Recombinant human growth hormone for reconditioning of respiratory muscle after lung volume reduction surgery

Endocrine and metabolic complications of COVID-19: lessons learned and future prospects

Coronavirus disease 2019 (COVID-19) is well known for its respiratory complications; however, it can also cause extrapulmonary manifestations, including cardiovascular, thrombotic, renal, gastrointestinal, neurologic, and endocrinological symptoms. Endocrinological complications of COVID-19 are rare but can considerably impact the outcome of the patients. Moreover, preexisting endocrinologic disorders can affect the severity of COVID-19. Thyroid, pancreas, adrenal, neuroendocrine, gonadal, and parathyroid glands are the main endocrinologic organs that can be targeted by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Endocrinological complications of COVID-19 are rare but can significantly deteriorate the patients' prognosis. Understanding the interaction between COVID-19 and the endocrine system can provide a potential treatment option to improve the outcome of COVID-19. In this article, we aim to review the short-term and long-term organ-based endocrinological complications of COVID-19, the pathophysiology, the influence of each complication on COVID-19 prognosis, and potential therapeutic interventions based on current published data. Moreover, current clinical trials of potential endocrinological interventions to develop therapeutic strategies for COVID-19 have been discussed.

Is Growth Hormone Insufficiency the Missing Link Between Obesity, Male Gender, Age, and COVID-19 Severity?

Evidence has emerged regarding an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with worse prognosis in elderly male patients with obesity, and blunted growth hormone (GH) secretion represents a feature of this population subgroup. Here, a comprehensive review of the possible links between GH-insulinlike growth factor 1 axis impairment and coronavirus disease 2019 (COVID-19) severity is offered. First, unequivocal evidence suggests that immune system dysregulation represents a key element in determining SARS-CoV-2 severity, as well as the association with adult-onset GH deficiency (GHD); notably, if GH is physiologically involved in the development and maintenance of the immune system, its pharmacological replacement in GHD patients seems to positively influence their inflammatory status. In addition, the impaired fibrinolysis associated with GHD may represent a further link between GH-insulin-like growth factor 1 axis impairment and COVID-19 severity, as it has been associated with both conditions. In conclusion, several sources of evidence have supported a relationship between GHD and COVID-19, and they also shed light upon potential beneficial effects of recombinant GH treatment on COVID-19 patients.

Growth hormone replacement therapy improves hypopituitarism-associated hypoxemia in a patient after craniopharyngioma surgery: A case report

RATIONALE

There are some reports about hypoxemia related to hypopituitarism. However, little is known about the relationship between growth hormone deficiency (GHD) and hypoxemia.

PATIENTS CONCERNS

A 23-year-old female presented with severe hypoxemia after the operations of craniopharyngioma. Laboratory tests found that serum growth hormone (GH) levels were extremely low.

DIAGNOSIS

She was diagnosed with growth hormone deficiency-related hypoxemia.

INTERVENTIONS

In addition to oxygenation, low doses of GH replacement therapy was conducted for 3-month.

OUTCOMES

After 3-month r-hGH replacement therapy, hypoxemia was improved significantly and the level of serum GH was elevated.

LESSONS

We've already known that hypopituitarism may induce hypoxemia owing to multiple possible mechanisms according to previous literature. But little is known about growth hormone deficiency-related hypoxemia. Our case shows that GH replacement therapy is an effective treatment, and it's significant to examination the level of GH in serum for hypoxemia patients especially when the cause of hypoxemia is unknown.

