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Binder G, Hähnel J, Weber K, Schweizer R. Adult height after treatment of neurosecretory dysfunction and comparison to idiopathic GHD. Clin Endocrinol (Oxf) 2022; 96:184-189. [PMID: 34647318 DOI: 10.1111/cen.14608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Neurosecretory dysfunction (NSD) causes growth hormone deficiency (GHD). Data on adult height after recombinant human growth hormone (rhGH) treatment are lacking. DESIGN AND PATIENTS We collected treatment data of all patients with NSD seen between 1990 and 2017 at our outpatient department (tertiary centre) and measured adult height. For comparison, patients with idiopathic GHD were used. Diagnoses were based on short stature (<-2 standard deviation score [SDS]), continuously low height velocity (<25th percentile), delayed bone age (by >1 SD) and low serum IGF-1 concentration (<-2 SDS). NSD was defined by normal GH challenge results, but subnormal spontaneous GH secretion. Exclusion criteria were no information on adult height, underweight and other short stature disorders. RESULTS Out of 67 patients diagnosed with NSD, six were still growing, 31 had test results exceeding validated GH cut-offs and three had other disorders causing short stature. Out of the 25 eligible patients with NSD, 21 could be recruited. These patients reached an adult height of -0.85 SDS (mean); 0.34 SDS below midparental height. Height gain during treatment was 2.01 SDS. This outcome was not different to 32 patients with idiopathic GHD. CONCLUSIONS Long-term results suggest the viability of the diagnosis of NSD and the efficacy of rhGH treatment.
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Affiliation(s)
- Gerhard Binder
- University-Children's Hospital Tübingen, Pediatric Endocrinology, Tübingen, Germany
| | - Julia Hähnel
- University-Children's Hospital Tübingen, Pediatric Endocrinology, Tübingen, Germany
| | - Karin Weber
- University-Children's Hospital Tübingen, Pediatric Endocrinology, Tübingen, Germany
| | - Roland Schweizer
- University-Children's Hospital Tübingen, Pediatric Endocrinology, Tübingen, Germany
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Inclusion and Withdrawal Criteria for Growth Hormone (GH) Therapy in Children with Idiopathic GH Deficiency—Towards Following the Evidence but Still with Unresolved Problems. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
According to current guidelines, growth hormone (GH) therapy is strongly recommended in children and adolescents with GH deficiency (GHD) in order to accelerate growth rate and attain normal adult height. The diagnosis of GHD requires demonstration of decreased GH secretion in stimulation tests, below the established threshold value. Currently, GHD in children is classified as secondary insulin-like growth factor-1 (IGF-1) deficiency. Most children diagnosed with isolated GHD present with normal GH secretion at the attainment of near-final height or even in mid-puberty. The most important clinical problems, related to the diagnosis of isolated GHD in children and to optimal duration of rhGH therapy include: arbitrary definition of subnormal GH peak in stimulation tests, disregarding factors influencing GH secretion, insufficient diagnostic accuracy and poor reproducibility of GH stimulation tests, discrepancies between spontaneous and stimulated GH secretion, clinical entity of neurosecretory dysfunction, discrepancies between IGF-1 concentrations and results of GH stimulation tests, significance of IGF-1 deficiency for the diagnosis of GHD, and a need for validation IGF-1 reference ranges. Many of these issues have remained unresolved for 25 years or even longer. It seems that finding solutions to them should optimize diagnostics and therapy of children with short stature.
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Influence of biochemical diagnosis of growth hormone deficiency on replacement therapy response and retesting results at adult height. Sci Rep 2021; 11:14553. [PMID: 34267285 PMCID: PMC8282600 DOI: 10.1038/s41598-021-93963-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated growth hormone deficiency (IGHD) is the most frequent endocrinological disorder in children with short stature, however the diagnosis is still controversial due to the scarcity of reliable diagnostic criteria and pre-treatment predictive factors of long term-response. To evaluate recombinant growth hormone (rGH) long-term response and retesting results in three different groups of children divided in accordance with the biochemical criteria of initial diagnosis. Height gain (∆HT) at adult height (AH) and retesting results were evaluated in 57 rGH treated children (M = 34, 59.6%) divided into 3 groups according to initial diagnosis: Group A (n = 25) with max GH peak at stimulation test < 8 µg/L, Group B (n = 19) between 8 and 10 µg/L and Group C (n = 13) with mean overnight GH < 3 µg/L (neurosecretory dysfunction, NSD). Retesting was carried out in all patients after at least one month off therapy upon reaching the AH. 40/57 (70.2%) patients were pre-pubertal at diagnosis and showed ∆HT of 1.37 ± 1.00 SDS, with no significant differences between groups (P = 0.08). Nonetheless, 46% patients in Group B showed ∆HT < 1SDS (vs 13% and 12% in Group A and C, respectively) and 25% children failed to reach mid-parental height (vs 6% and 0% in Group A and C, respectively). At AH attainment, IGHD was reconfirmed in 28% (7/25) and 10% (2/19) in Group A and B, respectively. A reduction of diagnostic cut-off at GH stimulation tests could better discriminate between "good" and "poor responders" and predict the persistence of IGHD through transition. Group C response and the predictive value of baseline IGF-I SDS bring back to light NSD: should we consider an underlying hypothalamic derangement when the clinical presentation is strongly consistent with IGHD but pharmacological stimulation test is normal?
