Influence of the high-affinity growth hormone (GH)-binding protein on plasma profiles of free and bound GH and on the apparent half-life of GH. Modeling analysis and clinical applications

Bioactive growth hormone in humans: Controversies, complexities and concepts

OBJECTIVE

To revisit a finding, first described in 1978, which documented existence of a pituitary growth factor that escaped detection by immunoassay, but which was active in the established rat tibia GH bioassay.

METHODS

We present a narrative review of the evolution of growth hormone complexity, and its bio-detectability, from a historical perspective.

RESULTS

In humans under the age of 60, physical training (i.e. aerobic endurance and resistance training) are stressors which preferentially stimulate release of bioactive GH (bGH) into the blood. Neuroanatomical studies indicate a) that nerve fibers directly innervate the human anterior pituitary and b) that hind limb muscle afferents, in both humans and rats, also modulate plasma bGH. In the pituitary gland itself, molecular variants of GH, somatotroph heterogeneity and cell plasticity all appear to play a role in regulation of this growth factor.

CONCLUSION

This review considers more recent findings on this often forgotten/neglected subject. Comparison testing of a) human plasma samples, b) sub-populations of separated rat pituitary somatotrophs or c) purified human pituitary peptides by GH bioassay vs immunoassay consistently yield conflicting results.

The Use and Abuse of Growth Hormone in Sports

GH is banned by the World Anti-Doping Agency as a performance-enhancing anabolic agent. Doping with GH likely began in the early 1980s and became more prevalent with the advent of recombinant technology well before any scientific evidence of benefit. The expectation that GH improves physical function stems from its anabolic and lipolytic properties. Athletic performance depends on muscle strength and the energy required to power muscle function. In recreational athletes, GH selectively improves anaerobic sprint capacity but has not been proven to significantly enhance muscle strength, power, or maximum rate of oxygen consumption. GH is secreted as a family of isoform peptides in a pulsatile manner reflecting intermittent secretion and rapid clearance. Its anabolic actions are largely mediated by IGF-I, which stimulates whole-body protein synthesis, including skeletal muscle and collagen proteins. Two methods have been validated for detecting GH abuse in athletes. The first (the isoform method) is based on distinguishing pure recombinant 22-kDa GH from the heterogeneous isoforms secreted from the pituitary. The second (the marker method) is based on measuring blood levels of GH-responsive proteins, specifically IGF-I and the N-terminal propeptide of type III collagen (P-III-NP). Only a handful of athletes have been caught since the implementation of GH doping tests in 2004. The low rate likely reflects the limitation of in-competition testing using current methods. Improved detection rates may be achieved by more out-of-competition testing, introducing athletes' biological passports, and the development of novel methods. Governance, operational, technical, and political factors influence the effectiveness of an anti-doping program.

Growth hormone doping in sports: a critical review of use and detection strategies

GH is believed to be widely employed in sports as a performance-enhancing substance. Its use in athletic competition is banned by the World Anti-Doping Agency, and athletes are required to submit to testing for GH exposure. Detection of GH doping is challenging for several reasons including identity/similarity of exogenous to endogenous GH, short half-life, complex and fluctuating secretory dynamics of GH, and a very low urinary excretion rate. The detection test currently in use (GH isoform test) exploits the difference between recombinant GH (pure 22K-GH) and the heterogeneous nature of endogenous GH (several isoforms). Its main limitation is the short window of opportunity for detection (~12-24 h after the last GH dose). A second test to be implemented soon (the biomarker test) is based on stimulation of IGF-I and collagen III synthesis by GH. It has a longer window of opportunity (1-2 wk) but is less specific and presents a variety of technical challenges. GH doping in a larger sense also includes doping with GH secretagogues and IGF-I and its analogs. The scientific evidence for the ergogenicity of GH is weak, a fact that is not widely appreciated in athletic circles or by the general public. Also insufficiently appreciated is the risk of serious health consequences associated with high-dose, prolonged GH use. This review discusses the GH biology relevant to GH doping; the virtues and limitations of detection tests in blood, urine, and saliva; secretagogue efficacy; IGF-I doping; and information about the effectiveness of GH as a performance-enhancing agent.

The effect of prolonged fasting on levels of growth hormone-binding protein and free growth hormone

OBJECTIVE

There are limited data on growth hormone-binding protein (GHBP) and free GH levels during the physiological challenge of a prolonged fast. Our aim was to explore the relationships between GHBP, free GH, total GH and non-esterified fatty acid (NEFA) levels during overnight and 24-hour fasts in healthy young adults.

DESIGN

We measured nocturnal levels of GHBP at three time-points (22:00, 03:00, 08:00), NEFA every 60 min and ultra-filtered free GH and total GH at 15-minute intervals for 10 h (22:00-08:00) during an overnight and a 24-hour fast in 7 female and 4 male normal-weight subjects aged 24.8 years (range: 22.8-26.9) with BMI 22.5 kg/m² (range: 18-27).

RESULTS

Spontaneous free and total GH levels were closely related during the overnight and 24-hour fasts (r=0.99, p<0.0001 and r=0.99, p<0.0001 respectively). 24 h of fasting led to an increase in levels of basal free GH (p=0.03), mean free GH (p=0.04), mean total GH (p=0.04) and NEFA (p<0.0001) whilst GHBP levels remained similar (p=0.8). Percentage free (over total) GH was similar during the overnight and prolonged fasts (p=0.3). There were no associations between levels of NEFA and free (r=0.24, p=0.5) or total GH (r=0.20, p=0.6).

CONCLUSIONS

A 24-hour fast led to parallel increases in free and total GH levels whilst there was no discernable change in GHBP levels or the fraction of free GH. This suggests that GHBP plays a role in limiting variations of circulating free GH levels. NEFA levels increased during the prolonged fast but they were not correlated with free or total GH levels.

Gender, sex-steroid, and secretagogue-selective recovery from growth hormone-induced feedback in older women and men

CONTEXT

GH negatively regulates its own secretion. How gender, sex steroids, and secretagogues modulate GH autofeedback is not known.

HYPOTHESIS/OBJECTIVE

Supplementation with sex steroids and/or a peptidyl secretagogue will enhance the escape of GH from autoinhibition, thus framing a mechanism for amplifying pulsatile GH secretion.

SUBJECTS AND SETTING

Ten healthy postmenopausal women and 10 comparably aged men participated at the Clinical-Translational Science Unit.

