Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Different forms of isolated GH deficiency (IGHD) have an autosomal recessive mode of inheritance. The most common one (type IB) is often caused by bi-allelic mutations in the GHRH receptor (GHRHR) gene (GHRHR). Although heterozygous carriers of GHRHR mutations appear normal, the small size of most of the families and the fact that stature is a complex and polygenic trait prevented so far a careful analysis of their phenotype. To test the hypothesis that heterozygosity for a GHRHR mutation may be associated with a mild phenotype, we studied large Brazilian kindred with familial IGHD (Itabaianinha cohort). In this population, GHD is caused by a homozygous null mutation of the GHRHR. Adults and children with GHD have severe short stature, reduced lean mass, increased % fat mass, increased waist to hip (W/H) ratio, increased total and LDL-cholesterol and C-reactive protein (CRPus), increased systolic blood pressure, and increased insulin sensitivity. We studied 77 adult subjects (age 25-75) heterozygous for the mutation (WT/MT) and compared them with age and sex-matched controls homozygous for the wild-type allele (WT/WT) from the same population. Genotyping was performed by denaturing gradient gel electrophoresis from genomic DNA. We found no difference in adult height; blood pressure and standard deviation score for serum IGF-I between the two groups. Body weight, body mass index, skin folds, waist, hip, lean and fat mass were all reduced in WT/MT subjects. %FM and W/P ratio were similar in the two groups. Fasting insulin and in HOMAIR were lower in WT/M than in WT/WT. The other biochemical parameters (total and fractionated cholesterol, triglycerides, Lp (a), CRPus) were not different between the two groups. Our data shows that heterozygosity for a null GHRHR mutation is not associated with reduction in adult stature or reduction in serum IGF-I, but it causes a parallel decline in fat and lean mass, and an increase in insulin sensitivity. Heterozygosis for a null GHRHR mutation is not associated with reduction in adult stature or in serum IGF-I, but is causes changes in body composition and increase in HOMAIR. These effects do not seem to be modulated by changes circulating IGF-I. / Diferentes formas de Deficiência Isolada do Hormônio do Crescimento (DIGH) são de herança autossômica recessiva. A mais comum (tipo IB) é freqüentemente causada por mutações bi-alélicas no gene do receptor de GHRH (GHRHR). Embora portadores heterozigotos da mutação do gene do GHRHR pareçam normais, o tamanho pequeno da maior parte das famílias e o fato que a estatura é um complexo determinado por características poligênicas levaram-nos a analisar cuidadosamente a hipótese de um fenótipo para a heterozigose. Para testar a hipótese de que a heterozigose para uma mutação do GHRHR poderia estar associado a um fenótipo intermediário foi estudada uma extensa família com DIGH familial (Coorte de Itabaianinha/Sergipe). Nesta população a DIGH é causada por uma mutação nula em homozigose do gene do receptor do GHRHR. Os adultos e crianças com DIGH têm severa baixa estatura, massa magra reduzida e aumento de: percentagem (%) de massa gorda (% MG), cintura, relação cintura/quadril, Colesterol total, LDL Colesterol, Proteína C Reativa alta sensibilidade (PCRas) e a diminuição do Modelo Homeostático do Índice de Resistência à Insulina (HOMAIR). Nós estudamos 76 indivíduos adultos entre 25 e 75 anos de idade heterozigotos (WT/MT) para esta mutação e comparamos pareados para a idade e sexo com 77 indivíduos controles homozigotos para o alelo normal (WT/WT) da mesma população. O DNA genômico foi genotipado através da técnica de Eletroforese em gel com gradiente de desnaturação (DGGE). Não foi encontrada nenhuma diferença entre os indivíduos na altura dos adultos e níveis séricos de IGF-I entre os dois grupos. O peso, o índice de massa corpórea (IMC), dobras cutâneas, circunferência da cintura e quadril e massa magra (MM) estavam reduzidos no grupo de indivíduos WT/MT. A % de MG e a relação cintura/quadril foram semelhantes entre os dois grupos. A insulina e o HOMAIR foram mais baixos no grupo WT/MT. Os outros parâmetros bioquímicos (colesterol total e frações, Triglicérides, Lipoproteína (a) (LP (a)), Proteína C Reativa alta sensibilidade (PCRas) não foram diferentes entre os dois grupos. Em conclusão, a heterozigose para uma mutação nula no gene do receptor do GHRH não é associada com redução da estatura final nem nos níveis séricos de IGF-I, mas, causa alterações na composição corporal e aumento do HOMAIR. Estes efeitos parecem não ser modulados por alterações nas concentrações séricas de IGF-I).

