Growth hormone treatment in children with chronic renal failure: a meta-analysis of randomized controlled trials

The Role of Growth Hormone in Chronic Kidney Disease

Growth hormone (GH) has become a critical therapy for treating growth delay and failure in pediatric chronic kidney disease. Recombinant human GH treatment is safe and significantly improves height and height velocity in these growing patients and improved growth outcomes are associated with decreased morbidity and mortality as well as improved quality of life. However, the utility of recombinant human GH in adults with chronic kidney disease and end-stage renal disease for optimization of body habitus and reducing frailty remains uncertain. Semin Nephrol 41:x-xx © 2021 Elsevier Inc. All rights reserved.

Growth Promotion Ethics and the Challenge to Resist Cosmetic Endocrinology

The advancement of "human growth hormone (hGH)-for-height" - increasing height attainment in children short for reasons other than GH deficiency - arose from intuitive, deep-seated assumptions about the disability of short stature, its improvement with hGH-mediated height gain, and the safety of escalating dosages of hGH in healthy children. Evidence challenging these assumptions now strengthens criticism of hGH-for-height as cosmetic endocrinology. To counter this characterization, collective acceptance of guidelines is needed that advise nontreatment of the vast majority of short children, support strategies that minimize treatment duration and dosage, and restrain enhancement of normal adult stature. Through a clinical case analysis, ethical issues underlying these recommendations are explored. These include duties to provide informed assent and re-assent, protect children from unnecessary treatment, consider fairness to nontreated children, and allocate healthcare resources responsibly. Informed assent for hGH-for-height should ensure awareness of modest, variable height gain expectations, limited evidence for psychosocial benefit, ongoing studies for potential posttreatment adverse effects, and options for less expensive/invasive approaches, including nontreatment and counseling. Approaching growth pro-motion in this way fosters therapeutic restraint, resists the al lure of enhancement therapy, and minimizes contributions to society's perception that to be taller is to be better.
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Chronic kidney disease in children and adolescents in Brunei Darussalam

AIM: To determine epidemiology of Bruneian paediatric chronic kidney disease (CKD) patients and factors that affect growth and progression of disease.

METHODS: A cross-sectional study conducted on all children below 18 years old who were diagnosed with CKD over a ten year period (2004 to 2013). The reference population was all children (< 18 years old) suffering from CKD and attending the tertiary paediatric nephrology clinic in Brunei Darussalam. Demographic (current age, age of diagnosis, gender, ethnicity), anthropometric (weight and height), diagnosis, laboratory data (serum creatinine and haemoglobin, urinalysis) and blood pressure were extracted from the patients’ clinical case notes and recorded using a data collection form.

RESULTS: The study revealed a high national prevalence [736 per million child population (pmcp)] and incidence (91 pcmp) of CKD. If CKD was defined at Stage 1, 2, 3, 4 or 5, the associated prevalence figures were 736, 132, 83, 50 and 33 pmcp. Glomerulonephritis accounted for 69% of all prevalent cases, followed by congenital abnormalities of kidney and urinary tract (20%) and tubulointerstitial diseases (8%). Minimal change disease being the most common histological diagnosis. The median age of diagnosis was 4.5 years, with congenital disease patients experiencing an earlier onset of diagnosis. A large proportion of patients were below the 5% percentile for height and weight. Non-glomerular diseases, adolescent and female patients were significantly associated with poor growth, but not glomerular filtration rate, age of diagnosis or steroid usage.

CONCLUSION: Brunei has a high prevalence of chronic kidney disease in the paediatric population with glomerulonephritis being the most common disease.

Short Stature: Is It a Psychosocial Problem and Does Changing Height Matter?

Some proponents of recombinant human growth hormone (rhGH) treatment in growth hormone-sufficient children cite height, as an isolated physical characteristic, as being associated with psychosocial morbidity. Others question the reliability of the evidence underpinning the quality-of-life rationale for treatment as well as the bioethics of rhGH treatment. The following questions are addressed: (1) Is short stature an obstacle to positive psychosocial adjustment? and (2) Does increasing height with rhGH treatment make a difference to the person's psychosocial adaptation and quality of life? Three clinical case examples are used to illustrate the complexities associated with decision-making surrounding rhGH use.

The utility of the IGF-I generation test in children with chronic kidney disease

BACKGROUND

To determine if the insulin-like-growth factor (IGF-I) generation test is a marker for growth hormone (GH) sensitivity in children with chronic kidney disease (CKD).