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Lennartsson O, Nilsson O, Lodefalk M. Discordance Between Stimulated and Spontaneous Growth Hormone Levels in Short Children Is Dependent on Cut-Off Level and Partly Explained by Refractoriness. Front Endocrinol (Lausanne) 2020; 11:584906. [PMID: 33281744 PMCID: PMC7705110 DOI: 10.3389/fendo.2020.584906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/20/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND A growth hormone (GH) stimulation test is the recommended method for evaluating GH levels in children with possible GH deficiency (GHD). However, serial measurements of nocturnal spontaneous GH secretion are also performed. Divergent results from these tests have been reported, but with variable frequencies. OBJECTIVES To investigate whether performing one or two GH tests is associated with the probability to diagnose a child with GHD; the frequency of divergent results in the arginine-insulin tolerance test (AITT) and the nocturnal spontaneous test using different cut-off levels, and whether refractoriness may explain some of the discordance. METHODS In a population-based setting, the medical records of all short children evaluated for possible GHD during January 1993-February 2017 were reviewed. Twenty-one patients had been evaluated with one GH test only and 102 children had been evaluated with a spontaneous nocturnal GH test followed immediately by a complete AITT. Divergent results were defined as having a pathological response on only one of the tests when using 3, 5, 7, and 10 µg/L as cut-offs for peak GH on both tests, 1.1 and 3.3 µg/L for mean nocturnal values and receiver operating characteristic curves-derived cut-offs for nocturnal values. RESULTS Children evaluated with one test only were more often diagnosed with GHD compared with children evaluated with both tests (48 vs. 19%, p = 0.019). Divergent results were found in 6-42% of the patients, with higher frequencies seen when higher cut-offs were applied. A higher proportion of patients with stimulated peak values ≤ 7 and ≤ 5 µg/L had a spontaneous peak within 2 h before the start of the AITT compared with patients with higher stimulated peak values (68 vs. 45%, p = 0.026, and 77 vs. 48%, p = 0.033, respectively). CONCLUSIONS Divergent results between AITT and nocturnal spontaneous secretion are common in short children, dependent on the cut-offs applied and partly due to refractoriness. Performing both tests decreases the risk of over diagnosing GHD in short children.
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Affiliation(s)
- Otto Lennartsson
- Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
| | - Ola Nilsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Maria Lodefalk
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- *Correspondence: Maria Lodefalk,
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Meazza C, Elsedfy HH, Khalaf RI, Lupi F, Pagani S, Kholy ME, Tinelli C, Radetti G, Bozzola M. Serum α-klotho levels are not informative for the evaluation of growth hormone secretion in short children. J Pediatr Endocrinol Metab 2017; 30:1055-1059. [PMID: 28902627 DOI: 10.1515/jpem-2016-0464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/12/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND α-Klotho is a transmembrane protein that can be cleaved and act as a circulating hormone (s-klotho). s-Klotho serum levels seem to reflect growth hormone (GH) secretory status. We investigated the role of s-klotho as a reliable marker of GH secretion in short children and the factors influencing its secretion. METHODS We enrolled 40 short Egyptian children (20 GH deficiency [GHD] and 20 idiopathic short stature [ISS]). They underwent a pegvisomant-primed insulin tolerance test (ITT) and were accordingly reclassified as 16 GHD and 24 ISS. The samples obtained before and 3 days after pegvisomant administration, prior to the ITT, were used for assaying insulin-like growth factor (IGF)-I and s-klotho. RESULTS IGF-I and s-klotho serum levels were not significantly different (p=0.059 and p=0.212, respectively) between GHD and ISS. After pegvisomant, a significant reduction in IGF-I and s-klotho levels was found in both groups. s-Klotho significantly correlated only with IGF-I levels in both groups. CONCLUSIONS s-Klotho mainly reflects the IGF-I status and cannot be considered a reliable biomarker for GH secretion in children.
