Modified Clonidine Testing for Growth Hormone Stimulation Reveals α2-Adrenoreceptor Sub Sensitivity in Children with Idiopathic Growth Hormone Deficiency

Introduction

The association between short stature and increased risk of ischemic heart disease has been subject to studies for decades. The recent discussion of cardiovascular risk during growth hormone therapy has given new importance to this question. We have hypothesized that the autonomic system is a crucial element relating to this subject.

Methods

Heart rate variability calculated from 24-hour electrocardiogram data is providing insight into the regulatory state of the autonomous nervous system and is an approved surrogate parameter for estimating cardiovascular risk. We have calculated heart rate variability during clonidine testing for growth hormone stimulation of 56 children. As clonidine is a well-known effector of the autonomous system, stimulating vagal tone and decreasing sympathetic activity, we compared the autonomous reactions of children with constitutional growth delay (CGD), growth hormone deficiency (GHD) and former small for gestational age (SGA).

Results

During clonidine testing children with CGD showed the expected α₂-adrenoreceptor mediated autonomous response of vagal stimulation for several hours. This vagal reaction was significantly reduced in the SGA group and nearly non- existent in the GHD group.

Discussion

Children with GHD show a reduced autonomous response to clonidine indicating α₂-adrenoreceptor sub sensitivity. This can be found prior to the start of growth hormone treatment. Since reduction of HRV is an approved surrogate parameter, increased cardiovascular risk has to be assumed for patients with GHD. In the SGA group a similar but less severe reduction of the autonomous response to clonidine was found. These findings may enrich the interpretation of the data on growth hormone therapy, which are being collected by the SAGhE study group.     

Comparison of growth hormone sleep release and responses to pharmacological tests

The spontaneous release of growth hormone (GH) during nocturnal sleep was studied at age 5-19 years in 44 male and 15 female patients with severe growth retardation (-2.1 to -6.5 SD) among whom 43 were prepubertal and 16 pubertal. Comparison with the results of classical stimulation tests with ornithine, arginine and/or insulin showed good agreement in cases of classical hypopituitarism (n = 14) as in patients who seemed to be endocrinologically normal (n = 27). In 18 patients (31%) there was a discrepancy between sleep release and responses of GH to stimulation test: treatment with hGH was available in only 4 of these children and enhanced sharply their growth rate. It is suggested that a large span of intermediary situations exists between normal GH secretion and complete GH deficiency, deserving a controlled therapeutic trial with hGH.     

Growth hormone responses to sleep, insulin hypoglycaemia and arginine infusion

This study compares the peak serum growth hormone (GH) concentration during slow wave sleep with the serum GH responses to insulin-induced hypoglycaemia and intravenous arginine infusion in 23 children referred because of short stature (20) or precocious puberty (3). Peak serum GH concentration during sleep correlated significantly with peak GH response to insulin hypoglycaemia (r = 0.64, p less than 0.01) and arginine infusion (r = 0.57, p less than 0.01). 3 children had subnormal (less than 15 mU/l) peak serum GH concentrations during sleep but normal responses to either insulin-induced hypoglycaemia or intravenous arginine infusion. 1 child had a normal peak serum GH response to sleep but subnormal responses to insulin and arginine. Sleep studies of GH secretion may be indicated when the GH responses to pharmacological stimuli are inconsistent with the observed growth pattern.     

Growth hormone-releasing factor (GRF) stimulation test in the diagnosis of pituitary adenomas

The studies aimed at evaluation of pituitary reserve of growth hormone following stimulation with GRF have been carried out in a group of 33 patients (11 women and 22 men, of age between 25 and 62 years) with pituitary tumors. The studied material included cases with pituitary adenoma characterized by excessive secretion of growth hormone (somatotropinoma), prolactin (prolactinoma) or alpha subunits of glycoprotein hormones (alphoma), and those with hormonally inactive adenoma. The GRF stimulation tests were carried out in hospitalized patients after overnight fast between 8.00 and 10.00 a.m. Blood samples for hormonal determinations were taken before the test, and after 15, 30, 60, 90 and 120 minutes following intravenous administration of 100 micrograms of GRF 1-29. Besides growth hormone, also the blood serum concentrations of other pituitary hormones were determined in the patients studied, both in the basal state and during the dynamic tests. In patients with acromegaly the results of the determinations of growth hormone following stimulation with GRF showed considerable individual variability. In 5 cases there was an increase in blood serum growth hormone concentration. No response to GRF was noted in the remaining 8 cases. In adenoma cases of prolactinoma type, growth hormone concentration began to rise already at the 15-th minute of the test in most cases. In three cases of prolactinoma associated with acromegaly no response to GRF was observed. The cases of alphoma-type adenoma were usually characterized by the secretion of pituitary hormones other than growth hormone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of models of insulin release