METHODS

This was a randomized cross-over study in which children with CKD received low-dose (0.025 mg/kg/day) and high-dose (0.05 mg/kg/day) GH therapy in the framework of a 7-day IGF-I generation test. Blood samples were collected on day 1 (D1; pre-dose) and on day 8 (D8; post 7 doses) of GH therapy. All subjects received GH for 12 months at 0.05 mg/kg/day. Serum IGF-I was measured by radioimmunometric assay. Normative historic data from healthy children and those with idiopathic short stature were used for comparison.

RESULTS

Sixteen subjects (age 2-13 years) with creatinine clearances of between 25 and 75 ml/min/1.73 m(2) were enrolled. Annualized height velocity for all subjects was 10.3 ± 1.1 cm/year (mean ± standard deviation), with an annual change in height Z score of 0.7 ± 1.0. No correlation was found between the generated serum IGF-I levels (D8 - D1) and creatinine clearances, and with changes in height Z scores. Serum IGF-I levels on D1 and D8 in CKD subjects were lower than normative data, but with adequate IGF-I generation on D8.

CONCLUSIONS

Children with CKD were able to respond to GH therapy with both growth and an increase in serum IGF-I levels, but the IGF-I generation test was not a good predictor of growth response in this cohort.

Factors affecting growth and final adult height after pediatric renal transplantation

BACKGROUND

Growth retardation is a common problem for children with chronic kidney disease. Although renal transplantation (RTx) resolves endocrine metabolic and uremic disturbances, growth continues to be suboptimal. This study aims to describe changes in height from diagnosis to final adult height (FAH) in Korean renal allograft recipients and determine factors associated with posttransplantation growth.

METHODS

We retrospectively reviewed 63 renal allograft recipients who underwent RTx at <15 years of age with regular follow-up for >3 years afterwards. Pre- and post-RTx growth was analyzed by height Z scores (Ht_Z) at RTx, 2 and 5 years follow-up, and at FAH.

RESULTS

Ht_Z decreased from diagnosis to dialysis by -0.8 (P = .009) and from dialysis to RTx by -0.46 (P < .001). The mean baseline Ht_Z at RTx was -1.62 ± 1.36. The change in Ht_Z at 2 and 5 years after transplantation was 0.68 ± 0.88 and 0.48 ± 0.86, respectively. Both variables were negatively correlated with baseline age at RTx. Mean FAH was -1.22 ± 1.11 and was positively correlated with baseline height at RTx. Height at start of dialysis and dialysis duration were significant determinants of baseline height at RTx (P < .001).

CONCLUSIONS

Although there is significant posttransplant catch-up growth among younger recipients and among those with greater baseline height deficit, catch-up growth is not sustained and greater FAH is attained in those who are taller at RTx. Achieving greater height before dialysis and decreasing dialysis duration leads to maximal height at RTx as well as greater FAH.

Growth hormone in chronic renal disease

Severe growth retardation (below the third percentile for height) is seen in up to one-third children with chronic kidney disease. It is thought to be multifactorial and despite optimal medical therapy most children are unable to reach their normal height. Under-nutrition, anemia, vitamin D deficiency with secondary hyperparathyroidism, metabolic acidosis, hyperphosphatemia, renal osteodystrophy; abnormalities in the growth hormone/insulin like growth factor system and sex steroids, all have been implicated in the pathogenesis of growth failure. Therapy includes optimization of nutritional and metabolic abnormalities. Failure to achieve adequate height despite 3-6 months of optimal medical measures mandates the use of recombinant GH (rGH) therapy, which has shown to result in catch-up growth, anywhere from 2 cm to 10 cm with satisfactory liner, somatic and psychological development.

Growth hormone for children with chronic kidney disease

BACKGROUND

Growth retardation is a common complication of chronic kidney disease (CKD) in children and is of concern to families. Recombinant human growth hormone (rhGH) treatment has been used to help short children with CKD attain a height more in keeping with their age group. However there are concerns about the long-term benefits of rhGH in significantly improving adult height as well as concerns about potential adverse effects (deterioration in native kidney function, increased acute rejection in kidney transplant recipients, benign intracranial hypertension).

OBJECTIVES

To evaluate the benefits and harms of rhGH treatment in children with CKD.