DESIGN/INTERVENTIONS

Randomly ordered, double-blind, prospective crossover treatment with placebo vs. testosterone (men) or placebo vs. estradiol (women). Autofeedback was imposed by an iv pulse of GH. Recovery of feedback inhibition was quantified during constant infusion of saline, GHRH, or GH-releasing peptide-2 (three peptide categories).

OUTCOMES/RESULTS

During negative feedback, total (integrated) GH recovery depended upon gender (P = 0.017), sex hormone (P < 0.001), and peptide category (P < 0.001). Mechanistic analysis revealed that feedback-suppressed nadir GH concentrations were determined by sex-steroid treatment (P = 0.018) but not by gender (P = 0.444). Peak GH escape was controlled by both treatment (P = 0.004) and gender (P = 0.003). Nadir GH and peak GH during feedback were enhanced by GHRH or GHRP-2 (P < 0.001 for both). Gender × peptide (P = 0.012 for nadir GH), treatment × peptide (P < 0.001 total and peak GH), and gender × treatment (P = 0.017 nadir GH) regulated GH recovery interactively.

CONCLUSION

Gender, sex-steroid supplementation, and secretagogue type confer distinct feedback-rescuing effects, introducing a new level of complexity in the control of pulsatile GH regulation.

Growth hormone isoforms

Human growth hormone (GH) is a heterogeneous protein hormone consisting of several isoforms. The sources of this heterogeneity reside at the level of the genome, mRNA splicing, post-translational modification and metabolism. The GH gene cluster on chromosome 17q contains 2 GH genes (GH1 or GH-N and GH2 or GH-V) in addition to 2(-3) genes encoding the related chorionic somatomammotropin. Alternative mRNA splicing of the GH1 transcript yields two products: 22K-GH (the principal pituitary GH form) and 20K-GH. Post-translationally modified GH forms include N(alpha)-acylated, deamidated and glycosylated monomeric GH forms, as well as both non-covalent and disulfide-linked oligomers up to at least pentameric GH. GH fragments generated in the course of peripheral metabolism may be measured in immunoassays for GH. The GH-N gene is expressed in the pituitary, the GH-V gene in the placenta. Secretion of pituitary GH forms is pulsatile under control from the hypothalamus, whereas secretion of placental GH-V is tonic and rises progressively in maternal blood during the 2nd and 3rd trimester. Pituitary GH forms are co-secreted during a secretory pulse; no isoform-specific stimuli have been identified. There are minor differences in somatogenic and metabolic bioactivity among the GH isoforms, depending on species and assay system used. Both 20K-GH and GH-V have poor lactogenic activity. Oligomeric GH forms have variably diminished bioactivity compared to monomeric forms. GH isoforms cross-react in most immunoassays, but assays specific for 22K-GH, 20K-GH and GH-V have been developed. The metabolic clearance of 20K-GH and GH oligomers is delayed compared to that of 22K-GH. The heterogeneous mixture of GH isoforms in blood is further complicated by the presence of two GH-binding proteins, which form complexes with GH; isoform proportions also vary depending on the lag time from a secretory pulse because of different half-lives. GH forms excreted in the urine reflect monomeric GH isoforms in blood, but constitute only a minute fraction of the GH production rate. The heterogeneity of GH is one important reason for the notorious disparity among assay results. It also presents an opportunity for distinguishing endogenous from exogenous GH.

Overtrained horses alter their resting pulsatile growth hormone secretion

The influence of intensified and reduced training on nocturnal growth hormone (GH) secretion and elimination dynamics was studied in young (1.5 yr) Standardbred geldings to detect potential markers indicative for early overtraining. Ten horses trained on a treadmill for 32 wk in age-, breed-, and gender-matched fixed pairs. Training was divided into four phases (4, 18, 6, and 4 wk, respectively): 1) habituation to high-speed treadmill trotting, 2) normal training, in which speed and duration of training sessions were gradually increased, 3) in this phase, the horses were divided into 2 groups: control (C) and intensified trained (IT) group. In IT, training intensity, duration, and frequency were further increased, whereas in control these remained unaltered, and 4) reduced training (RT). At the end of phases 2, 3, and 4, blood was sampled overnight every 5 min for 8 h for assessment of GH secretory dynamics using pulse detection, deconvolution analysis, and approximate entropy (ApEn). Intensified training induced overtraining (performance decreased by 19% compared with C), which was associated with an increase in concentration peaks number (3.6 vs. 2.0, respectively), a smaller peak secretion pattern with a prolonged half-life (15.2 vs. 7.3 min, respectively), and an increased ApEn (0.89 vs. 0.49, respectively). RT did not lead to full recovery for the overtrained horses. The increased irregularity of nocturnal GH pulsatility pattern is indicative of a loss of coordinated control of GH regulation. Longer phases of somatostatin withdrawal are hypothesized to be the underlying mechanism for the observed changes in GH pulsatility pattern.

Motivations and methods for analyzing pulsatile hormone secretion

Endocrine glands communicate with remote target cells via a mixture of continuous and intermittent signal exchange. Continuous signaling allows slowly varying control, whereas intermittency permits large rapid adjustments. The control systems that mediate such homeostatic corrections operate in a species-, gender-, age-, and context-selective fashion. Significant progress has been made in understanding mechanisms of adaptive interglandular signaling in vivo. Principal goals are to understand the physiological origins, significance, and mechanisms of pulsatile hormone secretion. Key analytical issues are: 1) to quantify the number, size, shape, and uniformity of pulses, nonpulsatile (basal) secretion, and elimination kinetics; 2) to evaluate regulation of the axis as a whole; and 3) to reconstruct dose-response interactions without disrupting hormone connections. This review will focus on the motivations driving and the methodologies used for such analyses.

Determination of free growth hormone

CONTEXT

Approximately 50% of circulating GH is bound to the high-affinity GH-binding protein (GHBP), which is known to affect the pharmacokinetics, bioactivity, and quantitative determination of GH. Nevertheless, the presence of GHBP is rarely taken into account in the clinical use of GH measurements.

OBJECTIVE

Our objective was to develop an assay for free GH in serum.

METHODS

We used ultrafiltration by centrifugation. Due to the small molecular difference between GH and GHBP, the size of GHBP and GHBP-GH complexes was increased by preincubation of serum with a monoclonal GHBP antibody (MAb 263).

