Growth Hormone Insensitivity

Growth Hormone Insensitivity

National Organization for Rare Disorders, Inc.

Important

It is possible that the main title of the report Growth Hormone Insensitivity is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.

Synonyms

  • Laron syndrome
  • growth hormone resistance
  • growth hormone unresponsiveness
  • GH insensitivity
  • GHI

Disorder Subdivisions

  • GH receptor deficiency (GHRD)
  • GH inactivating antibodies
  • GH postreceptor deficiencies

General Discussion

Growth hormone insensitivity (GHI) is a group of extremely rare genetic disorders in which the body is unable to use the growth hormone that it produces. GHI can be caused by mutations in the growth hormone receptor (GHR) gene or mutations in genes involved in the action pathway within the cell after growth hormone binds to its receptor, preventing production of insulin-like growth factor (IGF-1), the substance responsible for the growth effects of growth hormone. Even more rarely, children with GH gene deletion who have been treated with recombinant GH develop antibodies that block GH binding to its receptor. Affected children fail to grow normally.



Children with GHRD who are treated with IGF-1 before puberty have improved growth, but, unlike children with GH deficiency given recombinant GH treatment, they do not have normal growth restored. Treatment for these conditions is only effective while the growing bones are still open, i.e. before the completion of adolescence. IGF-I insensitivity due to IGF-I receptor mutation mimics GHI, but results in less severe growth deficiency and is somewhat responsive to treatment with recombinant GH.



GHI is characterized by short stature and delayed bone age, as well as normal or high levels of circulating GH. Other common symptoms are delayed onset of puberty, prominent forehead, low blood sugar and obesity in adulthood. Except for an extremely rare form of GHI, where the gene for IGF-I is defective, brain development is normal, apparently because IGF-I can be made during fetal life without GH stimulation in the other conditions. Some, but definitely not all, patients with the less rare condition of IGF-I receptor deficiency may have mild intellectual impairment.



Introduction

Laron and colleagues in Israel, first reported the condition in 1966, based on observations that began in 1958, and have continued to the present. The molecular basis for the syndrome he described, genetic mutation of the GHR in some of the Israeli patients was initially described in 1989, and since then over 40 different mutations of this protein have been identified by many investigators. The other genetic defects in the action pathway of GH after its binding to the GHR and associated with varying effects of IGF-I deficiency have been described in the past 15 years.

Symptoms

There is a wide range of effects depending on the gene mutations involved (see Causes section). The very few individuals with IGF-I gene mutation have severe intellectual disability and intrauterine growth failure, with deafness and micrognathia. GHRD results in severe growth failure without deleterious effects on intrauterine growth or brain development, and the STAT5b mutation has similar growth effects but is also associated with severe immunocompetence impairment. The IGFALS mutation, while resulting in very low circulating IGF levels, has only modest effects on growth.



GHI is characterized by severe but proportionate short stature as a result of growth failure that begins at birth. Along with growth retardation, there are delays in tooth eruption. There is also disproportion between the growth of the skull and face, a saddle nose and deep-set eyes. Sexual development is moderately delayed in both genders. In females with these disorders, the onset of menses usually takes place between 16 to 19 years of age. Hands and feet are smaller than normal, in proportion to overall body size. A high-pitched voice may also be present and obesity is common in the adults, especially females.



High circulating levels of GH are found in the children but may not be obvious without stimulation tests in the adults. A high percentage of young patients have low blood sugar levels (hypoglycemia) that can be associated with seizures in some very young children. Recently, researchers have found that a population of individuals with GHRD in Ecuador (where approximately 1/3 of the world's population of GHRD has been identified) had absence of cancer and diabetes with molecular evidence of protection from aging changes in their DNA. This may be due to a protective effect from the low IGF-I levels.

Causes

GHI is inherited as an autosomal recessive genetic disorder and caused by mutation of the GH receptor gene or mutations in the genes involved in the action pathway within the cell after GH binds to its receptor, including STAT5b, IGF-1, and IGFALS.



Autosomal recessive inherited diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother. Defects occur when an individual inherits the same abnormal gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk for two carrier parents to both pass the defective gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%. The risk for most recessive conditions is the same for males and females.



All individuals carry a few abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.

Affected Populations

Worldwide, only about 250 cases of GHI due to GHRD have been reported. The ethnic background for most (90%) of the reported cases is known. About 65% of cases involve persons of Middle Eastern ancestry and a group of Ecuadorian conversos. (Conversos are Jews who converted to Christianity in Spain during the Inquisition, some of whom migrated to the New World) Subsequently, marriage among close relatives made the disorder more common among the descendants of these groups. STAT5b, IGF-1 and IGFALS mutations have been reported in only a few families.

Standard Therapies

Diagnosis

A diagnosis of GHI is usually made when failure to grow is accompanied by the typical facial appearance and central chubbiness that suggests GH deficiency, but with the finding of elevated GH levels.



Treatment

The orphan drug Increlex (recombinant IGF-I) has been approved for children whose growth failure is due to GHRD or GH inactivating antibodies. For more information, please contact:



Tercica Inc.

2000 Sierra Point Parkway, Suite 400

Brisbane, CA 94005

Phone: (650) 624-2900

Fax: (650) 624-4940

www.tercica.com



Treatment of GHI with recombinant human GH is not effective because the body cannot utilize the hormone to grow. Recombinant IGF-I therapy is associated with a risk of hypoglycemia which can be prevented by feeding. Fortunately, long-term effects of hypoglycemia have not been seen.