SEARCH METHODS

Randomised controlled trials (RCTs) were identified from the Cochrane Renal Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2011), MEDLINE (from 1966), EMBASE (from 1980), article reference lists and through contact with local and international experts in the field.Date of last search: December 29, 2011

SELECTION CRITERIA

RCTs were included if they were carried out in children aged zero to 18 years, diagnosed with CKD, who were pre-dialysis, on dialysis or post-transplant; if they compared rhGH treatment with placebo/no treatment or two doses of rhGH treatments; and if they included height outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for risk of bias and extracted data from eligible studies. Data was pooled using a random effects model with calculation of mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Sixteen studies (enrolling 809 children) were identified. Risk of bias assessment indicated that study quality was poor or poorly reported with only four and five studies respectively reporting adequate allocation concealment or blinding of study participants and investigators. Treatment with rhGH (28 IU/m²/wk) compared with placebo or no specific therapy resulted in a significant increase in height standard deviation score (HSDS) at one year (8 studies, 391 children: MD 0.82, 95% CI 0.56 to 1.07), and a significant increase in height velocity at six months (2 studies, 27 children: MD 2.85 cm/6 mo, 95% CI 2.22 to 3.48) and one year (7 studies, 287 children: MD 3.88 cm/y, 95% CI 3.32 to 4.44). Height velocity, though reduced, remained significantly greater than untreated children during the second year of therapy (1 study, 82 children: MD 2.30 cm/y, 95% CI 1.39 to 3.21). Compared to the 14 IU/m²/wk group, there was a 1.18 cm/y increase in height velocity in the 28 IU/m²/wk group (3 studies, 150 children: 1.18 cm/y, 95% CI 0.52 to 1.84) . The frequency of reported side effects of rhGH was generally similar to that of the control group.

AUTHORS' CONCLUSIONS

One year of 28 IU/m²/wk rhGH in children with CKD resulted in a 3.88 cm increase in height velocity above that of untreated patients. Studies were too short to determine if continuing treatment resulted in an increase in final adult height.

KDOQI US commentary on the 2009 KDIGO clinical practice guideline for the care of kidney transplant recipients

In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs.

Etiology and treatment of growth retardation in children with chronic kidney disease and end-stage renal disease: a historical perspective

Dramatic changes have occurred in our understanding of the etiology of the growth retardation associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD) during the past 50 years. Significant interest has been focused on preventing and/or correcting the growth retardation because of the emergence of the dual therapeutic modalities of dialysis and renal transplantation to prolong the lives of infants, children, and adolescents afflicted with CKD and ESRD. These efforts have resulted in a significant improvement in the height Z-score over the past two decades of children with CKD and ESRD. This has had a salutary impact on the final adult height of such children which should hopefully lead to an enhanced quality of life in the future. This report addresses the progress that has been made in the management of growth retardation in the pediatric population with CKD and ESRD.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Lack of effect of IGF-I on the glomerular filtration rate in non-diabetic patients with advanced chronic kidney disease

Recombinant human insulin-like growth factor I (rhIGF-I) acutely increases the glomerular filtration rate (GFR) in human volunteers and patients with advanced chronic kidney disease (CKD). However, on chronic administration, rhIGF-I induces tolerance to its renal effects attributed to a fall in serum IGF-binding protein 3 (IGFBP-3) enhancing its systemic clearance. Tolerance may be avoided by the use of an intermittent dosage regimen of rhIGF-I. A randomised, double-blind, placebo-controlled study was undertaken in non-diabetic patients with advanced CKD to establish whether intermittent subcutaneous injections of rhIGF-I (50 microg/kg, four days/week) could increase GFR over a 24 week period and thereby have the potential to delay the onset of renal replacement therapy. Twenty-seven patients were randomised into rhIGF-I/placebo groups using a 2:1 treatment ratio. GFR was determined by inulin clearance. RhIGF-I therapy produced a sustained increase serum total and free IGF-I elevating IGFBP-1 without decreasing IGFBP-3. Inulin clearance however, was not increased after either four weeks or over the 24 week observation period. Only 4/18 rhIGF-I treated patients compared to 6/9 placebo patients completed the study, the major reason being the requirement for dialysis. Compared with healthy volunteers, advanced CKD patients had elevated serum levels of IGFBP-1, IGFBP-2, tumour necrosis factor-alpha and asymmetric dimethylarginine, all factors proposed to mediate IGF-I resistance. In conclusion, although intermittent rhIGF-I therapy elevated serum total IGF-I and prevented any fall in serum IGFBP-3, it failed to increase GFR in non-diabetic patients with advanced CKD. The lack of efficacy was attributed to the presence of renal IGF-I resistance in CKD.