RESULTS

The ultrafiltration membrane almost completely retained all GHBP (>98.5%) and allowed free passage of unbound GH (>98.4%). Addition of increasing concentrations of GHBP reduced free GH dose dependently, and measured and calculated levels of free GH changed in parallel. During an insulin-tolerance test, free and total GH changed in parallel in all individuals (n = 11) and their peak values as well as area under the curve values were positively correlated (r = 0.89; P < 0.001 and r = 0.92; P < 0.001, respectively). Of note, the relative levels of free GH (calculated as the area under the curve of free to total GH) was inversely correlated with GHBP (r = -0.94; P < 0.001).

CONCLUSION

It is possible to measure free GH in human serum. Free GH correlated positively with total GH and inversely with GHBP. Measurement of free GH may be a helpful future tool in the management of GH disorders and in studies of GH-GHBP interrelationships.

Aspects of placental growth hormone physiology

Placental growth hormone (PGH) has been known for 20 years. Nevertheless, its physiology is far from understood. In this review, basal aspects of PGH physiology are summarised and put in relation to the highly homologous pituitary growth hormone (GH). During normal pregnancy, PGH progressively replaces GH and reach maximum serum concentrations in the third trimester. A close relationship to insulin-like growth factor (IGF)-I and -II levels is observed. Furthermore, PGH levels are positively associated to fetal growth. The potential importance of growth hormone receptors and binding protein for PGH effects is discussed. Finally, the review outlines current knowledge of PGH in pathological pregnancies.

Kinetics and secretion of placental growth hormone around parturition

OBJECTIVE

During pregnancy, placental growth hormone (PGH) is secreted into the maternal circulation, replacing pituitary GH. It is controversial whether PGH levels decline during vaginal birth. After placental expulsion, PGH is eliminated from the maternal blood. GH binding protein (GHBP) and body mass index (BMI) influence GH kinetics, but their impact on PGH kinetics is unknown. The present study was undertaken to define the kinetics of PGH during vaginal delivery and Caesarian section and to relate these kinetics to GHBP and BMI.

DESIGN

A short term, prospective cohort study.

METHODS

Twelve women had repeated blood samples drawn during vaginal delivery. From 26 women undergoing planned Caesarian delivery (CS) repeated blood samples were withdrawn before, during and after the CS, allowing PGH half-life determination.

RESULTS

During vaginal delivery, median PGH values did not change before expulsion of the placenta, although individual fluctuations were seen. Clearance of PGH from the maternal circulation was best described by a two-compartment model. The initial half-life of serum PGH was (mean +/- s.d.) 5.8 +/- 2.4 min, and the late half-life was (median) 87.0 min (range: 25.1-679.6 min). The late half-life was correlated to the pre-gestational BMI (r = 0.39, P = 0.047), but not to the serum GHBP concentration.

CONCLUSIONS

Serum PGH did not decrease significantly during vaginal delivery. Elimination of PGH fitted a two-compartment model, with an estimated initial half-life of 5.8 min. The late phase serum half-life of PGH was related to BMI, suggesting a role for maternal fat mass in PGH metabolism.

Physiology and pathophysiology of growth hormone-binding protein: methodological and clinical aspects

Circulating GH is partly bound to a high-affinity binding protein (GHBP), which in humans is derived from cleavage of the extracellular domain of the GH receptor. The precise biological function GHBP is unknown, although a regulation of GH bioactivity appears plausible. GHBP levels are determined by GH secretory status, body composition, age, and sex hormones, but the cause-effect relationships remain unclarified. In addition to the possible in vivo significance of GHBP, the interaction between GH and GHBP has methodological implications for both GH and GHBP assays. The present review concentrates on methodological aspects of GHBP measurements, GHBP levels in certain clinical conditions with a special emphasis on disturbances in the GH-IGF axis, and discusses the possible relationship between plasma GHBP and GH receptor status in peripheral tissues.

Prolactin and growth hormone signaling

Prolactin (PRL) and growth hormone (GH) act by way of their receptors as either hormones (systemically) or cytokines (locally). The Jak2/Stat5 pathway is the principal route by which PRL/GH activate target genes. The availability of knockout mice for each member of this signaling cascade has provided opportunities to understand their unique interactions. Jak2 is important in alternative signal transduction schema such as the MAP kinase and PI3K/Akt pathways. The putative Jak2/RUSH pathway is based on the fact that RUSH mediates the ability of PRL to augment progesterone-dependent gene transcription. New evidence shows that suppressors, regulators, and degraders control Jak2/Stat5. This review focuses on the most recent advances in the field of PRL/GH signal transduction.

Growth hormone binding protein and maternal body mass index in relation to placental growth hormone and insulin requirements during pregnancy in type 1 diabetic women

In pregnancy, the growth hormone axis is shifted from pituitary growth hormone (GH) to placental growth hormone (PGH). Their common binding protein, GH binding protein (GHBP), displays peak serum levels at mid-gestation in normal individuals. In the non-pregnant state, diabetes is known to be associated with elevated levels of GH and decreased levels of insulin-like growth factors (IGFs) and GHBP. Diabetes in pregnancy may therefore as well be associated with disturbances in the growth hormone axis. In the present study, we aimed at investigating the impact of GHBP and maternal body mass index (BMI) on levels of PGH, thereby enabling estimation of any association between free PGH and weight adjusted insulin requirements. In 51 type 1 diabetic women, blood samples were collected in gestational week 10+, 16+, 22+, 28+ and 34+, and analysed for their serum content of GHBP, PGH, and GH. Serum GHBP increased from the first weeks of pregnancy to median 2.07 nmol/l (range 1.17-4.26) in week 22+, then declined to median 1.29 nmol/l (range 0.77-2.35) in week 34+ (ANOVA P < 0.001). Serum PGH levels were highest in week 34+ at median 21.3 microg/l (range 5.1-165.4) (P < 0.001), whereas a steady decrease in GH values was observed throughout pregnancy to a median 0.17 microg/l (range 0-5.53). The fraction of calculated free PGH to total PGH increased from mid-gestation onwards to 55.2% (37.0-87.1) in week 34+ at a median level of free PGH of 10.4 microg/l (range 1.9-144.0) (P < 0.001). Similarly, the molar ratio of total PGH to GHBP increased to a maximum of 0.68 (0.12-6.62) in week 34+. As in normal pregnancies, the correlation between BMI and GHBP was lost in late pregnancy. The newborns birth weight z-score correlated with total PGH and derivatives here-of in week 34+. Neither total nor weight adjusted insulin requirements correlated to total PGH, calculated free PGH, nor GHBP. In conclusion, PGH and GHBP display a similar course during pregnancy in type 1 diabetic women as described in normal women. The well-known association between GHBP and BMI was lost in late pregnancy. Calculated levels of free PGH were positively associated to fetal growth, but not to maternal insulin requirements.

