|
1
|
Cordido M, Juiz-Valiña P, Urones P, Sangiao-Alvarellos S, Cordido F. Thyroid Function Alteration in Obesity and the Effect of Bariatric Surgery. J Clin Med 2022; 11:jcm11051340. [PMID: 35268429 PMCID: PMC8911439 DOI: 10.3390/jcm11051340] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/26/2022] Open
Abstract
The most common endocrine disease in obesity is hypothyroidism and secondary endocrine alterations, including abnormal thyroid function, are frequent in obesity. It is unclear whether impaired thyroid function is the cause or the consequence of increased adiposity; furthermore, there are no clear data regarding the best way to dose levothyroxine for patients with both hypothyroidism and obesity, and the effect of bariatric surgery (BS). The aim of the present article is to review some controversial aspects of the relation between obesity and the thyroid: (1) Thyroid function in obesity and the effect of BS (2) Thyroid hormone treatment (THT) in obese patients with hypothyroidism and the effect of BS. In summary: In morbidly obese patients, TSH is moderately increased. Morbid obesity has a mild central resistance to the thyroid hormone, reversible with weight loss. In morbidly obese hypothyroid patients, following weight loss, the levothyroxine dose/kg of ideal weight did not change, albeit there was an increment in the levothyroxine dose/kg of actual weight. From a clinical practice perspective, in morbid obesity, diagnosing mild hypothyroidism is difficult, BS improves the altered thyroid function and THT can be adapted better if it is based on ideal weight.
Collapse
Affiliation(s)
- María Cordido
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Urgencias, Hospital Universitario A Coruña, 15006 A Coruña, Spain
| | - Paula Juiz-Valiña
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Paula Urones
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981178127 (S.S.-A. & F.C.); Fax: +34-981178204 (S.S.-A. & F.C.)
| | - Fernando Cordido
- Grupo Fisiopatoloxía Endócrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (M.C.); (P.J.-V.); (P.U.)
- Instituto de Investigación Biomedica (INIBIC), Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981178127 (S.S.-A. & F.C.); Fax: +34-981178204 (S.S.-A. & F.C.)
| |
Collapse
|
|
2
|
Juiz-Valiña P, Cordido M, Outeiriño-Blanco E, Pértega S, Urones P, García-Brao MJ, Mena E, Pena-Bello L, Sangiao-Alvarellos S, Cordido F. Evaluation of Thyroid Hormone Replacement Dosing in Morbidly Obese Hypothyroid Patients after Bariatric Surgery-Induced Weight Loss. J Clin Med 2021; 10:jcm10163685. [PMID: 34441981 PMCID: PMC8396870 DOI: 10.3390/jcm10163685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/05/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022] Open
Abstract
The most frequent endocrine disease in obese patients is hypothyroidism. To date, there are no clear data regarding what happens to the dose of levothyroxine (LT4) after bariatric surgery (BS). The objective of the present study was to evaluate thyroid hormone replacement dose in morbidly obese hypothyroid patients after BS-induced weight loss. We explore the best type of measured or estimated body weight for LT4 dosing. We performed an observational study evaluating patients with morbid obesity and hypothyroidism who underwent BS. We included 48 patients (three men). In morbidly obese hypothyroid patients 12 months after BS-induced weight loss, the total LT4 dose or the LT4 dose/kg ideal body weight did not change, while there was a significant increase in LT4 dose/body surface area, LT4 dose/kg weight, LT4 dose/kg adjusted body weight, LT4 dose/kg body fat, and LT4 dose/kg lean body weight. There were no differences in LT4 dose and its variation between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). The present study strongly suggests that LT4 dosing in obese hypothyroid patients can be individually adapted more precisely if it is based on ideal body weight.
Collapse
Affiliation(s)
- Paula Juiz-Valiña
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - María Cordido
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Elena Outeiriño-Blanco
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Sonia Pértega
- Unidad Epidemiologia Clínica y Bioestadística, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
| | - Paula Urones
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - María Jesús García-Brao
- Servicio Cirugía General y Digestiva, Hospital Universitario A Coruña, 15006 A Coruña, Spain; (M.J.G.-B.); (E.M.)
| | - Enrique Mena
- Servicio Cirugía General y Digestiva, Hospital Universitario A Coruña, 15006 A Coruña, Spain; (M.J.G.-B.); (E.M.)
| | - Lara Pena-Bello
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
| | - Fernando Cordido
- Grupo Fisiopatoloxía Endocrina, Nutricional e Médica (FENM), Facultad de Ciencias de la Salud, Universidade da Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (P.U.); (L.P.-B.)