Genetic counseling is recommended for patients and their families.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government website.



For information about clinical trials being conducted at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:



Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: prpl@cc.nih.gov



For information about clinical trials sponsored by private sources, contact:

www.centerwatch.com



Contact for additional information about growth hormone insensitivity:



Arlan L. Rosenbloom, MD

Adjunct Distinguished Service Professor Emeritus

Department of Pediatrics

University of Florida College of Medicine

Gainesville, Florida

rosenal@peds.ufl.edu

References

TEXTBOOKS

Rosenbloom AL. Growth hormone insensitivity syndrome. In: Radovick S, ed. Pediatric Endocrinology: A Practical Clinical Guide. 2nd ed. New York, NY: Springer Science (in press).



Allan DB, Rose SR, Reiter EO. Normal growth and growth disorders In: Kappy MS, Allen DB, Geffner M, eds. Principles and Practice of Pediatric Endocrinology. Springfield, IL: Charles C Thomas; 2005:77-211.



Rosenbloom AL, Connor EL. Hypopituitarism and other disorders of the growth

hormone (GH)-insulin like growth factor-I (IGF-I) axis. In: Lifshitz F, ed. Pediatric Endocrinology. Vol. 2. 5th ed, New York, NY: Informa Healthcare; 2007:65-100.



JOURNAL ARTICLES

Guevara-Aguirre, J, Balasubramanian P, Guevara-Aguirre M, et al. Growth hormone receptor deficiency is associated with a major reduction in pro-aging signaling, cancer, and diabetes in humans. Sci Transl Med. 2011;3(70):70ra13. http://www.ncbi.nlm.nih.gov/pubmed/21325617



David A, Hwa V, Metherell LA, et al. Evidence for a continuum of genetic, phenotypic, and biochemical abnormalities in children with growth hormone insensitivity. Endocr Rev. 2011;32:472-97.



Rosenbloom AL. Mecasermin (recombinant human insulin like growth factor-I). Adv Therapy. 2009;26:40-54.



Rosenbloom AL. The physiology of human growth: a review. Reviews in Endocrinology. 2008;36-48.



Rosenfeld RG, Belgorosky A, Camacho-Hubner C, Savage MO, Wit JM, Hwa V. Defects in growth hormone receptor signaling. Trends Endocrinol Metab. 2007;18:134-141.



Walenkamp MJ, van der Kamp HJ, Pereira AM, Kant SG, van Duyvenvoorde HA, Kruithof MF. A variable degree of intrauterine and postnatal growth retardation in a family with a missense mutation in the insulin-like growth factor I receptor. J Clin Endocrinol Metab. 2006;91:3062-3070.



Kornreich L, Horev G, Schwarz M, Karmazyn B, Laron Z. Laron syndrome abnormalities: spinal stenosis, os odontoideum, degenerative changes in atlanto-odontoid joint, and small oropharynx. AJNR Am J Neuroradiol. 2002;23(4):625-31.



Laron Z, Pertzelan A, Mannheimer S. Genetic pituitary dwarfism with high serum concentration of growth hormone -- a new inborn error of metabolism? Isr J Med Sci. 1966;2:152-155.



INTERNET

Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. Laron Syndrome. Entry No: 262500. Last Edited November 22, 2011. Available at: http://www.ncbi.nlm.nih.gov/omim/. Accessed July 17, 2012.



Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. Growth Hormone Insensitivity With Immunodeficiency. Entry No: 245590. Last Edited October 12, 2012. Available at: http://www.ncbi.nlm.nih.gov/omim/. Accessed July 17, 2012.



Rosenbloom AL, Guevara-Aguirre J. Growth Hormone Resistance. Emedicine. http://emedicine.medscape.com/article/922902-overview accessed. Updated April 18, 2012. Accessed July 17, 2012.



Zvi Laron, MD: The man behind Laron syndrome. Endocrine Today. http://www.healio.com/endocrinology/news/print/endocrine-today/%7B3D0E1CEB-3309-4899-84F7-C12033B7C82E%7D/Zvi-Laron-MD-The-man-behind-Laron-syndrome. July 2010. Accessed July 17, 2012.

Resources

Human Growth Foundation

997 Glen Cove Avenue

Suite 5

Glen Head, NY 11545

Tel: (516)671-4041

Fax: (516)671-4055

Tel: (800)451-6434

Email: hgf1@hgfound.org

Internet: http://www.hgfound.org/



MAGIC Foundation

6645 W. North Avenue

Oak Park, IL 60302

Tel: (708)383-0808

Fax: (708)383-0899

Tel: (800)362-4423

Email: mary@magicfoundation.org

Internet: http://www.magicfoundation.org



Little People of America, Inc.

250 El Camino Real Suite 201

Tustin, CA 92780

Tel: (714)368-3689

Fax: (714)368-3367

Tel: (888)572-2001

Email: info@lpaonline.org

Internet: http://www.lpaonline.org/



Genetic and Rare Diseases (GARD) Information Center

PO Box 8126

Gaithersburg, MD 20898-8126

Tel: (301)251-4925

Fax: (301)251-4911

Tel: (888)205-2311

TDD: (888)205-3223

Internet: http://rarediseases.info.nih.gov/GARD/



For a Complete Report

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