A model for insulin secretion with a storage and a labile compartment, as well as a provisionary factor, is combined with a signal model in which the signal can be the difference between an excitation and an inhibition, or the difference in concentrations inside and outside some cell components. The model, using a single set of values for the parameters, accounts in a semiquantitative manner for all of the regularly appearing features of the insulin secretion from thein vitro perfused pancreas to a wide range of patterns of glucose and tolbutamide stimulation. Among the features which can be accounted for are: early and late secretion of insulin as a function of glucose in terms of a single parameter; the apparent depletion and recovery during a pulsed pattern of stimulation by tolbutamide; the hypersecretion following a short period of rest during a prolonged stimulation by glucose; the negative spike which occurs when the concentration of glucose, which has been maintained for a period of time, is suddenly reduced to a lower level; and the appropriate responses to slow and fast ramp functions of glucose concentration.     

Effect of insulin on the activity of amino acid transport systems in cultured human fibroblasts

The regulation of amino acid transport by insulin has been studied in cultured human fibroblasts. Among the six amino acid transport systems operating in cultured human fibroblasts, two systems (A and X-C) are strongly stimulated by insulin and four (ASC, X-AG, y+ and L) are essentially not sensitive to the presence of the hormone in the incubation medium. The hormonal stimulation of system A and system X-C became significant after 3 h of incubation and increased up to 12 h. The stimulatory effect was related to insulin concentration, with a half-maximal stimulation at 10(-9) M hormone concentration. Insulin enhanced transport activity by increasing the maximal velocity (Vmax) of transport, without significant changes in Km values.     

Comparison of the acute metabolic effects of 22,000-dalton and 20,000-dalton growth hormone in human subjects

The acute metabolic effects of 20,000-dalton human growth hormone (hGH20K) in man have not previously been tested. We compared changes in concentrations of free fatty acids (FFA), glucose, and insulin in nine growth hormone deficient children following injection of 22,000-dalton intact human growth hormone (hGH22K) and the smaller variant, hGH20K. There was a significant decline (37%) in the mean FFA concentration from baseline to 1/2 hour post-injection and from baseline to 1 hour post-injection (36%) in the children given hGH22K, but no such decline was seen after injection of hGH20K. No significant differences in mean insulin or glucose concentrations were noted between the two treatment groups, and glucose and insulin concentrations did not acutely change after injection of either hormone. The results of this study indicate that hGH20K has a diminished activity for suppression of FFA as compared to hGH22K. This suggests that GH residues 32-46, missing in hGH20K, constitute all or part of the region of hGH22K producing this response, or that the different primary structures of the two hormones result in tertiary structural differences and altered biological activity.     

Defective blood glucose counter-regulation in diabetics is a selective form of autonomic neuropathy.

Administration of a low-dose insulin infusion to normal subjects results in a mild drop in blood glucose concentration (1.1 mmol/1 (20 mg/100 ml)) and the resetting of the basal glucose at the lower concentration. Clinical hypoglycaemia does not develop, and there is a significant release of glucagon, growth hormone, and cortisol. A similar infusion in insulin-requiring diabetics results in hypoglycaemia accompanied by a release of growth hormone and cortisol but no significant release of glucagon. Subsequently giving arginine to these patients results in a significant release of glucagon, indicating that the alpha cell is intact and can respond to local, direct stimulation. In one patient the defect in glucagon response to impending hypoglycaemia developed after two years'' insulin treatment. This type of dissociated response'' of the alpha cell has been reported in animals after denervation of the pancreas, and insulin-requiring diabetics may develop a selective form of autonomic neuropathy affecting the vagal control of glucagon release.     

Effects of stimulation of hypothalamic “feeding areas” on endocrines and metabolism in normal and diabetic monkeys

Electrical stimulation of hypothalamic “feeding areas” (VMH & LHA) through stereotaxically implanted electrodes was carried out in normal and streptozotocinized diabetic conscious male rhesus monkeys. In normal monkeys, the VMH stimulation resulted in a significant decrease in serum insulin and blood glucose while opposite responses were observed following LHA stimulation. Serum growth hormone, FFA and plasma cortisol levels increased significantly on stimulation of LHA and VMH in normal animals. The pattern of blood glucose and serum growth hormone responses to stimulation of “feeding areas” was similar in normal and diabetic animals. The serum insulin, FFA and plasma cortisol were largely unaffected while growth hormone increased significantly by stimulation of these areas in diabetes. The present study indicates that the stimulation of “feeding areas” does not alter the diabetic syndrome significantly nor does diabetes prevent the changes in metabolism seen after stimulation of “feeding areas.”     