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Different forms of isolated GH deficiency (IGHD) have an autosomal recessive mode of inheritance. The most common one (type IB) is often caused by bi-allelic mutations in the GHRH receptor (GHRHR) gene (GHRHR). Although heterozygous carriers of GHRHR mutations appear normal, the small size of most of the families and the fact that stature is a complex and polygenic trait prevented so far a careful analysis of their phenotype. To test the hypothesis that heterozygosity for a GHRHR mutation may be associated with a mild phenotype, we studied large Brazilian kindred with familial IGHD (Itabaianinha cohort). In this population, GHD is caused by a homozygous null mutation of the GHRHR. Adults and children with GHD have severe short stature, reduced lean mass, increased % fat mass, increased waist to hip (W/H) ratio, increased total and LDL-cholesterol and C-reactive protein (CRPus), increased systolic blood pressure, and increased insulin sensitivity. We studied 77 adult subjects (age 25-75) heterozygous for the mutation (WT/MT) and compared them with age and sex-matched controls homozygous for the wild-type allele (WT/WT) from the same population. Genotyping was performed by denaturing gradient gel electrophoresis from genomic DNA. We found no difference in adult height; blood pressure and standard deviation score for serum IGF-I between the two groups. Body weight, body mass index, skin folds, waist, hip, lean and fat mass were all reduced in WT/MT subjects. %FM and W/P ratio were similar in the two groups. Fasting insulin and in HOMAIR were lower in WT/M than in WT/WT. The other biochemical parameters (total and fractionated cholesterol, triglycerides, Lp (a), CRPus) were not different between the two groups. Our data shows that heterozygosity for a null GHRHR mutation is not associated with reduction in adult stature or reduction in serum IGF-I, but it causes a parallel decline in fat and lean mass, and an increase in insulin sensitivity. Heterozygosis for a null GHRHR mutation is not associated with reduction in adult stature or in serum IGF-I, but is causes changes in body composition and increase in HOMAIR. These effects do not seem to be modulated by changes circulating IGF-I. / Diferentes formas de Deficiência Isolada do Hormônio do Crescimento (DIGH) são de herança autossômica recessiva. A mais comum (tipo IB) é freqüentemente causada por mutações bi-alélicas no gene do receptor de GHRH (GHRHR). Embora portadores heterozigotos da mutação do gene do GHRHR pareçam normais, o tamanho pequeno da maior parte das famílias e o fato que a estatura é um complexo determinado por características poligênicas levaram-nos a analisar cuidadosamente a hipótese de um fenótipo para a heterozigose. Para testar a hipótese de que a heterozigose para uma mutação do GHRHR poderia estar associado a um fenótipo intermediário foi estudada uma extensa família com DIGH familial (Coorte de Itabaianinha/Sergipe). Nesta população a DIGH é causada por uma mutação nula em homozigose do gene do receptor do GHRHR. Os adultos e crianças com DIGH têm severa baixa estatura, massa magra reduzida e aumento de: percentagem (%) de massa gorda (% MG), cintura, relação cintura/quadril, Colesterol total, LDL Colesterol, Proteína C Reativa alta sensibilidade (PCRas) e a diminuição do Modelo Homeostático do Índice de Resistência à Insulina (HOMAIR). Nós estudamos 76 indivíduos adultos entre 25 e 75 anos de idade heterozigotos (WT/MT) para esta mutação e comparamos pareados para a idade e sexo com 77 indivíduos controles homozigotos para o alelo normal (WT/WT) da mesma população. O DNA genômico foi genotipado através da técnica de Eletroforese em gel com gradiente de desnaturação (DGGE). Não foi encontrada nenhuma diferença entre os indivíduos na altura dos adultos e níveis séricos de IGF-I entre os dois grupos. O peso, o índice de massa corpórea (IMC), dobras cutâneas, circunferência da cintura e quadril e massa magra (MM) estavam reduzidos no grupo de indivíduos WT/MT. A % de MG e a relação cintura/quadril foram semelhantes entre os dois grupos. A insulina e o HOMAIR foram mais baixos no grupo WT/MT. Os outros parâmetros bioquímicos (colesterol total e frações, Triglicérides, Lipoproteína (a) (LP (a)), Proteína C Reativa alta sensibilidade (PCRas) não foram diferentes entre os dois grupos. Em conclusão, a heterozigose para uma mutação nula no gene do receptor do GHRH não é associada com redução da estatura final nem nos níveis séricos de IGF-I, mas, causa alterações na composição corporal e aumento do HOMAIR. Estes efeitos parecem não ser modulados por alterações nas concentrações séricas de IGF-I).