In vitro bioassay as a predictor of in vivo response

Background

There is a substantial discrepancy between in vitro and in vivo experiments. The purpose of the present work was development of a theoretical framework to enable improved prediction of in vivo response from in vitro bioassay results.

Results

For dose-response curve reaches a plateau in vitro we demonstrated that the in vivo response has only one maximum. For biphasic patterns of biological response in vitro both the bimodal and biphasic in vivo responses might be observed.

Conclusion

As the main result of this work we have demonstrated that in vivo responses might be predicted from dose-effect curves measured in vitro.

Laboratory measurement of growth hormone

Growth hormone (GH) measurements are complicated by the heterogeneous nature of GH, as well as by the presence of the GH binding protein in plasma. Several isoforms of GH exist, and specific assays for each are currently either unavailable, impractical, or not clinically indicated. Bioassays include the in vivo assays based on rat weight gain, tibial line widening, or IGF-I generation. In vitro bioassays, based on the proliferation of cell lines expressing the prolactin receptor or GH receptor, are sensitive but prone to nonspecific interference by factors present in serum. Immunoassays (RIA, IRMA, ELISA, and immunofunctional assay design) are widely used in the clinical laboratory because of speed, sensitivity, and convenience. Discrepancies among results rendered by different immunoassays have become more apparent as monoclonal assays have superseded polyclonal assays, presumably because different antibodies recognize different epitopes among the heterogeneous mixture of GH isoforms in serum. Some assays, especially those with short, nonequilibrium incubation times are vulnerable to interference by the GH binding protein present in serum. Recommendations are given for strategies designed to minimize disparity of results obtained by different GH immunoassays applied to serum. Urinary GH measurements, while technically feasible, are of limited clinical utility because of biological variation in urinary GH excretion.

A truncated isoform of c-Mpl with an essential C-terminal peptide targets the full-length receptor for degradation

Thrombopoietin and its cognate receptor c-Mpl are the primary regulators of megakaryopoiesis and platelet production. They also play an important role in the maintenance of hematopoietic stem cells. Here, we have analyzed the function of a truncated Mpl receptor isoform (Mpl-tr), which results from alternative splicing. The mpl-tr variant is the only alternate mpl isoform conserved between mouse and humans, suggesting a relevant function in regulating Mpl signaling. Despite the presence of a signal peptide and the lack of a transmembrane domain, Mpl-tr is retained intracellularly. Our results provide evidence that Mpl-tr exerts a dominant-negative effect on thrombopoietin-dependent cell proliferation and survival. We demonstrate that this inhibitory effect is due to down-regulation of the full-length Mpl protein. The C terminus of Mpl-tr, consisting of 30 amino acids of unique sequence, is essential for the suppression of thrombopoietin-dependent proliferation and Mpl protein down-regulation. Cathepsin inhibitor-1 (CATI-1), an inhibitor of cathepsin-like cysteine proteases, counteracts the effect of Mpl-tr on Mpl protein expression, suggesting that Mpl-tr targets Mpl for lysosomal degradation. Together, these data suggest a new paradigm for the regulation of cytokine receptor expression and function through a proteolytic process directed by a truncated isoform of the same receptor.

Differential impact of simple childhood obesity on the components of the growth hormone-insulin-like growth factor (IGF)-IGF binding proteins axis

Simple childhood obesity is characterized by normal or even accelerated growth in spite of reduced growth hormone (GH) secretion. There are conflicting reports on the effects of obesity upon components of the GH-insulin-like growth factor-I (IGF-I)-IGF binding proteins (IGFBPs) system. In the present study we aimed to determine GH, IGF-I, IGFBP-3 and IGFBP-2 as well as some of the less explored components of this axis (IGFBP-3 proteolytic activity, IGFBP-3 plasma fragments, and total acid labile subunit [ALS]) in 22 obese and 17 age-matched control children. We also evaluated not only total GH binding protein (GHBP) serum levels but also GHBP bound to GH (complexed) in both groups. Obese and control groups strongly differed in BMI (obese: 4.7 +/- 0.36 vs control: 0.37 +/- 0.25 SDS, p <0.0001). In the obese group, we found lower GH serum levels, but normal serum levels of GH-GHBP complex, IGF-I, IGFBP-3, IGF-I/IGFBP-3 molar ratio, IGFBP-3 proteolytic activity, IGFBP-3 plasma fragments and total ALS. Obese children presented higher total circulating GHBP (6.0 +/- 0.44 vs 2.9 +/- 0.29 nmol/l, p <0.001) and insulin levels (10.5 +/- 1.5 vs 5.1 +/- 0.8 mU/l, p <0.001), while IGFBP-2 (4.6 +/- 0.5 vs 6.6 +/- 0.7%, p <0.05) and the ratio IGFBP-2/IGF-I (0.032 +/- 0.019 vs 0.095 +/- 0.01, p = 0.013) were lower than in controls. BMI and insulin were directly, and IGFBP-2 serum levels inversely, correlated to total GHBP serum levels when multiple regression analysis was performed (r = 0.74, p <0.001). By stepwise regression analysis, insulin (r = -0.37, p <0.05) and BMI (r = -0.52, p <0.01) inversely determined IGFBP-2. In summary, obese children present normal growth in spite of reduced GH secretion, probably because the combination of increased total GHBP and normal GH-GHBP complex serum levels (suggesting increased GH receptor [GHR] number and a normal serum GH reservoir, respectively) allow for the achievement of normal levels of IGF-I, IGFBP-3, IGFBP-3 proteolytic activity, IGFBP-3 plasma fragments and total ALS. Reduced IGFBP-2 serum levels and a lower ratio of IGFBP-2/IGF-I in obese children may suggest an increase of tissue IGF-I bioavailability, thus promoting its action. Normal IGF-I and GH availability may be contributing to maintain normal growth in obese children.