In vitro enhancement of insulin secretion by growth hormone

Using the isolated perfused hamster pancreas bovine growth hormone at a concentration of 7.5 ug per ml was recycled for 1 hour prior to stimulation by glucose. Under these conditions the total insulin secreted was roughly doubled compared to the controls during 1 hour of glucose stimulation.     

Growth hormone in blood sampled continuously during pentobarbitone-induced sleep in children.

Growth hormone has been estimated in blood sampled continuously in periods each lasting 30 min during the first 3-4 h of pentobarbitone-induced sleep in 69 children. With only two half-hour samples, almost the same information was obtained as with the estimation of growth hormone in all samples. In this way 95% of normally growing children showed growth hormone levels of 5 muU/ml of more. Children with growth retardation of unknown cause and overweight children showed on the average lower growth hormone levels, not rarely even below 5 muU/ml. Pituitary dwarfs all had maximum growth hormone levels of 3 muU/ml or less. Growth hormone levels during sleep may be normal in children who show negative results on provocation, while subnormal growth hormone levels during sleep have been encountered in some children with retarded growth who had a normal response upon provocation.     

Insulin receptor gene expression during development: developmental regulation of insulin receptor mRNA abundance in embryonic rat liver and yolk sac, developmental regulation of insulin receptor gene splicing, and comparison to abundance of insulin-like growth factor 1 receptor mRNA.

Insulin gene expression has been demonstrated in nonpancreatic tissues early in development, suggesting that this hormone might have actions significant for the differentiating embryo. Because such actions imply ligand-receptor binding, we quantified mRNAs encoding the two known forms of insulin receptor in rat liver and yolk sac, two endodermally derived tissues shown to express insulin genes, between gestation days (E) 13 and E21 (mid-organogenesis to parturition). Because of its presumed importance for fetal growth, we estimated the abundance of mRNA encoding insulin-like growth factor 1 (IGF 1) receptor in the same samples for comparison. The abundance of insulin receptor mRNA exceeded that for IGF 1 receptor mRNA in liver and yolk sac at all times studied. This difference was greater in liver, where insulin receptor mRNAs were three to more than 50 times more abundant than IGF 1 receptor mRNA on gestation days E13-E16, times which antedate the development of significant hepatic metabolic actions of insulin. The marked abundance of mRNAs encoding insulin receptors is consistent with the hypothesis that insulin has significant actions in specific tissues during the organogenic period.     

Antidiabetic action of somatostatin after oral glucose loading: due to suppression of glucagon and growth hormone or of intestinal carbohydrate absorption?

To elucidate the mechanism by which somatostatin lowers blood glucose concentration and insulin requirement following carbohydrate ingestion in insulin dependent diabetic patients (IDDM; n = 6), the amount of insulin required for the assimilation of a 50 g glucose load was determined by means of an automated glucose-controlled insulin infusion system with and without concomitant somatostatin infusion. During the 3 hour period following glucose loading plasma concentrations of glucagon and growth hormone were diminished by somatostatin, as were the rise in blood glucose and insulin requirement (4.0 +/- 1.2 U) when compared with the control study (11.3 +/- 1.5 U; p less than 0.01). With cessation of somatostatin blood glucose levels and insulin requirement rose during the following 2 hour observation period (7.5 +/- 1.2 U) but remained basal during the control study (0.7 +/- 0.6 U; p less than 0.0005). Thus the integrated amounts of insulin required for glucose hormone were temporarily suppressed by somatostatin. It is concluded that the diminished insulin requirement and delayed rise in blood glucose during somatostatin administration after an oral glucose load is not due to its "antidiabetic" action by suppressing glucagon and growth hormone release. Our findings favour inhibition of intestinal carbohydrate absorption as the determining cause for the "antidiabetic" action of somatostatin.     

Effects of growth hormone on sleep-waking patterns in cats.

Cats given growth hormone in doses from 50–1000 μg, i.p., showed a selective elevation of REM sleep in the first 3 hr postinjection. Bovine thyrotropin control injections did not alter sleep patterns. When the effect of growth hormone on sleep was blocked by REM deprivation for the first 3 hr, the REM elevating effect of growth hormone still occurred in the subsequent sleep period. These results suggest that growth hormone affects the central nervous system, either directly or indirectly. Also, the greatly increased secretion of growth hormone, which has been reported during slow-wave sleep in man, may play a role in the occurrence of REM sleep.     