Several recessive diseases present heterozygous phenotype. In Itabaianinha, Brazil, there is a big cohort with the homozygous mutation c.57 +1 G> A in the GHRH receptor (GHRHR) gene, leading to severe short stature. Previous study shows that heterozygous individuals (MUT/N) exhibit similar height, insulin like growth factor type 1 (IGF - I) and percentage of fat mass, but reduced weight, body mass index (BMI) and muscle mass. However, only 10 % of these were 60 or more years old. Moderate reduction in the GH/ IGF-I axis activity may have a greater impact on the aging period, when the activity of this axis naturally decreases. We question whether the study of heterozygosity for the mutation would result in a partial phenotype in the elderly cohort individuals. 843 individuals were analyzed in a cross sectional study by height, weight, systolic and diastolic blood pressure and BMI in two groups (young, 20-40 years of age) and old (60-80 years) of MUT/N individuals, and compared to a large number of individuals of normal genotype (N/N). SDS weight was lower [-0.13 (1.4) and -0.56 (1.8), p=0.03], and BMI had a trend toward reduction [0.08 (1.40) and 0.33 (1.4), p=0.060] in young MUT/N in comparison to young N/N. SDS height was lower in older MUT/N individual vs. N/N [-2.79 (1.1) and -2.37(1.0), p=0.04], corresponding to a reduction of 4.16 cm. We conclude the previous data reduction in weight and BMI in young and show reduced stature in older MUT/N subjects, suggesting different effects of heterozygosis through the ages. The reduction of muscle mass already present at young age, aggravated by aging may contribute to this reduction in height. Heterozygous GHRHR mutations may be a factor contributing to frailty in elderly. / Várias doenças recessivas cursam com fenótipo em heterozigose. Em Itabaianinha, Sergipe, reside uma grande coorte com a mutação homozigótica c.57 +1 G>A no gene do receptor do GHRH (GHRHR) cursando com baixa estatura acentuada. Estudo prévio mostrou que os indivíduos heterozigotos adultos (MUT/N) para esta mutação apresentam altura, fator de crescimento semelhante à insulina tipo 1 (IGF-I) e percentual de massa gorda similares, mas redução de peso, do índice de massa corpórea (IMC) e da massa muscular (MM). Contudo apenas 10% destes tinham mais de 60 anos. Redução moderada na atividade do eixo GH-IGF-I pode ter um impacto maior no período de envelhecimento, quando a atividade deste eixo naturalmente diminui. Questionamos se a heterozigose para a referida mutação traduziria em um fenótipo parcial nos indivíduos idosos dessa coorte. Realizamos um estudo transversal em 843 indivíduos divididos em dois grupos (jovens, 20-40anos de idade, e idosos, 60-80 anos de idade) de indivíduos heterozigotos (MUT/N) e controles normais (N/N). A altura (cm), peso (Kg), pressão arterial diastólica e sistólica (PAD e PAS mmHg) e o IMC (Kg/m2) foram analizados. Os dados foram expressos em média, desvio padrão e escore desvio padrão (EDP). O EDP do peso foi menor [0,13 (1,40) e -0,56 (1,80), p=0,03], e IMC apresentou uma tendência de redução [0,08 (1,40) e 0,33 (1,40), p=0,060] no grupo MUT/N jovem em comparação N/N jovem. O EDP da altura foi menor nos indivíduos MUT/N idosos em comparação aos N/N idosos [-2,79 (1,10) e -2,37(1,00), p=0,04], correspondendo a uma redução de 4,16 cm. Estes achados reforçam os dados anteriores de redução no peso e IMC em adultos jovens MUT/N e mostram redução na estatura em indivíduos idosos, sugerindo efeitos diferentes da heterozigose nos diferentes grupos etários. A redução da massa muscular já presente em adultos jovens, agravada pelo envelhecimento, pode contribuir para esta redução estatural. A mutação heterozigótica pode ser um fator contribuinte para fragilidade no idoso.