Sex-steroid modulation of growth hormone (GH) secretory control: three-peptide ensemble regulation under dual feedback restraint by GH and IGF-I

Technical, genetic, and clinical developments have unveiled a burgeoning array of novel effectors of GH secretion. The present appraisal of central neuroregulatory components of the somatotropic axis highlights a simplifying concept of ensemble control by the final common peptides, GH-releasing hormone (GHRH), GH-releasing peptide(s) (GHRP, ghrelin), and somatostatin. These potent signals act individually, antagonistically, and synergistically to direct pulsatile GH secretion. GHRH, GHRP/ghrelin, and somatostatin further adapt to autonegative feedback by GH and IGF-I. Estradiol modulates the impact of each of the primary peptidyl inputs; viz.: (i) enhances submaximally effective feedforward by discrete pulses of (injected) recombinant human GHRH-1,44-amide (as defined by increased agonistic potency and pituitary sensitivity); (ii) potentiates the submaximally stimulatory effects of GHRP-2, a hexapeptidyl mimetic of ghrelin; (iii) blunts dose-dependent inhibition of fasting GH secretion by somatostatin- 14; and (iv) relieves rhGH-enforced negative feedback on GHRP-2 (but not on basal, exercise, or GHRH)-stimulated GH secretion. The foregoing estrogenic activities collectively augment GH secretory burst mass by amplifying feedforward (via both GHRH and GHRP) and attenuating feedback (imposed by somatostatin and GH). Whether testosterone fully mimics the foregoing mechanistic actions of estradiol is not known. In conclusion, the present conceptual platform of tri-peptide-directed feedforward and GH/IGF-I-mediated feedback should aid in unraveling some of the complex regulatory dynamics targeted by sex-steroid hormones.

Human GH pulsatility: an ensemble property regulated by age and gender

Age and gender impact the full repertoire of neurohormone systems, including most prominently the somatotropic, gonadotropic and lactotropic axes. For example, daily GH production is approximately 2-fold higher in young women than men and varies by 20-fold by sexual developmental status and age. Deconvolution estimates of 24-h GH secretion rates exceed 1200 microg/m2 in adolescents and fall below 60 microg/m2 in aged individuals. The present overview highlights plausible factors driving such lifetime variations in GH availability, i.e., estrogen, aromatizable androgen, hypothalamic peptides and negative feedback by GH and IGF-I. In view of the daunting complexity of potential neuromodulatory signals, we underline the utility of conceptualizing a simplified three-peptide regulatory ensemble of GHRH, GHRP (ghrelin) and somatostatin. The foregoing signals act as individual and conjoint mediators of adaptive GH control. Regulation is enforced at 3-fold complementary time scales, which embrace pulsatile (burst-like), entropic (orderly) and 24-h rhythmic (nycthemeral) modes of GH release. This unifying platform offers a convergent perspective of multivalent control of GH outflow.

Neuroendocrine facets of human puberty

The unfolding of pubertal growth and maturation entails multisystem collaboration. Most notably, the outflow of gonadotropins and growth hormone (GH) proceeds both independently and jointly. The current update highlights this unique dependency in the human.

Impact of experimental blockade of peripheral growth hormone (GH) receptors on the kinetics of endogenous and exogenous GH removal in healthy women and men

Organs that respond to and metabolize GH are enriched in cognate high-affinity receptors. However, whether isologous receptors mediate the de facto access of ligand to cellular degradative pathways is not known. To address this query, we assessed the distribution and whole-body elimination kinetics of (endogenous and exogenous) GH before and after administration of a novel, potent, and selective recombinant human (rh) GH receptor antagonist peptide, pegvisomant. Sixteen healthy young adults (nine men and seven women) participated in a double-blind, prospectively randomized, within-subject cross-over study. The intervention comprised a single sc injection of placebo vs. a high dose of pegvisomant (1 mg/kg sc) timed 62 and 74 h before the overnight sampling and daytime infusion sessions, respectively. The half-life, metabolic clearance rate (MCR), and distribution volume of GH were quantitated by way of: 1) deconvolution analysis of serum GH concentration time series collected every 10 min for 10 h; 2) exponential regression analysis of the decay of GH concentrations after a 6-min iv pulse of rhGH (1 and 10 micro g/kg); 3) calculation of the MCR during constant iv infusion of rhGH (0.5 and 5.0 micro g/kg every 2 h); and 4) exponential fitting of the elimination time-course of GH concentrations following cessation of each constant infusion. Concentrations of GH and pegvisomant were measured in separate, noncross-reactive, two-site monoclonal, immunofluorometric assays. Pegvisomant concentrations averaged 4860 +/- 480 micro g/liter (+/-SEM) across the infusion interval, thus exceeding low steady state GH concentrations by 3000-fold. Inhibitory efficacy of the GH receptor antagonist peptide was affirmed by way of a 34% reduction in the serum total IGF-I concentration, i.e., from 257 +/- 37 (placebo) to 170 +/- 24 (drug) micro g/liter (P < 0.001); and a reciprocal 77% elevation of the (10-h) mean GH concentration, i.e., from 1.3 +/- 0.23 (placebo) to 2.3 +/- 0.42 (drug) micro g/liter (P = 0.003). ANOVA disclosed that prior administration of pegvisomant (compared with placebo) did not alter: 1) the calculated half-life (minutes) of secreted GH, which averaged 15 +/- 1.3 (placebo) and 14 +/- 0.69 (drug); 2) the half-time of disappearance (minutes) of an iv pulse of rhGH, 15 +/- 1.0 (placebo) and 13 +/- 0.5 (drug) (for the 10 micro g/kg dose); 3) the distribution volume (milliliters per kilogram) of rhGH, 59 +/- 6.2 (placebo) and 58 +/- 3.5 (drug); 4) the steady state GH concentration (micrograms per liter) attained during constant iv infusion of rhGH (at a rate of 5 micro g/kg every 2 h), 18.2 +/- 2.4 (placebo) and 18.3 +/- 2.3 (drug); 5) the half-life (minutes) of elimination of GH from equilibrium, 16 +/- 0.98 (placebo) and 16 +/- 1.8 (drug); and 6) the steady state MCR (liters per kilogram per day) of rhGH, 3.8 +/- 0.32 (placebo) and 3.5 +/- 0.31 (drug). In ensemble, the present data refute the a priori postulate that vascular-accessible GH receptors determine the in vivo pseudoequilibrium kinetics of GH disappearance in the human.

Pharmacokinetics and acute lipolytic actions of growth hormone. Impact of age, body composition, binding proteins, and other hormones

The biologic actions of endogeneous growth hormone (GH) depend on its secretion and clearance rates as well as sensitivity at the receptor level. Aberrations in GH pharmacokinetics and pharmacodynamics may occur with increasing age, and have been implicated in diseases such as obesity, diabetes mellitus, and critical illness. In this review, recent insights into the association between GH metabolism and age, body composition, binding proteins and other hormones are discussed.