Growth hormone treatment started in the first year of life in infants with chronic renal failure

Infants with chronic renal failure (CRF) are at high risk of experiencing severe growth retardation. We report a study of 12 infants with CRF who have been treated with recombinant human growth hormone (rhGH) since the age of 0.5 +/- 0.3 years. A control group comprised 15 infants with less severe CRF who were being treated during the same period, but who did not receive rhGH. Despite the infants in the rhGH group had more severe renal failure, they grew at least as well as those in the control group and experienced catch-up growth that started earlier and was more sustained; they also gained more weight. Between the age of 0.5 and 2.5 years, the height standard deviation score (HtSDS) improved from -2.0 +/- 1.2 to -0.9 +/- 0.9 in the rhGH group (p < 0.005) and from -1.6 +/- 1.6 to -1.0 +/- 1.9 in the control group (p=non significant, n.s.). The average gain in HtSDS was +1.1 +/- 0.8 in the treated group and +0.6 +/- 1.4 in the control group (p = n.s.). During the same period, the weight SDS improved from -2.2 +/- 0.9 to -0.6 +/- 1.2 (p < 0.005) and from -1.9 +/- 1.2 to -1.3 +/- 1.2 (p=n.s.) in the treatment and control groups, respectively. Nutritional intake was similar in both groups, while parathyroid hormone levels tended to increase, although not significantly, after rhGH treatment (p=n.s.). The results of this pilot study suggest that very early treatment with rhGH in patients with early-onset CRF may improve growth.

[Growth hormone therapy for children with chronic diseases]

Growth disorders are commonly observed in children suffering from chronic diseases. The pathogenesis of growth failure is multifactorial. In chronic inflammatory diseases such as juvenile idiopathic arthritis and inflammatory bowel disease, growth is also affected by pro-inflammatory cytokines. Patients with chronic diseases might also become growth hormone (GH) deficient. However, normal or increased GH secretion with reduced plasma concentrations of insulin-like growth factor-I indicate a degree of GH insensitivity in some patients. Growth damage can increase with specific treatments, especially if glucocorticoids are used. GH therapy has been used to reduce the consequences of the disease and long-term steroid therapy in these patients. In this review, it is reported the encouraging results of GH treatment in growth-retarded children with chronic diseases, both in well defined indications as well in situations still under investigation.

Use of rhGH in children with chronic kidney disease: lessons from NAPRTCS

We evaluated the utilization and potential benefits of recombinant human growth hormone (rhGH) in children with chronic kidney disease (CKD) and following renal transplantation in a large patient cohort. We queried the chronic renal insufficiency (CRI), dialysis, and transplant registries of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) to characterize the frequency of rhGH utilization, factors related to its usage, and the relationship between rhGH usage and catch-up growth. Data from 6,505, 5,122, and 4,478 CRI, dialysis, and transplant patients, respectively, was evaluated. Percentage utilization of rhGH 2 years after registry entry was 22%, 33%, and 3% in children with a height standard deviation score (SDS)<-1 and age<17 years (termed candidate group) in CRI, dialysis, and transplant patients, respectively. Multivariate logistic regression analysis showed that the likelihood of using rhGH was significantly correlated with age, gender, geographical region of residence and height category within the candidate group (p<0.01). The use of rhGH was associated with catch-up growth in 27%, 11%, and 25% of candidate CRI, dialysis, and transplant patients, respectively. In the candidate group, percentage catch-up growth was highest in children who were Tanner stage 1-2, who comprised 19.4%, 7.1%, and 25.5% of the CRI, dialysis, and transplant patients, respectively. Using multiple regression analysis, the estimated impact of rhGH on final adult height (age>19 years) was 0.80, 0.50, and 0.19 SDS, in CRI, dialysis, and transplant patients, respectively. Thus, rhGH can improve height gain in some children with CKD. The use of rhGH appears to be most effective in prepubertal children with CRI.