- Instituto de Investigación Biomedica (INIBIC) and Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña, 15006 A Coruña, Spain
- Servicio Endocrinología y Nutrición, Hospital Universitario A Coruña, 15006 A Coruña, Spain;
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
| |
Collapse
|
|
3
|
Altered GH-IGF-1 Axis in Severe Obese Subjects is Reversed after Bariatric Surgery-Induced Weight Loss and Related with Low-Grade Chronic Inflammation. J Clin Med 2020; 9:jcm9082614. [PMID: 32806629 PMCID: PMC7463679 DOI: 10.3390/jcm9082614] [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] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022] Open
Abstract
Endocrine disorders are common in obesity, including altered somatotropic axis. Obesity is characterized by reduced growth hormone (GH) secretion, although the insulin-like growth factor-1 (IGF-1) values are controversial. The aim of this study was to evaluate the effect of weight loss after bariatric surgery in the GH–IGF-1 axis in extreme obesity, in order to investigate IGF-1 values and the mechanism responsible for the alteration of the GH–IGF-1 axis in obesity. We performed an interventional trial in morbidly obese patients who underwent bariatric surgery. We included 116 patients (97 women) and 41 controls (30 women). The primary endpoint was circulating GH and IGF-1 values. Circulating IGF-1 values were lower in the obese patients than in the controls. Circulating GH and IGF-1 values increased significantly over time after surgery. Post-surgery changes in IGF-1 and GH values were significantly negatively correlated with changes in C-reactive protein (CRP) and free T4 values. After adjusting for preoperative body mass index (BMI), free T4 and CRP in a multivariate model, only CRP was independently associated with IGF-1 values in the follow-up. In summary, severe obesity is characterized by a functional hyposomatotropism at central and peripheral level that is progressively reversible with weight loss, and low-grade chronic inflammation could be the principal mediator.
Collapse
|
|
4
|
Juiz-Valiña P, Cordido M, Outeiriño-Blanco E, Pértega S, Varela-Rodríguez BM, García-Brao MJ, Mena E, Pena-Bello L, Sangiao-Alvarellos S, Cordido F. Central Resistance to Thyroid Hormones in Morbidly Obese Subjects Is Reversed after Bariatric Surgery-Induced Weight Loss. J Clin Med 2020; 9:jcm9020359. [PMID: 32012985 PMCID: PMC7073690 DOI: 10.3390/jcm9020359] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
Endocrine abnormalities are common in obesity, including altered thyroid function. The altered thyroid function of obesity may be due to a mild acquired resistance to the thyroid hormone. The aim of this study was to investigate the effect of weight loss after bariatric surgery (BS) on resistance to thyroid hormones in patients with extreme obesity compared with a control group. We performed an observational study evaluating patients with extreme obesity who underwent BS. We included 106 patients (83 women) and 38 controls (24 women). The primary endpoint was the thyrotroph thyroxine resistance index (TT4RI) and thyroid stimulating hormone (TSH) index (TSHRI). The parameters were studied before and after surgery. TSHRI and TT4RI were higher in the obese patients than in the control group. TT4RI and TSHI decreased significantly over time after surgery, with this decrease being associated with the excessive body mass index (BMI) loss and C-reactive protein (CRP). In extreme obesity, BS promotes a significant decrease in the increased TT4RI and TSHI. This decrease of TT4RI and TSHI is progressive over time after BS and significantly associated with excess BMI lost and CRP. Extreme obesity is characterized by a mild reversible central resistance to thyroid hormones.
Collapse
Affiliation(s)
- Paula Juiz-Valiña
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
- CICA (Centro de Investigaciones Científicas Avanzadas), As Carballeiras, s/n Campus de, San Vicente de Elviña, 15008 A Coruña, Spain
| | - María Cordido
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
- CICA (Centro de Investigaciones Científicas Avanzadas), As Carballeiras, s/n Campus de, San Vicente de Elviña, 15008 A Coruña, Spain
| | | | - Sonia Pértega
- Clinical Epidemiology and Biostatistics Unit, University Hospital A Coruña, 15006 A Coruña, Spain;
| | - Bárbara María Varela-Rodríguez
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
- CICA (Centro de Investigaciones Científicas Avanzadas), As Carballeiras, s/n Campus de, San Vicente de Elviña, 15008 A Coruña, Spain
| | - María Jesús García-Brao
- Department of Digestive and General Surgery, University Hospital A Coruña, 15006 A Coruña, Spain (E.M.)
| | - Enrique Mena
- Department of Digestive and General Surgery, University Hospital A Coruña, 15006 A Coruña, Spain (E.M.)
| | - Lara Pena-Bello
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
- CICA (Centro de Investigaciones Científicas Avanzadas), As Carballeiras, s/n Campus de, San Vicente de Elviña, 15008 A Coruña, Spain
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
| | - Fernando Cordido
- Endocrine, Nutritional and Metabolic Diseases Group, Faculty of Health Sciences, University of A Coruña, 15006 A Coruña, Spain; (P.J.-V.); (M.C.); (B.M.V.-R.)