Altered GH elimination kinetics in type 1 diabetes mellitus can explain the elevation in circulating levels: bicompartmental approach

Type 1 diabetes mellitus (DM 1) is associated with elevated circulating GH concentrations. Because these high GH levels could be explained either by an augmented pituitary secretion and/or delayed elimination clearance or distribution, we sought to evaluate GH pharmacokinetics to propose a model that better explains the elimination kinetics in patients with DM 1 and assess possible differences with normal volunteers that could justify elevation in GH circulating levels in these patients. A multicompartmental analysis was applied to serum GH concentrations measured at different times for 150 min in six patients with DM 1 and six age-, sex-, and body mass index-matched normal subjects after the administration of an iv bolus of recombinant human GH (200 microg), previous suppression of endogenous GH release with octreotide. The best fitting to the GH disappearance profiles was obtained with the biexponential equation in both groups. From it, we propose a bicompartmental model to explain GH kinetics in normal and diabetic patients. The mean transit time in both compartments and the mean residence time in patients with DM 1 were more than twice the values from control group. So in DM 1 elevated circulating GH concentrations are, at least partially, caused by a delayed GH plasmatic clearance. The DM 1 patients included in this study had a normal renal function; thus, our results agree with the hypothesis that DM 1 constitutes a GH-insensitivity state because a reduced GH clearance by its receptor-mediated mechanism might explain the delayed GH elimination kinetics shown in patients with DM 1. However, the possibility of additional factors contributing to the slowed GH removal from circulation is not completely excluded.

Growth hormone treatment in adults: is there a true gender difference?

The importance of growth hormone (GH) deficiency in adults became evident at the end of the 1980s, when the first clinical studies on GH replacement therapy in adults were published. Since then, accumulated experience has shown a great individual variability in the response to GH replacement, including a potential difference in responsiveness between genders. The aim of this paper is to review the data regarding the effects of gender differences on GH pharmacokinetics, pharmacodynamics, and efficacy of replacement. In addition, we start with a short review of the possible role of GH in sexual development and sexual life.

Growth hormone binding protein 2001

The present state of knowledge about growth hormone binding proteins (GHBP) is reviewed, with particular emphasis on the high affinity GHBP, which represents the circulating ectodomain of the growth hormone receptor (GHR). GHBP is conserved through vertebrate evolution, is produced in many tissues (especially liver) by either alternative GHR mRNA splicing (rodents) or by proteolytic cleavage from the GHR (humans, rabbits and several other species). The metalloprotease TACE (tumor necrosis factor-alpha converting enzyme) is the likely enzyme responsible for cleavage, but the structural requirements for TACE recognition or catalysis, and hence the precise cleavage point in the GHR, are unknown. GHBP is widely distributed in biological fluids, with marked concentration differences amongst them. GHBP binds about half of the circulating GH under basal conditions but is easily saturated at high GH levels; it subserves complex functions, including a circulating buffer/reservoir function for GH, prolongation of plasma GH half-life, competition with GHRs for GH, and probably unproductive heterodimer formation with the GHR. The net effect of these partly enhancing and partly inhibitory functions on GH action in vivo is complex and difficult to ascertain. Serum GHBP levels roughly parallel GHR expression (particularly in liver) through the life span, with very low levels in fetal life, upregulation to adult levels during childhood, and decline in senescence. Rodent pregnancy is associated with a massive increase in GHBP expression. Although the regulation of GHBP expression/production is not necessarily tightly linked to GHR expression, in general, low GHBP levels occur in conditions associated with GH resistance (e.g., malnutrition, uncontrolled diabetes, catabolic states, renal failure, hypothyroidism). Conversely, obesity, a condition with enhanced GH responsivity, is associated with elevated GHBP levels. This suggests that in many (but not all) instances of abnormal GH action, the GHBP level reflects GHR status. Laron syndrome (genetic GHR deficiency/dysfunction due to mutations in the GHR gene) is associated with low or undetectable GHBP in 75-80% of patients; GHBP measurement can therefore be used diagnostically. Depending on the design of assays for serum GH, endogenous GHBP may interfere to varying degrees, and GH assays should be individually validated and optimized in this regard. The ultimate biological role and physiological significance of the GHBP remain to be established.

Estimation of growth hormone secretion rate: impact of kinetic assumptions intrinsic to the analytical approach

We compared four common mathematical techniques to determine daily endogenous growth hormone (GH) secretion rates from diurnal plasma GH concentration profiles in 24 women (16 upper- or lower-body obese and 8 normal-weight individuals). Two forms of deconvolution analysis and two techniques based on a priori determined GH clearance estimates were employed. Deconvolution analyses revealed significant differences in the 24-h GH secretion rate between normal-weight and upper-body obese women, whereas the other two techniques did not. Moreover, deconvolution analyses predicted that the reduction in mean plasma GH concentrations in upper-body obese women was accounted for by impaired GH secretion, whereas the other methods suggested that obesity increases GH metabolic clearance. Thus we infer that disparate conclusions concerning GH secretion can be drawn from the same primary data set. The different inferences likely reflect dissimilar kinetic assumptions and the particular limitations intrinsic to each analytical approach. Accordingly, we urge caution in the facile comparison of calculated GH secretion data in humans, especially when kinetic and secretion measurements are performed under different conditions. The most appropriate way to determine the GH secretion rate in humans must be balanced by the exact intent of the experiment and the acceptability of different assumptions in that context.

Explicating hypergonadotropism in postmenopausal women: a statistical model

Neurohormone secretion is viewed here as a variable (unknown) admixture of basal and pulsatile release mechanisms, convolved with individually fitted biexponential elimination kinetics. This construct allows maximum-likelihood estimates of both (regulated and constitutive) components of hormone secretion. Thereby, we infer that a prolonged slow-component half-life of gonadotropin removal and amplified pulsatile (and total) daily luteinizing hormone (LH) secretion rates jointly explicate the postmenopausal elevation in serum LH concentrations without a necessary rise in basal LH secretion rates. This biomathematical formulation should be useful in exploring other neuroregulatory mechanisms that underlie single or dual alterations in the basal versus pulsatile modes of hormone secretion.

Influence of obesity and body fat distribution on growth hormone kinetics in humans

We studied the kinetics of exogenous recombinant 22-kDa human growth hormone (rhGH) in premenopausal women with upper body obesity (UBO), lower body obesity (LBO), or normal body weight. A bolus of 100 mU rhGH was administered during a continuous infusion of somatostatin to suppress endogenous GH secretion. GH kinetics were investigated with noncompartmental analysis of plasma GH curves. GH peak values in response to GH infusion and plasma half-life of GH were not significantly different between normal weight and obese subjects. In contrast, GH clearance was 33% higher in LBO women and 51% higher in UBO women compared with clearance in normal weight controls. The difference in clearance between LBO and UBO was not statistically significant. Altered GH clearance characteristics contribute to low circulating GH levels in obese humans. Body fat distribution does not appear to affect GH kinetics.

