Two years in growth hormone 2017-18

This brief review highlights new studies in three areas of the GH field, namely diagnostics, therapeutics and biomarkers. The diagnosis of GH deficiency has always presented a challenge: there is no "gold standard" test of GH status, and GH levels during stimulation testing are affected by many factors that limit diagnostic accuracy. Two new approaches to diagnosis have been proposed: one involves a classical endocrine test of GH production using a GH secretagogue to test the Ghrelin axis, and shows promise in the diagnosis of adult GH deficiency. The other uses a completely different approach analysing the individual's gene expression profile as a surrogate for GH status with high levels of test accuracy. From the therapeutic aspect, there have been significant efforts to produce a long-acting (LA) GH on the premise that this will improve adherence and patient convenience. Aspects of LA-GH pharmacology are considered, and it will be interesting to see in future years what place LA-GH GH takes in the market. Long term surveillance is a vital part of therapeutics; recent studies across Europe have provided reassurance on the safety of recombinant human GH (r-hGH) for those with uncomplicated growth disorders, but do emphasise the need to continue observation through adulthood. The search for biomarkers that precisely reflect GH action in children and adults is an ongoing task. One of the newer bone markers that shows promise is a fragment of collagen type X which now requires further investigation in humans. In parallel with the diagnostic studies, gene expression profiles at the start of r-hGH treatment have been used to predict GH response in children with GHD and girls with Turner syndrome. These data are promising but need evaluation across a range of growth disorders. R-hGH is an effective, safe therapy used in both children and adults. There is however a need to continue to refine diagnosis, treatment and most importantly long-term pharmacovigilance to ensure that the right patients have the best treatment with robust safety profiles.

Reduced pericellular sensitivity to IGF-I in fibroblasts from girls with Turner syndrome: a mechanism to impair clinical responses to GH

Girls with Turner syndrome (TS) are treated with supraphysiological doses of growth hormone (GH) to improve final height; however in some girls, the growth response can be poor. This may reflect aberrations in GH and/or IGF-I actions at the cellular level, and thus this study compared the response of skin fibroblasts from normal children (n = 5) and girls with TS (n = 8) to GH, IGF-I, or a combination, by assessing the IGF binding protein (IGFBP) profile of conditioned medium harvested over 7 d. The two cell types had a comparable IGFBP profile; IGFBP-3 and IGFBP-4 were the most abundant species. TS fibroblasts produced more IGFBP-3 (d 7, 51.4 ± 45 ng/mL versus 20 ± 22 ng/mL; p < 0.05) than control cells; levels of IGFBP-4 were similar (21 ± 12 ng/mL versus 30 ± 21 ng/mL). GH did not influence IGFBP production. IGF-I treatment did not affect IGFBP-4 levels but enhanced the production of IGFBP-3 by both cell types (p < 0.05). However, the response of TS fibroblasts to IGF-I was approximately half that observed in normal cells (p < 0.05). Altered IGF-I activity, because of reduced bioavailability and/or reduced sensitivity, could contribute to the need for high GH doses in TS and for the poor response to GH in some girls with TS.

Reduced appetite and body mass index with delayed puberty in a mother and son: association with a rare novel sequence variant in the leptin gene

INTRODUCTION

Leptin deficiency caused by mutations within the leptin gene (LEP) results in severe early onset obesity, hypogonadism, pubertal delay and immune system abnormalities. Constitutional delay in growth and puberty (CDGP) is a common condition seen in paediatric clinics, in which children present with delayed growth and puberty but usually also have a slim body habitus. We hypothesized that LEP variants may play a role in the phenotype seen in CDGP.

AIM

To screen a group of children with CDGP for pathogenic sequence variants in LEP.

PATIENTS AND METHODS

Denaturing HPLC was used to screen for LEP sequence variants in DNA samples from 78 children with CDGP (predominantly white males) and 112 control subjects. DNA fragments with a WAVE pattern deviant from wild type were directly sequenced. A STAT3 luciferase reporter assay in human embryonic kidney (HEK293) cells transiently transfected with the leptin receptor was used to test activity of mutant leptin.

RESULTS

One child with CDGP was identified to be heterozygous for a novel missense variant (c.68C>G), which results in a proline to arginine substitution (p.P23R). This sequence variant was not identified in any of the other control subjects, but was identified in his mother who shared a similar phenotype of slim body habitus, reduced appetite and pubertal delay (menarche aged 15 years). The leptin variant showed similar stability in serum compared with wild type and did not demonstrate increased activity in an in vitro reporter gene assay.

CONCLUSIONS

This is the first report of a sequence variant within the LEP gene associated with reduced body mass index rather than obesity. We hypothesize that this variant has increased bioactivity in vivo.