Assessing short-statured children for growth hormone deficiency

AIM: To optimize the workup of short-statured children by defining the most appropriate tools for diagnosing growth hormone (GH) deficiency. METHODS: Patients were assigned to prepubertal (n = 113) or pubertal (n = 112, including 25 boys primed with testosterone) age groups. Mean plasma GH concentration during sleep, GH peak after provocative test, and insulin-like growth factor I (IGF-I) were measured in a single evaluation. RESULTS: The mean GH concentration during sleep was more often normal (n = 155) than the GH peak after provocative tests (n = 105) or the IGF-I concentration (n = 88). Prepubertal patients with a normal body mass index (BMI) had mean GH concentrations during sleep that correlated positively with height, growth rate, GH peak after provocative tests, and IGF-I (p < 0.0005 for all) and negatively with the difference between target and patient heights (p = 0.01) and BMI (p < 0.05). Pubertal patients with a normal BMI had a mean GH concentration during sleep that correlated positively with GH after provocative tests (p < 0.0001) and IGF-I (p < 0.005). Mean GH concentration during sleep and IGF-I concentration for boys primed with testosterone were more often normal (n = 23) than the GH peak after provocative tests (n = 14). All 9 patients with pituitary stalk interruption had low IGF-I concentrations; 1 patient had a normal GH peak after provocative test, and 2 patients had normal mean GH concentrations during sleep. CONCLUSIONS: Measuring the GH concentration during sleep and priming boys with pubertal delay can help to exclude idiopathic GH deficiency. Magnetic resonance imaging is needed to exclude anatomic abnormalities when GH and/or IGF-I concentrations are low.     

Renal response to furosemide in normal subjects during hyperinsulinaemic clamp

The study has been performed in an attempt to provide further data on the supposed direct action of insulin on the kidney, based on the assumption that any effect of insulin on sodium reabsorption via co-transport should shift the dose-response curve to the furosemide administration. In five normal male volunteers plasma insulin concentration was changed by means of a hyperinsulinaemic euglycaemic clamp. The diuresis and natriuresis following intravenous injections of furosemide (in increasing doses) were measured in basal conditions and during clamp. No significant difference was found between the experiments performed in the two conditions. Our study has not identified a direct sodium-retaining effect of insulin on the furosemide-sensitive mechanisms of the renal tubule.     

“Right On!”

New facts have emerged about growth hormone (hgh) secretion in man giving rise to new conceptions and to new questions.• In well-nourished, lean human beings growth hormone is released in early deep sleep and the pattern of release observed from night to night is fairly constant.• The release of growth hormone in sleep occurs when plasma glucose is not fluctuating and after insulin has fallen to a very low level. Plasma-free fatty acids may rise about two hours later but insulin does not rise in response to nocturnal hgh release.• The releases of growth hormone in sleep appear to meet the needs for a physiological test for the study of problems of growth. Correlations of this test with the many pharmacologic maneuvers in current use for diagnosis remain to be made.• Growth hormone secretion as judged by plasma concentrations relates to protein intake, such that protein depletion initiates compensatory elevation of plasma concentrations of growth hormone. Further elevations may occur with glucose loading—so-called “paradoxical” responses. In contrast, there is compensatory suppression of growth hormone secretion in obesity. Repletion of protein in the malnourished and reduction of weight in obesity cause return toward normal secretion of hgh.• Levodopa as a possible specific stimulus to growth hormone release has just been reported and the implications of this finding for the child of short stature cannot yet be assessed.     

Sequential analysis of the brain's transfer properties during consecutive REM episodes

Classical analysis of the spontaneous sleep EEG has revealed alterations of REM sleep in psychiatric diseases and under the influence of drugs. In order to elucidate possible functional differences between different REM episodes even in healthy subjects we investigated in 10 volunteers the transfer properties of the brain by measuring auditory (AEP) and visual evoked potentials (VEP) from scalp positions F_z, C_z and P_z during the night. According to linear system theory we computed the so-called amplitude-frequency characteristics (AFC) from averaged AEPs and VEPs during the first and each of the following 3 REM episodes. These functions describe the relationship between the input and output of the investigated system. A 3-factorial analysis of variances with the independent factors frequency band, REM episode and electrode position revealed a statistically significant main effect for the factor REM episode under auditory stimulation (P = 0.05), whereas no significant main effect for REM episode was found under visual stimulation (P = 0.88). Applying a 2-factorial analysis of variance with the independent factors REM episode and electrode position in the case of auditory stimulation we could demonstrate a statistically significant main effect (P = 0.029) for the factor REM episode in the beta range (12.5–20 Hz). A subsequent analysis of contrasts revealed that the first REM episodes could be differentiated from each other. For auditory stimulation the beta resonance during the first REM episode appears enhanced compared to each of the later REM episodes. These findings point to a functional difference of the brain's transfer functions between the first and the 3 following REM episodes, indicating different information processing during consecutive paradoxical sleep.