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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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Zadik Z. The lost honor of neurosecretory growth hormone dysfunction. J Pediatr Endocrinol Metab 2009; 22:767-8. [PMID: 19960885 DOI: 10.1515/jpem.2009.22.9.767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Costalonga EF, Jorge AAL, Mendonça BB, Arnhold IJP. [Mathematical models for predicting growth responses to growth hormone replacement therapy]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2008; 52:839-849. [PMID: 18797591 DOI: 10.1590/s0004-27302008000500016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 04/21/2008] [Indexed: 05/26/2023]
Abstract
Growth prediction models are algorithms derived from multiple regression analyses including variables that influence growth responses to GH therapy in a defined group of subjects over a defined period of time. Mathematical equations can be derived from the knowledge acquired with the relative importance of each variable, which provide objective measurements of each subject's growth potential in response to GH therapy on different situations. Therefore, these equations can be used as tools to improve evidence-based decision regarding to growth promoting treatment strategies to be used in each child, optimizing cost-effectiveness with the lowest cumulative GH dose. Several models have already been developed to predict growth responses to GH for different short stature causes, but they still have low clinical usefulness, due to their low predictive power and low prevision accuracy. This has lead to a growing interest in the addition of new variables, such as biochemical or genetic markers, which could improve prevision accuracy and then allow, in the future, GH therapy individualization according to the specific needs of each child.
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Affiliation(s)
- Everlayny F Costalonga
- Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
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Abstract
OBJECTIVE Provocative stimulation tests for GH assessment have poor reproducibility and can often elicit false positive results in normal children. The aim of our study was to evaluate the capability of pegvisomant, as an enhancer of GH secretion, in unmasking false-positive results in short children undergoing GH testing. DESIGN A prospective study was conducted between March 2005 and April 2006. PATIENTS Twenty-one short children (8 males and 13 females), aged 1.0-14.5 years, with a height of < 2 SD scores below the mean were included in the study. METHODS All subjects underwent an L-DOPA stimulation test with evaluation of GH. At the end of the test, 1 mg/kg of pegvisomant was given subcutaneously and 3 days later an L-DOPA stimulation test was repeated. RESULTS There was a significant decrease of IGF-I SDS following pegvisomant (-1.75 +/- 0.24 vs.-2.65 +/- 0.23; P < 0.0001) and a significant increase of the GH-peak (6.2 +/- 0.91 vs. 15.3 +/- 2.30 microg/l; P < 0.0001). Among the 21 patients examined, 18 (85.7%) had an insufficient response (< 10 microg/l) at the first stimulation. Ten of them (55.5%) showed normal secretion after priming with pegvisomant, while insufficient secretory reserve was confirmed in the remaining eight. CONCLUSIONS Pegvisomant priming before GH stimulation tests can be used to improve the reliability of the diagnostic work up in GH deficiency. Further studies are required, however, to clarify whether this procedure should be recommended in the routine evaluation of GH status.
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Affiliation(s)
- Giorgio Radetti
- Department of Paediatrics, Regional Hospital of Bolzano, Bolzano, Italy.
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Cole TJ, Hindmarsh PC, Dunger DB. Growth hormone (GH) provocation tests and the response to GH treatment in GH deficiency. Arch Dis Child 2004; 89:1024-7. [PMID: 15499055 PMCID: PMC1719706 DOI: 10.1136/adc.2003.043406] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify factors, particularly the growth hormone (GH) provocation test result, affecting growth response to GH treatment in children with GH deficiency (GHD). SUBJECTS A total of 337 prepubertal GHD patients aged <10 years from the UK Pharmacia KIGS database (GH response to provocation test <20 mU/l). OUTCOME MEASURE Annual change in height standard deviation score (SDS) (revised UK reference) in the first and second years of treatment. RESULTS Height increased by 0.74 SDS units (SD 0.39) in the first year of treatment and 0.37 units (SD 0.27) in the second. Adjusting for age, height, weight, midparent height, and injection frequency, the strongest predictor of first year growth response was the GH provocation test result; halving the result predicted an extra height increment of 0.09 units (p<0.0001). It predicted the second year response less well (p<0.0002) and after adjusting for the first year response was not predictive at all. CONCLUSIONS Among patients referred for possible GHD, the GH provocation test, though not a gold standard for diagnosis, is a valuable predictor of growth response in the first year of treatment. A year's treatment is recommended for cases with a marginal provocation test result, with the option to continue treatment if the response is adequate. The value of unified protocols for single or repeated provocation tests needs to be assessed.
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Affiliation(s)
- T J Cole
- Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College, London, UK.
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Affiliation(s)
- Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Department of Health and Human Services, Rockville, Maryland, USA.
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Zadik Z. Physiological but not pharmacological growth hormone tests predict adult height. Clin Endocrinol (Oxf) 2003; 59:25-6. [PMID: 12807499 DOI: 10.1046/j.1365-2265.2003.01816.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Zvi Zadik
- Pediatric Endocrine Unit, Kaplan Medical Center, Rehovot, Israel
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