Growth hormone expression in the perinatal and postnatal rat lung

It is now established that the lung is a target site for pituitary growth hormone (GH) action, because pathophysiological states of pituitary GH excess and deficiency are associated with impaired pulmonary function. The onset of lung development and differentiation is, however, before the ontogenic differentiation of pituitary somatotrophs. GH may be involved, nevertheless, in lung development, because it is present in extrapituitary tissues of preimplantation mouse embryos and in the lung buds of embryonic chickens. The possibility that GH may be expressed in the rat lung during fetal and neonatal development, therefore, has been assessed. GH mRNA was detected in the lung, and its 693-bp sequence was identical to that in the pituitary gland. By in situ hybridization, this transcript was found to be abundantly expressed in the lungs of embryonic day (ED) 17 rats in mesenchymal, mucosal epithelial, and smooth muscle cells. This transcript was expressed in neonates until at least day 14 postnatally and was localized to type I and II epithelial cells and to pulmonary tissue macrophages and alveolar macrophages. GH immunoreactivity paralleled GH mRNA cellular localization throughout the time course studied. This immunoreactivity was specific and was lost after antibody preabsorption. The perinatal and postnatal lung is, therefore, an extrapituitary site of GH gene expression during development. Given that the GH receptor is present in the lung from early development, lung GH may have autocrine and/or paracrine roles in lung growth or differentiation or in pulmonary function.

Effects of exogenous growth hormone on resting pulmonary function in children with thermal injury

Burned children living beyond the acute phase of injury often have extensive physical functional limitations, such as impaired spirometry pulmonary function (PF). In patients with both lung disease and nutritional compromise, such as cystic fibrosis, studies suggest that growth hormone (GH) therapy improves PF. However, whether GH will improve PF in burned children is presently unknown. We therefore evaluated whether GH administration of 0.05 mg/kg/day for 1 year would improve PF in burned children. Thirty children, aged 7 to 18, with a 40% or more total body surface area burned were randomized into two groups and studied. One group received GH (n = 17) and the other received saline (n = 13). No differences were noted at hospital discharge between groups in age, % total body surface area, height, and weight. At 12 months after burn, both groups had similar height and weight. Baseline PF were below normal in both groups, but no statistical differences were noted between groups. At 1 year, there was a significant increase in PF in both groups; however, this increase in PF was similar in both groups. We conclude that the response in PF in burned children from the administration of GH prescribed for up to 1 year is limited.

Hormones and breathing

A number of hormones, including hypothalamic neuropeptides acting as neurotransmitters and neuromodulators in the CNS, are involved in the physiologic regulation of breathing and participate in adjustment of breathing in disease. In addition to central effects, some hormones also control breathing at peripheral chemoreceptors or have local effects on the lungs and airways. Estrogen and progesterone seem to protect from sleep-disordered breathing, whereas testosterone may predispose to it. Progesterone and thyroxine have long been known to stimulate respiration. More recently, several hormones such as corticotropin-releasing hormone and leptin have been suggested to act as respiratory stimulants. Somatostatin, dopamine, and neuropeptide Y have a depressing effect on breathing. Animal models and experimental human studies suggest that also many other hormones may be involved in respiratory control.

Sex differences in genioglossus muscle response to changes in pharyngeal resistance

The genioglossus (GG) muscle's response to partial oropharyngeal occlusion was studied in age-matched, healthy awake men (n = 16) and women (n = 15). A miniature balloon was placed in the retroglossal pharynx, and the GG's electromyographic (EMG) reflexive response was evaluated in different body postures. We assumed that inflating the pharyngeal balloon and changing the body posture from upright to supine would increase pharyngeal airway resistance. Our hypothesis was that the change in airway resistance would elicit a different response in the GG muscle depending on sex. Our results showed that GG activity during natural breathing was higher in women than in men. GG EMG activity did not change upon inflation of the balloon in women. In contrast, when the balloon was inflated in the men, the GG's basal activity increased (P <.01) in both the upright and the supine positions. Women appeared to show a higher GG baseline EMG activity during spontaneous breathing at rest, while men were more responsive to the partial occlusion of the pharyngeal airway.

Dangers of growth hormone therapy in critically ill patients

Prolonged length of stay is the major challenge for modern intensive care because of the associated morbidity and the impact on resource utilization. Severe trauma or infection is associated with a catabolic response, which is characterized by increased protein turnover and negative nitrogen balance. Severe catabolism leads to end-organ dysfunction and muscular weakness, prolonging the need for mechanical ventilation. Catabolism cannot be prevented with standard parenteral or enteral nutritional formulas. In order to prevent the complications of catabolism in intensive care patients, recombinant growth hormone has been applied as an experimental therapy for two decades in patients requiring parenteral nutrition and in patients with respiratory failure. Administration of recombinant growth hormone has resulted in positive nitrogen balance, and studies in mechanically ventilated patients suggest that it may shorten the need for ventilatory support. In contrast to the results of these relatively small studies, a recent multinational randomized controlled trial revealed that the administration of recombinant growth hormone (with doses 10-20 times higher than used for replacement therapy) increases mortality of critically ill patients. The excessive mortality in patients treated with recombinant growth hormone was related to infections and development of multiple organ failure, leading to the conclusion that administration of high doses of recombinant growth hormone cannot be recommended for critically ill patients. This review reinforces that conclusion.