Η αυξητική ορμόνη (GH), πολυλειτουργική ορμόνη που παράγεται από τα σωματοτρόπα κύτταρα του πρόσθιου λοβού της υπόφυσης, προάγει την μεταγεννητική ανάπτυξη σκελετικών και μαλακών ιστών. Επίσης, ασκεί ποικίλες άλλες βιολογικές δράσεις, όπως ρύθμιση του μεταβολισμού των υδατανθράκων, των πρωτεϊνών και του λίπους. Κατά συνέπεια, η ανεπάρκεια της εκτός από αναπτυξιακά μπορεί να προκαλέσει και σοβαρά μεταβολικά προβλήματα. Η GH δρα στους περιφερικούς ιστούς άμεσα αλλά και έμμεσα μέσω του ινσουλινόμορφου αυξητικού παράγοντα IGF-I. Μετά από πρόσδεση της GH στον υποδοχέα της (GHR), ο IGF-I παράγεται στο ήπαρ, όπου απελευθερώνεται στην γενική κυκλοφορία, αλλά παράγεται και τοπικά στους περιφερικούς ιστούς, όπου δρα με αυτοκρινή ή παρακρινή τρόπο. Η έκκριση της GH από την υπόφυση έχει παλμική μορφή και ρυθμίζεται κυρίως μέσω τριών υποφυσιοτρόπων παραγόντων: εκλυτική ορμόνη της GH (GHRH), σωματοστατίνη (SRIF) και γκρελίνη. Η απελευθέρωση της GHRH και της SRIH από τον υποθάλαμο επηρεάζεται και από μια ποικιλία άλλων νευροδιαβιβαστών, νευροορμονών και νευροπεπτιδίων. Έχει υπολογιστεί σε διάφορες μελέτες ότι κοντό ανάστημα συσχετιζόμενο με ανεπάρκεια της αυξητικής ορμόνης (GHD) παρατηρείται με συχνότητα 1 στις 4000 έως 1 στις 10000 γεννήσεις. Παρόλο που οι περισσότερες περιπτώσεις είναι σποραδικές και θεωρούνται αποτέλεσμα περιβαλλοντικών εγκεφαλικών προσβολών ή αναπτυξιακών ανωμαλιών, γενετική αιτιολογία προτείνεται περίπου στο 10% των GHD περιπτώσεων, λόγω του ότι έχει προσβληθεί ένας τουλάχιστον πρώτου βαθμού συγγενής. Η διάγνωση της GHD είναι μια πολύπλευρη διαδικασία που απαιτεί εκτενή κλινική εκτίμηση, αξιολόγηση σωματομετρικών παραμέτρων, βιοχημικές δοκιμασίες του GH-IGF άξονα, και ακτινολογική εκτίμηση. Η GHD μπορεί να παρουσιάζεται είτε ως μεμονωμένο πρόβλημα (IGHD) είτε σε συνδυασμό με πολλαπλές ορμονικές ανεπάρκειες (CPHD). Μοντέλα ζώων έχουν χρησιμοποιηθεί για μελέτη της φυσιολογικής λειτουργίας του υποθαλαμικού-GH άξονα και των πιθανών διαταραχών που οδηγούν σε IGHD/CPHD στους ανθρώπους. Σύμφωνα με τα κλινικά χαρακτηριστικά, τον τρόπο κληρονομικότητας και την ανταπόκριση στην εξωγενή θεραπεία, τέσσερις τύποι οικογενούς IGHD έχουν περιγραφεί στον άνθρωπο. Μεταλλαγές έχουν βρεθεί να συμβαίνουν στο GH γονίδιο (GH1) και στο γονίδιο του υποδοχέα της GHRH (GHRH-R). Πολυμορφισμοί στον υποκινητή του GH1 γονιδίου μειώνουν επίσης την έκφραση του. Πρόσφατα, μεταλλαγές στο γονίδιο του υποδοχέα της γκρελίνης (GHS-R) συσχετίστηκαν με IGHD. Μεταλλαγές σε διακριτά γονίδια μεταγραφικών παραγόντων, που είναι βασικά για την ανάπτυξη και διαφοροποίηση των κυττάρων του πρόσθιου λοβού της υπόφυσης, όπως Pit1/POU1F1, PROP1, HESX1, LHX3, LHX4, έχουν αναγνωρισθεί μέχρι σήμερα σε ανθρώπους με CPHD. Καθώς μεγάλο ποσοστό οικογενών περιπτώσεων IGHD/CPHD δεν οφείλεται σε μεταλλαγές σε κάποιο από τα ήδη γνωστά γονίδια, φαίνεται να εμπλέκονται μεταλλαγές σε επιπρόσθετα υποψήφια γονίδια. Περαιτέρω γενετικές μελέτες μπορούν να συμβάλλουν σε καλύτερη κατανόηση της GHD, σε πρώιμη διάγνωση