Catch-up growth follows an abnormal pattern in experimental renal insufficiency and growth hormone treatment normalizes it

The primary goal of this study was to determine if the ability to undergo catch-up growth following a transient injury is preserved in an experimental model of moderate chronic renal failure (CRF) and the effect of growth hormone (GH) administration on such phenomenon. Young rats were subtotally nephrectomized (days 0 and 4) (Nx). From days 11 to 13, food intake was restricted in subgroups of Nx and control (C) rats (NxR and CR). After refeeding, subgroups of NxR and CR rats received GH from days 14 to 20 (NxRGH and CRGH). Rats were killed on days 14 (C, CR, Nx, NxR), 17 and 21 (C, CR, CRGH, Nx, NxR, NxRGH), and 36 (C, CR, Nx, NxR). Longitudinal growth rate was measured by osseous front advance in the proximal tibiae. With refeeding, growth rate of CR, NxR, and NXrGH rats became significantly greater than that of C, indicating catch-up growth. This occurred later and with lower growth rate in NxR than in CR rats, whereas the characteristics of catch-up growth in CR and NxRGH animals were similar. Changes in growth rate were associated with modifications in the morphology and proliferative activity of growth cartilage. We conclude that catch-up growth occurs in renal insufficiency but follows a different pattern from that observed with normal renal function. GH treatment normalizes the pattern of catch-up growth in CRF. Changes in growth velocity are associated to modifications in the structure and dynamics of growth cartilage.

Lost in publication: Half of all renal practice evidence is published in non-renal journals

Physicians often scan a select number of journals to keep up to date with practice evidence for patients with kidney conditions. This raises the question of where relevant studies are published. We performed a bibliometric analysis using 195 renal systematic reviews. Each review used a comprehensive method to identify all primary studies for a focused clinical question relevant to patient care. We compiled all the primary studies included in these reviews, and considered where each study was published. Of the 2779 studies, 1351 (49%) were published in the top 20 journals. Predictably, this list included Transplantation Proceedings (5.9% of studies), Kidney International (5.3%), American Journal of Kidney Diseases (4.7%), Nephrology Dialysis Transplantation (4.3%), Transplantation (4.2%), and Journal of the American Society of Nephrology (2.4%). Ten non-renal journals were also on this list, including New England Journal of Medicine (2.4%), Lancet (2.3%), and Diabetes Care (2.2%). The remaining 1428 (51%) studies were published across other 446 journals. When the disciplines of all journals were considered, 59 were classified as renal or transplant journals (42% of articles). Other specialties included general and internal medicine (16%), endocrinology (diabetes) and metabolism (6.5%), surgery (6.2%), cardiovascular diseases (6.1%), pediatrics (4.3%), and radiology (3.3%). About half of all renal practice evidence is published in non-renal journals. Browsing the top journals is important. However, relevant studies are also scattered across a large range of journals that may not be routinely scanned by busy physicians, and keeping up with this literature requires other continuing education strategies.

Growth hormone for children with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is an uncommon but important condition. Growth retardation, one of the complications of CKD, is of concern to families. Recombinant human growth hormone (rhGH) treatment has been used to help short children with CKD attain a height more in keeping with their age group. However, there are concerns that rhGH may have an adverse effect on the preservation of native kidney function, predispose to acute rejection in kidney transplant recipients, and cause benign intracranial hypertension and slipped capital femoral epiphysis.

OBJECTIVES

To evaluate the benefits and harms of rhGH treatment in children with CKD.

SEARCH STRATEGY

Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, article reference lists and through contact with local and international experts in the field. Date of most recent search: July 2005

SELECTION CRITERIA

RCTs were included if they were carried out in children aged 0-18 years, diagnosed with CKD, who were pre-dialysis, on dialysis or post-transplant; if they compared rhGH treatment with placebo/no treatment or two doses of rhGH treatments; and if they included height outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for methodological quality and extracted data from eligible trials. Data was pooled using a random effects model with calculation of weighted mean difference (MD) for continuous outcomes and relative risk (RR) for categorical outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fifteen RCTs (629 children) were identified. Treatment with rhGH (28 IU/m(2)/wk) resulted in a significant increase in height standard deviation score (SDS) at one year (MD 0.78 SDS, 95% CI 0.52 to 1.04), and a significant increase in height velocity at six months (MD 2.85 cm/6 mo, 95%CI 2.22 to 3.48) and one year (MD 3.80 cm/y, 95%CI 3.20 to 4.39). Compared to the 14 IU/m(2)/wk group, there was a 1.34 cm/y (0.55 to 2.13) increase in height velocity in the 28 IU/m(2)/wk group. The frequency of reported side effects of rhGH were similar to that of the control group.

AUTHORS' CONCLUSIONS

One year of 28 IU/m(2)/wk rhGH in children with CKD resulted in a 3.80 cm/y increase in height velocity above that of untreated patients. Trials were too short to determine if continuing treatment resulted in an increase in final adult height.