Effect of insulinlike growth factor-1 treatment in children with cystic fibrosis

OBJECTIVES

Malnutrition is common in cystic fibrosis (CF) and adversely affects survival. Because insulinlike growth factor-1 (IGF-1) has insulinlike effects in terms of carbohydrate metabolism and is growth promoting, the authors hypothesized that its use would increase linear growth rate and decrease insulin requirements in children with CF.

METHODS

The authors used a double-blind placebo-controlled crossover design. Seven prepubertal children aged 9.6 to 13 years (5 boys and 2 girls) were treated with placebo or IGF-1 for 6 months. After a 6-month washout period, patients received the alternative therapy for 6 months. The primary outcome measure was linear growth rate. Secondary outcome measures were changes in body mass index, body composition determined by dual energy x-ray absorptiometry, forced expiratory volume (FEV(1)), and the blood glucose/insulin ratio.

RESULTS

The mean height z score at baseline was -1.5 +/- 0.8. At entry, the mean serum IGF-1 level was 124 +/- 25 ng/mL (normal range, 110-771 ng/mL). With treatment, mean serum IGF-1 levels increased twofold to threefold for all patients. The half-life for IGF-1 was 10.3 hours. We observed no significant difference in linear growth rate, weight gain, rate of accretion of lean body mass, or mean FEV(1) during treatment with IGF-1 compared with placebo. The glucose/insulin ratio, an indirect index of insulin sensitivity, was significantly increased with IGF-1 treatment compared with placebo ( P < 0.02). No adverse events related to IGF-1 were detected.

CONCLUSIONS

Treatment with IGF-1 for 6 months did not promote linear growth in prepubertal children with CF. However, the glucose/insulin ratio was increased without changing blood glucose levels with IGF-1 treatment suggesting increased insulin sensitivity.

Management of catabolism in metabolically stressed patients: a literature survey about growth hormone application

In the effort to improve the long-term outcome in critically ill patients, the utilization of anabolic agents, such as human recombinant growth hormone, has been proposed in order to reduce catabolism and improve nutritional status. A recent multicentre study regarding the use of human recombinant growth hormone in intensive care unit patients showed an unexpected increase in the mortality rate in human recombinant growth hormone-treated patients. This finding is in contrast with previous literature data reporting either no differences or an even lower mortality rate with the administration of human recombinant growth hormone. This review evaluates the possible reasons for this dramatic difference in outcomes between the multicentre study and the existing literature. Articles dealing with human recombinant growth hormone administration either in intensive care unit patients (n=26) or in postoperative patients (n=16) have been reviewed. Our analysis suggests that the low caloric intake given to patients enrolled in the multicentre study might have been inadequate to compensate for the hypermetabolism of these patients, and could not support the prolonged and delayed administration of high doses of human recombinant growth hormone. Whether the beneficial metabolic effects of human recombinant growth hormone translate into better clinical outcomes deserves further investigation. In addition, the careful selection of patients to be treated, and close monitoring of both the adequacy of caloric support and modality of human recombinant growth hormone administration would favour the safety of human recombinant growth hormone utilization in critical care settings.

Preoperative treatment with recombinant human growth hormone prevents ischemia reperfusion-induced diaphragmatic dysfunction

BACKGROUND

Respiratory complications continue to be a major cause of morbidity and mortality following major vascular surgery. The recent UK Small Aneurysm Trial cited preoperative respiratory function as the major predictor of outcome following elective aortic surgery.

