across the UK over 6 months through distributing electronic surveys. RESULTS At least three different GH stimulation tests were used by 33% of departments. Glucagon and insulin doses varied most, and sampling frequency varied most using insulin. All laboratories use a recommended chemiluminescence immunoassay with an acceptable coefficient of variability. The GH peak for diagnosing GH deficiency varied from 6 to 8 μg/l. A wide range of clinical scenarios prompted retesting in the transition period, suggesting nonstandardized current practice. Seventy-five per cent of departments use sex steroid priming, but follow criteria variously combining bone age, chronological age and pubertal stage, together with variations in steroid type and dose. CONCLUSIONS Although a contentious diagnostic test, GH stimulation tests remain the gold standard for diagnosing GH deficiency. Our data suggest that together with variation in indication, protocol and interpretation, there is considerable variation in current practices pertaining to priming and retesting in transition. Given the current financial climate and the need for careful resource management, this study emphasizes the considerable need for consensus in the investigation, diagnosis and long-term follow-up of these children, at least nationally if not internationally.
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Affiliation(s)
- Alexander D Chesover
- Department of Paediatrics, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - Mehul T Dattani
- Department of Paediatric Endocrinology, UCL Institute of Child Health/Great Ormond Street Hospital for Children/UCL Hospitals, London, UK
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Shen Y, Zhang J, Zhao Y, Yan Y, Liu Y, Cai J. Diagnostic value of serum IGF-1 and IGFBP-3 in growth hormone deficiency: a systematic review with meta-analysis. Eur J Pediatr 2015; 174:419-27. [PMID: 25213432 DOI: 10.1007/s00431-014-2406-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/08/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Serum insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3) are conventionally considered available for the diagnosis of growth hormone deficiency (GHD), but the results about their diagnostic values are inconsistent among some recent epidemiological studies. The aim of this study is to assess the diagnostic values of serum IGF-1 and IGFBP-3 for GHD by conducting a systematic review and meta-analysis. Studies on serum IGF-1 and IGFBP-3 used in GHD diagnosis were systematically searched from databases PubMed, EMBASE, and CNKI (up to December 2013). Characteristics of the studies and data were independently collected according to the inclusion criteria by two authors. The quality of included studies was assessed using quality assessment of diagnostic accuracy studies (QUADAS). Both sensitivity (SEN) and specificity (SPE) of IGF-1 and IGFBP-3 in GHD diagnosis were estimated on statistical software Meta-DiSc and Stata. A total of 12 studies were included for the final analysis. IGF-1 had SEN of 0.66, SPE of 0.69, positive likelihood ratio (PLR) of 2.48, negative likelihood ratio (NLR) of 0.51, area under the summary receiver operating characteristic curve (SROC) of 0.78, and Q* value of 0.72. Serum IGFBP-3 had SEN of 0.50, SPE of 0.79, PLR of 2.69, NLR of 0.64, area under SROC of 0.80, and Q* value of 0.73. CONCLUSION Serum IGF-1 and IGFBP-3 are useful for the diagnosis of GHD and can be utilized as auxiliary diagnosis indexes for provocative test.
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Affiliation(s)
- Yi Shen
- Department of Epidemiology and Medical Statistics, Nantong University, Nantong, Jiangsu, China,
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Tafuri KS, Wilson TA. Growth hormone deficiency and diabetes insipidus as a complication of endoscopic third ventriculostomy. J Clin Res Pediatr Endocrinol 2012; 4:216-9. [PMID: 23032148 PMCID: PMC3537290 DOI: 10.4274/jcrpe.801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 12/25/2012] [Indexed: 12/01/2022] Open
Abstract
Endoscopic third ventriculostomy (ETV) has become the procedure of choice for the treatment of obstructive hydrocephalus in children and adults. Endocrinological complications of ETV in children are rare. Diabetes insipidus (DI) is the most common and accounts for only 0.5% of complications from ETV. The majority of documented cases are transient. To date, there are no documented cases of multiple pituitary hormone deficiencies. We present here a 6-year-old girl with growth hormone deficiency and permanent DI which developed as a complication of ETV. This patient is unique in both demonstrating multiple pituitary hormone deficiencies and the classical triphasic response of DI after ETV. We postulate that these complications were caused by compression of the pituitary stalk and hypothalamic injury during the procedure. We compare our case presentation to experimental studies conducted in rats.
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Affiliation(s)
- Kimberly S. Tafuri
- Stony Brook University, Department of Pediatrics, Stony Brook Childrens Hospital, Division of Pediatric Endocrinology, Stony Brook, NY
,* Address for Correspondence: Stony Brook University, Department of Pediatrics, Stony Brook Childrens Hospital, Division of Pediatric Endocrinology, Stony Brook, NY Phone: +631 444-3429 E-mail:
| | - Thomas A. Wilson
- Stony Brook University, Department of Pediatrics, Stony Brook Childrens Hospital, Division of Pediatric Endocrinology, Stony Brook, NY
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Abstract
PURPOSE OF REVIEW We review recent developments in the therapy of growth disorders, focusing mainly on recent developments in the field of growth hormone (GH) therapy. RECENT FINDINGS Review of current practice reveals wide variation in the approach to short stature and the institution of GH therapy. No new indications for GH treatment have been approved by the Food and Drug Administration since 2007, but off-label use has been explored in several chronic illnesses. There is also increasing focus on GH effects beyond increase in stature (e.g. effects on body composition and bone density). As the experience with GH increases, the long-term risks and outcomes are better understood and risks appear to be low. Data regarding beneficial effects of GH in Prader-Willi syndrome are accumulating but questions remain about patient selection, start age and safety. Recombinant insulin-like growth factor 1 has become more widely available and has been aggressively promoted for Food and Drug Administration-approved indications as well as off-label uses in the last few years. The use of aromatase inhibitors has been tempered by concern about side-effects and lack of efficacy. SUMMARY Growth hormone remains the mainstay of therapy for growth disorders, though other options, including recombinant insulin-like growth factor 1, are being investigated in various settings.