Applying the Growth Failure in CKD Consensus Conference: evaluation and treatment algorithm in children with chronic kidney disease

Growth failure is a common and significant clinical problem for children with chronic kidney disease (CKD), particularly those with chronic renal insufficiency (CRI). Children with CRI (typically defined by a glomerular filtration rate [GFR] <75 mL/min/1.73 m2) who have growth impairment exhibit a variety of medical and psychological problems in addition to increased mortality. Growth failure in children with CKD is usually multifactorial in etiology, including abnormalities in the growth hormone (GH)-insulin-like growth factor (IGF)-I axis and a variety of nutritional and metabolic concerns characteristic of CKD. Proper management of these factors contributes to better growth in affected children. Although the safety and efficacy of recombinant human GH (rhGH) therapy in promoting growth in children with CKD are well established, recent data indicate that the use of rhGH administration in children with CKD and growth failure remains low. Recently, guidelines were developed by the Consensus Conference for Evaluation and Treatment of Growth Failure in Children with CKD. This paper focuses on the application of these guidelines to children with CKD.

Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement

Growth failure is a clinically important issue in children with chronic kidney disease (CKD) and is associated with significant morbidity and mortality. Many factors contribute to impaired growth in these children, including abnormalities in the growth hormone (GH)-insulin-like growth factor-I (IGF-I) axis, malnutrition, acidosis, and renal bone disease. The management of growth failure in children with CKD is complicated by the presence of other disease-related complications requiring medical intervention. Despite evidence of GH efficacy and safety in this population, some practitioners and families have been reluctant to institute GH therapy, citing an unwillingness to comply with daily injections, reimbursement difficulties, or impending renal transplantation. Suboptimal attention to growth failure management may be further compounded by a lack of clinical guidelines for the appropriate assessment and treatment of growth failure in these children. This review of growth failure in children with CKD concludes with an algorithm developed by members of the consensus committee, outlining their recommendations for appropriate steps to improve growth and overall health outcomes in children with CKD.

Use of growth hormone in children

The introduction of recombinant DNA-derived human growth hormone (rhGH) in the mid-1980s allowed studies to be undertaken in a number of growth disorders other than the classic indication--growth-hormone deficiency (GHD). In patients with GHD, optimizing the dose and frequency of rhGH administration, and early instigation of therapy, has led to near-normalization of final height. The use of rhGH in the treatment of Turner syndrome, Prader-Willi syndrome, intrauterine growth restriction, and chronic renal failure demonstrated the efficacy of therapy, although the increase in final height (5-7 cm) is less than that achieved in GHD. Cost-benefit implications need to be considered in the next phases of evaluating the role of rhGH therapy in these indications. To date, rhGH has only received approval for the management of idiopathic short stature in the US; as with the other wider growth indications, the lack of formal randomized, controlled trials hampers the full evaluation of efficacy, and a cautious approach should, therefore, be adopted for this particular indication. rhGH has a good safety record, although there are current concerns about the possible long-term increased risk of colonic and lymphatic malignancy, which will require monitoring through national cancer registries.

Growth Hormone Treatment of Short Stature: Status of the Quality of Life Rationale

The unlimited availability of biosynthetic human growth hormone (rhGH) has contributed to the disassociation of the treatment of short stature from its causes. The rationale for treatment has traditionally rested upon the assumption that short stature, in the extreme, may constitute a physical disability, and otherwise represents a significant psychosocial burden for the individual. This review summarizes what is known about the psychosocial aspects of short stature and the quality of life benefits of rhGH treatment. Stereotypes and assumptions about short stature are evaluated in light of empirical findings. Problems of psychosocial adjustment are relatively common in the general population. Because of the salience of short stature, and its potential to serve as a lightning rod to divert attention from other factors interfering with a healthy psychological adaptation, the clinician must be watchful of misattributions for ongoing problems, or unrealistic predictions of the benefits of taller stature. For these reasons, the clinician should consider incorporating a psychosocial component in the diagnostic evaluation to broaden potential treatment recommendations. Finally, studies of factors influencing family decisions regarding factors for and against rhGH therapy provide important clues to how clinicians might enhance the informed consent process.

Impact of growth hormone supplementation on adult height in turner syndrome: results of the Canadian randomized controlled trial

BACKGROUND

A randomized, controlled trial of GH supplementation to adult height in girls with short stature due to Turner syndrome was conducted in Canada. We report results in subjects who completed the protocol and subjects who participated in follow-up.