AIM

The aim of this study was to investigate the effect of aortic clamping and revascularization on diaphragmatic muscle function in a small animal model and to evaluate the role of preoperative treatment with recombinant human growth hormone (rhGH) in preventing diaphragmatic muscle dysfunction.

METHODS

Male Sprague-Dawley rats (n = 18) were randomized into one of three groups: control (n = 6) underwent laparotomy only; IR (n = 6) had a laparotomy with infrarenal cross-clamping for 30 min followed by lower torso revascularization for 2 h; IR + rhGH (n = 6) were treated with rhGH (Genotropin 0.3 IU/kg/day) for 5 days before laparotomy and aortic cross-clamping for 30 min followed by lower torso revascularization for 2 h. Diaphragmatic muscle contractile function was assessed ex vivo using electrical field stimulation in a tissue bath.

RESULTS

Two hours of IR injury resulted in a significant impairment in diaphragmatic twitch (Control, 242.01 + 38.45 g; IR, 108.55 + 7.15 g). This impairment was prevented by pretreatment with rhGH (rhGH, 319.14 + 30.71 g; P < 0.01). Tetanic function was also significantly impaired by ischemia reperfusion injury (control, 605 + 77.63 g; IR, 228.12 + 14.38 g). Again, pretreatment with rhGH prevented this deterioration (IR + rhGH, 704.39 + 45.69 g; P < 0.05) compared with controls.

CONCLUSION

The results of this study suggest that preoperative administration of rhGH may have a role in preventing the diaphragmatic dysfunction associated with infrarenal aortic cross-clamping and revascularization.

Feeding the intensive care patient

The present review highlights recent findings (focusing on papers published between October 1999 and December 2000) in nutritional support of intensive care unit patients. During the past year, research focused on the use of enteral nutrition versus parenteral nutrition, and on the best composition of enteral nutrition and parenteral nutrition according to the clinical condition of the patient. With regard to enteral nutrition, the pH of nutritional support, the timing of administration and the technique of tube placement were debated. Immunomodulating agents and hormonal manipulations may improve outcomes of critically ill patients, but still warrant further research before they can be recommended for routine clinical use.

Mechanical ventilation in chronic obstructive lung disease

Exacerbations of COPD are a leading indication for MV in the intensive care unit. A thorough understanding of the pathophysiology of AVF in COPD is critical for physicians caring for these patients. In particular, physicians should understand DHI and use the ventilator and ancillary techniques to minimize its impact. Noninvasive positive-pressure ventilation should be considered strongly in relatively stable patients with an adequate mental status and manageable secretions. Once AVF resolves, patients should be removed from the ventilator as soon as is safe to do so to minimize the adverse effects of prolonged MV. An organized approach to weaning and identifying patients capable of independent breathing is crucial. Most patients with COPD and AVF benefit from MV and generally return to or approach their premorbid functional status. A significant subset, however, will not benefit from, or choose not to undergo, MV. Deciding upon appropriate therapeutic options for these patients relies heavily on effective communication between physician and patient. Comprehensive discussions before the development of AVF can assist decision-making after respiratory failure develops.

Inflammatory cytokines and acquired growth hormone resistance

Resistance to growth hormone (GH)-mediated induction of insulin-like growth factor I (IGF-I) is a common complication of catabolic diseases, including critical illness and post-surgical conditions. This resistance to GH is believed to be permissive to the development of protein catabolism, cachexia and wasting, which are associated with an increased mortality rate. Data from in vitro studies and animal models suggest that increased levels of inflammatory cytokines can induce cachexia and might inhibit the effects of GH on target tissues. The molecular mechanisms involved are unclear, although an effect of cytokines on GH receptor signalling has been suggested. The GH-activated pathways that mediate the increase in IGF-I levels are not well understood, thereby impeding the elucidation of the effect of inflammatory cytokines. Several signalling cascades, like the JAK-STAT and MAP kinase pathways, have been shown to be activated by GH and some inflammatory cytokines, hence raising the possibility of crosstalk on this level. Our data, however, indicate that inflammatory cytokines have little or no effect on GH-mediated JAK-STAT signalling. In this review, we discuss these results and the possibility that secondary changes in the structure of chromatin are likely to be involved in the induction of IGF-I gene transcription by GH.