και βελτίωση της θεραπευτικής αγωγής στα άτομα με GHD. / Growth hormone (GH), a multifunctional hormone which is synthesized in the somatotrope cells of the anterior pituitary gland, promotes postnatal development of skeletal and soft tissues. In addition, GH exerts multiple biological actions, such as regulating the metabolism of carbohydrates, proteins and fat. Consequently, GH deficiency (GHD) apart from causing developmental disorders can also have a deleterious effect on the body’s metabolism. GH acts on peripheral tissues both directly and indirectly, through the mediation of insulin-like growth factor-1 (IGF-1). Upon binding of GH to its receptor (GHR), IGF-1 is produced both in the liver, from where it is released into the general circulation, and locally in the peripheral tissues, such as bone, cartilage, and muscle, where it acts in an autocrine or paracrine fashion. GH is secreted from the pituitary gland in a pulsatile fashion. Major regulatory factors include three hypophysiotropic factors: GH releasing hormone (GHRH), somatostatin (SRIF), and ghrelin. Moreover, GH secretion can be affected by a variety of other neurotransmitters, neurohormones and neuropeptides. The diagnosis of GHD demands detailed clinical, auxological, radiological and biochemical evaluation of the GH-IGF axis. GHD may occur as isolated GHD (IGHD) or in combination with other pituitary hormone deficiencies (Combined Pituitary Hormone Deficiency, CPHD). The physiological actions of the hypothalamic-GH axis and the possible disorders leading to IGHD/CPHD in humans have been extensively studied in animal models. Short stature associated with GHD has been estimated to occur in about 1/4000-1/10000 in various studies. Whereas most cases are sporadic and believed to result from environmental cerebral insults or developmental anomalies, approximately 10% of the affected individuals have a first-degree relative with the same disorder, suggesting a hereditary trend and genetic factors affecting the disorder. Four types of familial IGHD have been described in humans according to clinical characteristics, the mode of inheritance and the response to exogenous therapy. Mutations reducing gene expression have been described in the GH1 gene and in the GHRH receptor (GHRH-R) gene. Polymorphisms found in the promoter of the GH1 gene can also reduce its expression. Recently, mutations in the ghrelin receptor (GHS-R) gene were associated with IGHD. Mutations in discrete genes of transcriptional factors necessary for the development and differentiation of anterior pituitary cells, such as Pit1/POU1F1, PROP1, HESX1, LHX3, LHX4 have been recognized in individuals with CPHD. Considering that a large proportion of familial cases of IGHD/CPHD are not caused by mutations in any of the known genes, mutations in additional candidate genes may be involved. Further genetic studies may contribute to a better understanding of GHD, earlier diagnosis and better therapeutic approaches for this disorder.