Impact of acute exercise intensity on pulsatile growth hormone release in men

To investigate the effects of exercise intensity on growth hormone (GH) release, 10 male subjects were tested on 6 randomly ordered occasions [1 control condition (C), 5 exercise conditions (Ex)]. Serum GH concentrations were measured in samples obtained at 10-min intervals between 0700 and 0900 (baseline) and 0900 and 1300 (exercise+ recovery). Integrated GH concentrations (IGHC) were calculated by trapezoidal reconstruction. During Ex subjects exercised for 30 min (0900-0930) at one of the following intensities [normalized to the lactate threshold (LT)]: 25 and 75% of the difference between LT and rest (0.25LT and 0.75LT, respectively), at LT, and at 25 and 75% of the difference between LT and peak (1.25LT and 1.75LT, respectively). No differences were observed among conditions for baseline IGHC. Exercise+recovery IGHC (mean +/- SE: C = 250 +/- 60; 0.25LT = 203 +/- 69; 0.75LT = 448 +/- 125; LT = 452 +/- 119; 1.25LT = 512 +/- 121; 1.75LT = 713 +/- 115 microg x l(-1) x min(-1)) increased linearly with increasing exercise intensity (P < 0.05). Deconvolution analysis revealed that increasing exercise intensity resulted in a linear increase in the mass of GH secreted per pulse and GH production rate [production rate increased from 16. 5 +/- 4.5 (C) to 32.1 +/- 5.2 microg x distribution volume(-1) x min(-1) (1.75LT), P < 0.05], with no changes in GH pulse frequency or half-life of elimination. We conclude that the GH secretory response to exercise is related to exercise intensity in a linear dose-response pattern in young men.

Evaluation of growth hormone assays using ratio plots

To permit comparison between growth hormone (GH) results obtained using the Pharmacia polyclonal assay and the Delfia monoclonal assay, we used both methods to measure GH concentrations in peak GH responses to the pyridostigmine-growth-hormone-releasing-hormone (PD-GHRH) test and in unstimulated samples from 40 healthy adults and 31 patients with suspected GH deficiency. Ratio plots were used for the comparison, and acceptability criteria were based on inherent analytical imprecision and on analytical quality specifications. The mean ratio (r; Pharmacia/Delfia) for the peak GH responses in 40 healthy adults was calculated to be 1.59, and the 95% prediction interval for ratios fulfilling the imprecision criterion was applied. For GH values &gt;1 mIU/L, the peak and unstimulated GH ratios in healthy adults and patients were within the 95% prediction interval, and fulfilled the biological criterion as well. Therefore, the conversion factor of 1.59 is applicable for the evaluation of GH-stimulation tests.

Granulocyte colony-stimulating factor receptor expression on human transitional cell carcinoma of the bladder

Receptors for granulocyte colony-stimulating factor (G-CSFRs) have been confirmed on the cell surfaces of several non-haematopoietic cell types, including bladder cancer cells. This observation has naturally led to the hypothesis that the expression of G-CSFR on these cells may enhance their growth by G-CSF. In this study, the expression of G-CSFR was determined in both established human bladder cancer cell lines and primary bladder cancers. We studied five different human bladder cancer cell lines (KU-1, KU-7, T-24, NBT-2 and KK) and 26 newly diagnosed bladder tumours. G-CSFR mRNA expressions on cultured cell lines were determined using the reverse transcriptase polymerase chain reaction (RT-PCR) method. Furthermore, the G-CSFR binding experiments on the cultured cell lines were conducted using the Na(125)I-labelled G-CSF ligand-binding assay method. Moreover, the G-CSFR mRNA expressions on primary bladder tumour specimens were assessed using the in situ RT-PCR method. Three out of the five cultured cell lines (KU-1, NBT-2 and KK) exhibited G-CSFR mRNA signals when the RT-PCR method was used. The G-CSFR binding experiments showed an equilibrium dissociation constant (K[d]) of 490 pM for KU-1, 340 pM for NBT-2 and 103 pM for KK cells. With in situ RT-PCR, the tumour cells of 6 out of 26 primary bladder tumour specimens (23.1%) presented positive G-CSFR mRNA signals. Thus, in this study, G-CSFR expression was frequently observed on bladder cancer cells. Therefore, the clinical use of G-CSF for patients with bladder cancer should be selected with great care.

Growth hormone binding protein and free growth hormone in chronic renal failure

Chronic renal failure in children is associated with growth failure. While the pathogenesis of uremic growth failure is multifactorial, an abnormal growth hormone/ insulin-like growth factor (GH-IGF) axis is an important contributory element. Patients with uremia exhibit insensitivity to the action of GH, as exemplified by high plasma GH levels, low IGF-I activity, and poor somatic growth. This insensitivity can be overcome by supraphysiological doses of exogenous GH. Plasma GH binding protein (GHBP, the circulating ectodomain of the GH receptor) levels are decreased in patients with renal failure, as are hepatic GH receptor levels in animal models. Since GHBP levels are thought to reflect GH receptor levels in tissues, it is likely that the uremic GH insensitivity in humans is mediated by a decreased number of GH receptors. Another implication of the low plasma GHBP is a disproportionate elevation of free plasma GH (the biologically active moiety) relative to total GH, lending additional support to the concept of GH insensitivity in uremia. GH kinetics are altered in renal failure because of: (1) inability to excrete GH and (2) changes in the bound fraction of GH in the circulation.

Facilitation of the growth promoting effect of growth hormone (GH) by an antibody to methionyl-GH

Despite the development of antibodies to methionyl growth hormone in a child with hypopituitarism, the patient grew at a rapid rate on low doses of somatotropin. Serum immunoglobulins from this patient stimulated the growth of Nb2 lymphoma cells in vitro in samples obtained within 48 hours after the last dose of growth hormone, while samples obtained several weeks after an injection of methionyl growth hormone did not. Immunoglobulins from normal subjects or from hyposomatotropic patients being treated with methionyl growth hormone who had not developed antibodies did not stimulate Nb2 lymphoma cell growth. We suggest that the antibodies to methionyl growth hormone in this child served as a reservoir for exogenous growth hormone or facilitated the interaction of growth hormone with the prolactin receptor on the Nb2 lymphoma cell.