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Affiliation(s)
- Omar Ali
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Smyczyńska J, Stawerska R, Lewiński A, Hilczer M. Do IGF-I concentrations better reflect growth hormone (GH) action in children with short stature than the results of GH stimulating tests? Evidence from the simultaneous assessment of thyroid function. Thyroid Res 2011; 4:6. [PMID: 21232100 PMCID: PMC3033853 DOI: 10.1186/1756-6614-4-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 01/13/2011] [Indexed: 11/12/2022] Open
Abstract
Background The diagnosis of growth hormone (GH) deficiency (GHD) in short children seems unquestionable when both GH peak in stimulating tests (GHST) and IGF-I concentration are decreased. However, the discrepancies between the results of GHST and IGF-I secretion are observed. It seems purposeful to determine the significance of GHST and IGF-I assessment in diagnosing GHD. The relationship between GH secretion and thyroid function, as well as GH influence on the peripheral thyroxine (T4) to triiodothyronine (T3) deiodination, mediated by IGF-I, were identified. Thus, clear differences in thyroid function between GH-deficient and non-GH-deficient subjects should exist. Methods Analysis comprised 800 children (541 boys), age 11.6 ± 3.1 years (mean ± SD), with short stature, in whom two (2) standard GHST (with clonidine and with glucagon) were performed and IGF-I, free T4 (FT4), free T3 (FT3) and TSH serum concentrations were assessed. The patients were qualified to the following groups: GHD - decreased GH peak in GHST and IGF-I SDS (n = 81), ISS - normal GH peak and IGF-I SDS (n = 347), low GH - normal IGF-I SDS, and decreased GH peak (n = 212), low IGF - decreased IGF-I SDS, and normal GH peak (n = 160). The relationships among the results of particular tests were evaluated. Results In the groups with decreased IGF-I concentrations (GHD Group and low IGF Group), the more severe deficit of height was observed, together with higher TSH and FT4 but lower FT3 levels than in groups with normal IGF-I concentrations (ISS Group and low GH Group), independently of the results of GHST. TSH, FT4 and FT3 concentrations were - respectively - similar in two groups with decreased IGF-I secretion, as well as in two groups with normal IGF-I levels. Significant correlations were found between patients' height SDS and IGF-I SDS, between FT3 and IGF-I SDS (positive), and between FT4 and IGF-I SDS (negative), with no correlation between GH peak and any of the parameters analyzed. Conclusion The assessment of thyroid function in children with short stature provides the evidence that measurement of IGF-I concentration may be a procedure reliable at least to the some degree in diagnosing GHD as the results of GHST.
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Affiliation(s)
- Joanna Smyczyńska
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Lodz, Poland.
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Leptin expression and leptin receptor gene polymorphisms in growth hormone deficiency patients. Hum Genet 2011; 129:455-62. [DOI: 10.1007/s00439-010-0941-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 12/22/2010] [Indexed: 12/13/2022]
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Tenenbaum-Rakover Y, Hujeirat Y, Admoni O, Khayat M, Allon-Shalev S, Hess O. Can auxology, IGF-I and IGFBP-3 measurements followed by MRI and genetic tests replace GH stimulation tests in the diagnosis of GH deficiency in children? J Pediatr Endocrinol Metab 2010; 23:387-94. [PMID: 20583544 DOI: 10.1515/jpem.2010.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS GH levels < 10 ng/ml in response to two different GH stimulation tests (GHSTs) are traditionally used to identify children with GH deficiency (GHD). Since GHSTs are imprecise, other diagnostic tools have been proposed. We assessed whether auxology, IGF-I and IGFBP-3 measurements followed by brain MRI and genetic analysis can replace the current diagnostic approach. METHODS Fifty-three children diagnosed with GHD by two different GHSTs. GH-1 gene was sequenced. RESULTS At presentation, 17% of patients were with height above -1.5 SD and 28% above -2.0 SD; 50% had IGF-1 concentration above -1.5 SD and 58% above -2.0 SD; 59% had pituitary anomalies demonstrated by MRI. Fourteen patients harbored the heterozygous R183H mutation, one patient had the N47D mutation and one had a novel F25Y mutation in GH-1. Using cut-off levels of -1.5 SD for height, IGF-I and IGFBP-3 excluded the diagnosis of GHD in 17, 68 and 79% of the children, respectively; a cut-off of -2 SD excluded 28, 88 and 96%, respectively. Further brain MRI and genetic tests excluded 81-96% and 96-100%, respectively, of children currently diagnosed with GH. CONCLUSION Use of the tested approach, which avoids carrying out two GHSTs, would exclude most children currently diagnosed with GHD. Until better tools become available, we recommend identifying GHD in children by an integrated approach combining phenotype, auxological parameters, hormonal measurements and two separate GHSTs, with MRI and genetic tests to support the diagnosis.
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