METHODS

One hundred fifty-four girls with Turner syndrome, aged 7-13 yr, were randomly assigned to one of two groups: 1) GH by sc injection six times per week (0.30 mg/kg.wk), and 2) control (C), no GH treatment. Both cohorts received standardized sex steroid replacement starting at a chronological age of 13 yr. Subjects were followed until protocol completion, defined as height velocity less than 2 cm/yr and bone age 14 yr or greater. A subsequent protocol addendum requested follow-up safety and efficacy assessment in all patients at least 1 yr after the last core protocol visit.

RESULTS

One hundred four patients completed the study (61 GH, 43 C), and 50 withdrew (15 GH, 35 C). At protocol completion, mean heights were 147.5 +/- 6.1 (GH) and 141.0 +/- 5.4 cm (C), respectively (P < 0.001). Of those who completed the protocol, 59 (40 GH, 19 C) had height data at least 1 yr after protocol completion; in that group, mean heights were 149.0 +/- 6.4 (GH) and 142.2 +/- 6.6 cm (C), respectively (P < 0.001). At protocol completion and follow-up, the mean height gain due to GH, estimated by analysis of covariance, was +7.2 cm (confidence interval 6.0, 8.4) and +7.3 cm (confidence interval 5.4, 9.2), respectively (both P < 0.001).

CONCLUSIONS

This is the first evidence from a randomized, controlled trial to adult height that GH supplementation with induction of puberty at a near physiological age increases the adult height of girls with Turner syndrome.

Long-term recombinant human growth hormone use in Australian children with renal disease

BACKGROUND

Recombinant human growth hormone (rhGH) has been used for 15 years to treat Australian children with short stature caused by chronic kidney disease. The Australia-wide growth hormone database, OZGROW, has prospectively collected data for all patients treated with rhGH. The impact of rhGH therapy on linear growth in patients with chronic renal failure (CRF) was assessed by retrospectively analysing this data.

METHODS

Growth data prior to and during treatment, bone age, and pubertal data were recorded from the database. Questionnaire data provided further information on underlying renal disease, medication use, bone disease, and final height. Patients were classified according to treatment modality; conservative management of CRF, haemodialysis or peritoneal dialysis, and transplant.

RESULTS

Data on 183 patients were analysed. The duration of rhGH therapy ranged from 1.2 to 10.5 years (mean 5.3 years). The height standard deviation score (Ht SDS) in each patient group at the start and end of rhGH treatment were as follows: Predialysis: -2.6 to -2.1; dialysis: -2.7 to -2.3; transplant: -3.1 to -2.8 (P = 0.0001). Thirty-nine patients achieved final adult height, with mean Ht SDS before rhGH therapy being -2.65, and at final height it was 2.3. The mean final height for the males was 161.8 cm and for the females, it was 149.5 cm.

CONCLUSION

The effect of treatment with rhGH was less dramatic than reported in the literature. However, the positive benefit of rhGH therapy was apparent both in the short and long-term. Therapy with rhGH maintained a steady Ht SDS with time; without rhGH, it would be anticipated that many children would show a steady decline in Ht SDS. The maximum benefit was seen in preterminal renal failure, and early therapy (before dialysis or transplantation) is recommended before an irrecoverable loss of height potential occurs.

Height and social adjustment: are extremes a cause for concern and action?

OBJECTIVE

Growth hormone treatment of hormone-sufficient short youths is predicated on the belief that short stature is associated with social problems with peers. This study assessed peer relations and social adjustment as a function of height in a community sample.

METHODS

A cross-sectional study was conducted at 1 public school district in Western New York of students of both genders who attended grades 6 to 12 (N = 956). Target groups included participants of short stature (height <or=-1.6 standard deviation, ie, <or=5th percentile for age- and gender-adjusted population norms; n = 68) and tall stature (>or=1.6 standard deviation; >or=95th percentile; n = 58) and classmates of average height (between the 25th and 75th percentiles; n = 123) used for within-class comparisons. All remaining unclassified classmates (n = 704) also provided data. Self- and peer-rated assessment of social reputation and social acceptance was measured.

RESULTS

Minimal effects of height on measures of social functioning were detected despite substantial statistical power. We detected no significant relationships between height and measures of friendship, popularity, or reputation with peers. Findings did not vary by gender of participant, by peer- or self-report, or by whether data from the entire sample were used or target groups were contrasted with comparison participants. Shorter students were perceived by peers to be younger than their age. This influence was restricted to lower grades and did not have an impact on measures of social acceptance or reputation with peers.