Analytical methods for evaluating episodic secretory activity within neuroendocrine axes

We review here our recent analytical methods designed to: (a) detect abrupt increases and decreases in serially measured concentrations of hormones, substrates, or metabolites in body fluids (discrete peak detection); (b) carry out combined calculations of in vivo hormone secretion and metabolic clearance without the infusion of labeled compounds (deconvolution analysis); and (c) assess nonequilibrium concentrations of total, bound, and free hormones or effectors following the injection or secretion of finite amounts of one or more ligands into a closed compartment containing high-affinity transport or binding proteins. First, in relation to discrete peak detection, we illustrate the application of Cluster analysis to immunoradiometrically assayed growth hormone (GH) profiles collected in blood sampled every 30 s over night in healthy young men. Secondly, as examples of deconvolution analysis, both a waveform-independent and a waveform-specific methodology are presented, and their applications discussed (e.g., for episodic GH secretion). Thirdly, to illustrate nonequilibrium interactions between a single blood transporter protein and a hormone/ligand, we highlight the impact of the high-affinity GH binding protein in plasma on the nonsteady-state time course of GH secretion and removal. Collectively, these novel neuroendocrine tools permit a more demanding and quantitative analysis of the temporal regulation of hormone, substrate, or metabolite secretion, distribution, interconversion, irreversible metabolic removal, and association with one or more high- or low-affinity plasma binding proteins. Based upon these dynamic principles, the complex operation of neuroendocrine feedback axes in vivo can be defined and assessed quantitatively and relevant hypotheses of regulation formulated and tested specifically.

Metabolic effects of growth hormone administered subcutaneously once or twice daily to growth hormone deficient adults

OBJECTIVE

The aim of this study was to compare the metabolic effects of GH administered subcutaneously either once or twice daily. The actions of GH might depend upon a pulsatile pattern of serum GH. Pulsatile and continuous intravenous delivery of GH, however, induce similar short-term metabolic effects in GH deficient patients. An improved growth response is obtained in GH deficient children when a fixed weekly GH dose is administered by daily subcutaneous injections instead of twice or thrice-weekly intramuscular injections. A more pulsatile pattern and serum GH levels above zero might be achieved by further increasing the injection frequency. Increased daytime GH levels might, however, adversely affect the circadian patterns of metabolic indices, which have been demonstrated to be more successfully reproduced by evening compared with morning GH administration.

DESIGN AND MEASUREMENTS

In a cross-over study, 8 GH deficient patients (age 16-43 years) were treated with 3 IU/m2/24 h of human GH. The dose was injected in the evening for 4 weeks and for another 4 weeks two-thirds was injected in the evening and one-third in the morning. At the end of each period the patients were admitted to the hospital for 37 hours. Steady-state profiles of GH, IGF-I, IGF binding proteins 1 and 3, insulin, glucose, lipid intermediates and metabolites were obtained following administration of 3 IU/m2 of GH (at 1900 h (one injection) and at 1900 and 0800 h (two injections)).

RESULTS

Similar mean integrated levels of serum GH (mU/l) were obtained (7.46 +/- 0.84 (one injection) vs 6.46 +/- 0.62 (two injections) (P = 0.15)). Mean levels +/- SEM of serum IGF-I (micrograms/l) were significantly increased (P < 0.01) following two daily GH injections (330.3 +/- 48.1 (one injection) vs 399.1 +/- 53.0 (two injections)). Serum IGFBP-3 levels were not significantly different on the two occasions, while levels of the GH independent IGFBP-1 (micrograms/l) were slightly but significantly lower following twice-daily GH injections (1.61 +/- 0.42 vs 1.13 +/- 0.56, respectively (P < 0.04)). The pattern of IGFBP-1 was opposite to that of insulin. Similar levels of insulin and glucose were obtained with both GH regimens, while levels of non-esterified fatty acids were significantly higher following once-daily GH injection (P < 0.001).

CONCLUSIONS

Twice-daily GH injections, apart from producing a more physiological serum GH profile, were superior to one injection in increasing serum IGF-I and decreasing IGFBP-1 levels. Both of these changes tend to amplify the effects of the administered GH. Twice-daily injections, however, resulted in lower night-time levels of lipid intermediates.

Heterogeneity of circulating growth hormone

Human growth hormone (GH) represents a family of related proteins arising from two genes, alternative mRNA splicing, and several post-translational modifications. In addition, post-secretory events occur when GH enters the circulation. The full scale of GH heterogeneity is only beginning to be appreciated, and new GH forms or related proteins may be discovered in the future. GH measurements are affected by GH heterogeneity. Immunoassays are influenced by the mixture of GH variants, but are not sensitive to GH binding proteins (GHBPs). In contrast, radioreceptor assays are sensitive to both GH variant mixtures and to the high affinity GHBP. It is hoped that in the future, these problems can be minimized by rigorous characterization of existing antibodies with respect to epitope recognition on various GH forms, and ultimately, by production of GH variant-specific antibodies that permit direct and individual assessment of the circulating members of the GH family.

Metabolic clearance of recombinant human growth hormone in health and chronic renal failure

Despite the increasing therapeutic use of recombinant human growth hormone (rhGH), its metabolic clearance has not been investigated in detail. To evaluate the kinetics of rhGH as a possible function of GH plasma concentration and glomerular filtration rate (GFR), we investigated the steady state metabolic clearance rate (MCR), disappearance half-life, and apparent volume of distribution of rhGH at low and high physiological as well as supraphysiological plasma GH levels during pharmacological suppression of endogenous GH secretion in human subjects with normal and reduced renal function. GH in plasma and urine was determined by an immunoradiometric assay, and GFR by inulin clearance. In all subjects MCR decreased and plasma half-life increased with increasing plasma GH concentrations (P < 0.001). MCR of rhGH was approximately half in patients with chronic renal failure at each GH level and plasma half-life was increased by 25-50%. Allowing for the linear dependence of MCR on GFR and assuming single-compartment distribution, the estimated renal fraction of total MCR was 25-53 and 4-15% in controls and patients, respectively. Saturation of extrarenal disposal of GH was suggested by an inverse hyperbolic relationship between extrarenal MCR and plasma GH concentrations in all subjects. Fractional GH excretion was up to 1,000-fold higher in patients than in controls. We conclude that MCR of hGH is a function of plasma GH concentrations and GFR. Extrarenal elimination is saturable in the upper physiological range of GH concentrations, whereas renal MCR is independent of plasma GH levels. The kidney handles GH like a microprotein involving glomerular filtration, tubular reabsorption, and urinary excretion.