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, 15006 A Coruña, Spain
- CICA (Centro de Investigaciones Científicas Avanzadas), As Carballeiras, s/n Campus de, San Vicente de Elviña, 15008 A Coruña, Spain
- Department of Endocrinology, University Hospital A Coruña, 15006 A Coruña, Spain;
- Correspondence: (S.S.-A.); (F.C.); Tel.: +34-981-178-127 (S.S.-A. & F.C.); Fax: +34-981-178-204 (S.S.-A. & F.C.)
| |
Collapse
|
|
5
|
Effect of Weight Loss after Bariatric Surgery on Thyroid-Stimulating Hormone Levels in Euthyroid Patients with Morbid Obesity. Nutrients 2019; 11:nu11051121. [PMID: 31137484 PMCID: PMC6566754 DOI: 10.3390/nu11051121] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 12/14/2022] Open
Abstract
Obesity is associated with several endocrine abnormalities, including thyroid dysfunction. The objective of this study was to investigate the effect of weight loss after bariatric surgery on thyroid-stimulating hormone (TSH) levels in euthyroid patients with morbid obesity. We performed an observational study, evaluating patients with morbid obesity submitted to bariatric surgery. We included 129 patients (92 women) and 31 controls (21 women). Clinical, anthropometric, biochemical, and hormonal parameters were evaluated. The primary endpoint was circulating TSH (µU/mL). Fasting TSH levels were higher in the obese group (3.3 ± 0.2) than in the control group (2.1 ± 0.2). The mean excessive body mass index (BMI) loss (EBMIL) 12 months after bariatric surgery was 72.7 ± 2.1%. TSH levels significantly decreased in the obese patients after surgery; 3.3 ± 0.2 vs. 2.1 ± 0.2 before and 12 months after surgery, respectively. Free thyroxine (T4) (ng/dL) levels significantly decreased in the obese patients after surgery; 1.47 ± 0.02 vs. 1.12 ± 0.02 before and 12 months after surgery, respectively. TSH decreased significantly over time, and the decrement was associated with the EBMIL. In euthyroid patients with morbid obesity, weight loss induced by bariatric surgery promotes a significant decline of the increased TSH levels. This decrement of TSH is progressive over time after surgery and significantly associated with excess BMI loss.
Collapse
|
|
6
|
Salzano A, D'Assante R, Lander M, Arcopinto M, Bossone E, Suzuki T, Cittadini A. Hormonal Replacement Therapy in Heart Failure: Focus on Growth Hormone and Testosterone. Heart Fail Clin 2019; 15:377-391. [PMID: 31079696 DOI: 10.1016/j.hfc.2019.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A growing body of evidence led to the hypothesis that heart failure (HF) could be considered a multiple hormone deficiency syndrome. Deficiencies in the main anabolic axes cannot be considered as mere epiphenomena, are very common in HF, and are clearly associated with poor cardiovascular performance and outcomes. Growth hormone deficiency and testosterone deficiency play a pivotal role and the replacement treatment is an innovative therapy that should be considered. This article appraises the current evidence regarding growth hormone and testosterone deficiencies in HF and reviews novel findings about the treatment of these conditions in HF.
Collapse
Affiliation(s)
- Andrea Salzano
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK; Department of Translational Medical Sciences, Federico II University, Via Pansini 5, Naples 80138, Italy
| | | | - Mark Lander
- Department of Acute Medicine, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK
| | - Michele Arcopinto
- Department of Translational Medical Sciences, Federico II University, Via Pansini 5, Naples 80138, Italy; Emergency Department, A Cardarelli Hospital, Via Cardarelli 9, Naples 80131, Italy
| | - Eduardo Bossone
- Cardiology Division, A Cardarelli Hospital, Via Cardarelli 9, Naples 80131, Italy
| | - Toru Suzuki
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Antonio Cittadini
- Department of Translational Medical Sciences, Federico II University, Via Pansini 5, Naples 80138, Italy; Interdisciplinary Research Centre in Biomedical Materials (CRIB), Piazzale Tecchio 80, Naples 80125, Italy.
| |
Collapse
|
|
7
|
Salzano A, Marra AM, D’Assante R, Arcopinto M, Suzuki T, Bossone E, Cittadini A. Growth Hormone Therapy in Heart Failure. Heart Fail Clin 2018; 14:501-515. [DOI: 10.1016/j.hfc.2018.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
|
8
|
Treatment with Growth Hormone for Adults with Growth Hormone Deficiency Syndrome: Benefits and Risks. Int J Mol Sci 2018; 19:ijms19030893. [PMID: 29562611 PMCID: PMC5877754 DOI: 10.3390/ijms19030893] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/07/2018] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Pharmacological treatment of growth hormone deficiency (GHD) in adults began in clinical practice more than 20 years ago. Since then, a great volume of experience has been accumulated on its effects on the symptoms and biochemical alterations that characterize this hormonal deficiency. The effects on body composition, muscle mass and strength, exercise capacity, glucose and lipid profile, bone metabolism, and quality of life have been fully demonstrated. The advance of knowledge has also taken place in the biological and molecular aspects of the action of this hormone in patients who have completed longitudinal growth. In recent years, several epidemiological studies have reported interesting information about the long-term effects of GH replacement therapy in regard to the possible induction of neoplasms and the potential development of diabetes. In addition, GH hormone receptor polymorphism could potentially influence GH therapy. Long-acting GH are under development to create a more convenient GH dosing profile, while retaining the excellent safety, efficacy, and tolerability of daily GH. In this article we compile the most recent data of GH replacement therapy in adults, as well as the molecular aspects that may condition a different sensitivity to this treatment.
Collapse
|