CONCLUSIONS

Extremes of stature in the general population-either short or tall-have minimal detectable impact on peer perceptions of social behavior, friendship, or acceptance. Findings are not supportive of the need to intervene a priori because of the potential risk of negative stature-related social sequelae. Furthermore, if problems with peer relationships are identified among short or tall youths, then factors other than stature should be considered as etiologically important.

End-stage renal disease: endocrine aspects of treatment

End-stage renal disease (ESRD) is a deadly disease unless supportive treatment is administered in the form of haemodialysis, peritoneal dialysis or kidney transplantation. Although marked improvements have occurred in the efficiency of dialysis and in overall care, patients with ESRD still have poor long-term survival. The outcome is largely dependent on age, nutritional status, efficiency of dialysis and underlying reason for renal failure. As a consequence of renal failure, these patients experience a number of endocrine and metabolic disorders that may affect their well being and overall outcome. Disturbances in the somatotropic axis have been documented at several different levels, including an end-organ resistance to both growth hormone (GH) and insulin-like growth factor-I (IGF-I). A consequence seen in childhood is reduced growth velocity and short final height that may be overcome by long-term GH treatment, and it is possible that metabolism and nutritional status in adults with ESRD may be influenced by these abnormalities. Although a few small trials of GH treatment in adults with ESRD suggest that nutritional status may improve, long-term trials are needed to demonstrate other benefit of such treatment. This review will give a brief description of endocrine problems in adult patients with ESRD with a focus on the somatotropic axis, and it will review the experience reported in published trials of GH treatment in this patient group.

Expanded spectrum of recombinant human growth hormone therapy

The efficacy of recombinant human growth hormone in the treatment of growth hormone deficiency is well established. In recent years, the use of recombinant human growth hormone as a therapeutic modality has greatly increased and has expanded beyond the realm of replacement for growth hormone deficiency. Recombinant human growth hormone has been employed to ameliorate growth failure in multiple other disorders. For some, like Turner syndrome, recombinant human growth hormone has become the standard of care. For others, the ultimate benefit of recombinant human growth hormone remains to be determined. Although recent investigations provide encouraging short-term data, it is important to recognize that the impact of recombinant human growth hormone therapy on adult height has not been established in a number of conditions.

Growth hormone for children with chronic renal failure

OBJECTIVES

To evaluate the benefits and harms of recombinant human growth hormone (hGH) treatment in children with chronic renal failure (CRF).

SEARCH STRATEGY

Published and unpublished randomised controlled trials (RCTs) were identified from the Cochrane Controlled Trials Register, Medline, Embase, article reference lists and through contact with local and international experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included if they were carried out in children aged 0-18 years, diagnosed with CRF who are pre-dialysis, on dialysis or post-transplant; if they compared hGH treatment with placebo/no treatment or two doses of hGH treatments; and if they included height outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for methodological quality and extracted data from eligible trials. The primary outcome measure was difference in mean change in height standard deviation score (SDS). Secondary outcome measures included change in height SDS from treatment onset to completion, change in height SDS during puberty, change in height velocity, final height, quality of life and adverse effects. To estimate summary treatment effects, data was pooled using a random effects model with calculation of weighted mean difference (WMD) for continuous outcomes and relative risk for categorical outcomes.

MAIN RESULTS

Ten RCTs involving 481 children were identified. Treatment with hGH (28 IU/m(2)/wk) resulted in a significant increase in height standard deviation score (SDS) at one year (four trials, WMD0.77, 95% confidence limits (CI) 0.51 to 1.04), and a significant increase in height velocity at six months (two trials, WMD 5.7 cm/yr, 95%CI 4.4 to 7.0) and one year (two trials, WMD 4.1 cm/yr, 95%CI 2.6 to 5.6), but there was no further increase in height indices during the second year of administration. Compared to the 14 IU/m(2)/wk group, there was a 1.4 cm/yr (0.6 to 2.2) increase in height velocity in the 28 IU/m(2)/wk group. The frequency of reported side effects of hGH were similar to that of the control group.

REVIEWER'S CONCLUSIONS

On average, one year of 28 IU/m(2)/wk hGH in children with CRF results in a 4 cm/yr increase in height velocity above that of untreated controls, however, it is not certain if this will result in an increase in final adult height. Benefits of longer courses or higher doses of treatment warrants further study.