The effect of different patterns of growth hormone administration on the IGF axis and somatic and skeletal growth of the dwarf rat

Normal childhood growth is determined by ultradian and infradian variations in GH secretion, yet GH treatment of children with short stature is restricted to daily fixed doses. We have used GH-deficient dwarf rats to determine whether variable GH dose regimens promote growth more effectively than fixed doses. Animals were treated with saline or 4.2 mg of recombinant bovine GH given as 1) 700 microg/wk in 100 microg/day doses, 2) alternating weekly doses of 966 (138 microg/day) or 434 microg (62 microg/day), or 3) 700 microg/wk in randomized daily doses (5-250 microg/day). Body weight and length were measured weekly. Femur and tibia lengths and internal organ, fat pad, and muscle weights were recorded at the end of the study (6 wk); blood was collected for IGF axis measurements. GH promoted femur [F(3,60) = 14.67, P < 0.05], tibia [F(3,60) = 14.90, P < 0.05], muscle [F(3,60) = 10.37, P < 0.05], and organ growth [liver: F(3,60) = 9.30, P < 0.05; kidney: F(3,60) = 2.82, P < 0.05] and an increase in serum IGF-I [F(3,60) = 9.18, P < 0.05] and IGFBP-3 [F(3,60) = 6.70, P < 0.05] levels. IGF-I levels correlated with final weight (r = 0.45, P < 0.05) and length (r = 0.284, P < 0.05) in the whole cohort, but within each group, growth parameters correlated with serum IGF-I only in animals treated with random GH doses. The variable regimens promoted femur length (P < 0.05) and muscle (P < 0.05) and kidney (P < 0.05) weight more effectively than treatment with the fixed regimen. This study demonstrates that aspects of growth are improved following introduction of infradian variation to GH treatment in a GH-deficient model. The data suggest that varying the pattern of GH doses administered to children may enhance growth performance without increasing the overall GH dose.

A pilot study to evaluate gene expression profiles in peripheral blood mononuclear cells (PBMCs) from children with GH deficiency and Turner syndrome in response to GH treatment

Response to GH treatment is variable and dependent on diagnosis and dose. We used a pharmacogenomic approach to assess whether this variability is reflected in patterns of GH-induced gene expression in peripheral blood mononuclear cells (PBMCs) taken from three children with GH deficiency (GHD) and three girls with Turner syndrome (TS). Analysis of the response to GH treatment revealed that in GHD, 15 probe sets (11 genes) showed a fold change > +/- 1.4 at a P-value < 0.0005 (and a false detection rate <or= 15%). These genes included a suppressor of cytokine signalling (SOCS1) and a modulator of cAMP response elements (CREM). In marked contrast, in TS no genes fulfilled these criteria. ANOVA identified a subset of genes significantly affected by diagnosis, GH treatment or an interaction between diagnosis and treatment (P < 0.05, n = 2266). Cluster analysis indicated that genes up-regulated in both GHD and TS were related to DNA metabolism and transcription. Genes up-regulated in GHD but down-regulated in TS were involved in RNA processing and metabolism, whereas those down-regulated in GHD and up-regulated in TS were related to immune function. This pilot study has shown that major changes in gene expression in PBMCs can only be seen with confidence in GHD inferring that the pattern of gene expression in response to GH in GHD vs. TS is distinct and disease-specific. Further studies in larger cohorts will be required to evaluate whether GH-induced PBMCs gene expression patterns can predict responses to GH in a clinical setting.

The Relationship between Nocturnal Urinary Leptin and Gonadotrophins as Children Progress towards Puberty

BACKGROUND/AIMS

Leptin is necessary for normal human pubertal development but its exact role in the period leading up to the onset of puberty has not been defined. This study has assessed the relationship between leptin and gonadotrophin secretion over time as children progress into puberty.

SUBJECTS AND METHODS

Twenty children (13 boys and 7 girls) judged to be close to the initiation of puberty were recruited. Three consecutive first morning urine samples were collected from each subject each month over 6 months. At the end of the study, the children were classified into those who remained physically prepubertal (n = 7) and those that had advanced in puberty (n = 13). Leptin and gonadotrophins were measured by immunoradiometric and immunofluorometric assay, respectively.

RESULTS

Total urinary leptin excreted over 6 months was higher in girls than in boys, both prepubertally and in early puberty, and in both sexes, was higher in those advancing into puberty than in those remaining prepubertal (girls 8.0 vs. 3.4 ng/l and boys 3.6 vs. 1.7 ng/l; both p < 0.05). In the whole group, when controlling for gender, there was a significant correlation between both leptin and luteinizing hormone (LH; r = 0.43, p < 0.001) and leptin and follicle-stimulating hormone (FSH; r = 0.32, p = 0.001). The possibility of a lead relationship was explored by pairing leptin values with the gonadotrophin values in the following month. Leptin was significantly correlated with FSH but not LH in both pre- and peripubertal children (prepubertal r = 0.45, p = 0.01; peripubertal r = 0.32, p = 0.01).

CONCLUSIONS

This study has shown that in children approaching and progressing into puberty, leptin is associated with LH and FSH over the same time frame, and with FSH when leptin is acting as the lead hormone. These data imply that leptin is an important facilitator of the early phases of human puberty.

The contributions of plasma IGF-I, IGFBP-3 and leptin to growth in extremely premature infants during the first two years

We determined the contributions of IGF-I, IGFBP-3 and leptin to growth in extremely premature infants over the first two years. Weight (Wt), crown-to heel length (CHL), plasma IGF-I, IGFBP-3 and leptin were measured in infants (gestation 24-33 wk) at birth (n = 54), expected date of delivery (EDD) and 6, 12 and 24 mo post-EDD (n = 29). Area under the curve (AUC) for hormone levels was calculated over 4 periods: birth-EDD, EDD-200 d, EDD-350 d and EDD-700 d. IGFBP-3, but not IGF-I or leptin, on day 1 correlated with birth Wt SD scores (SDS) (r = 0.46, p = 0.002) and CHL SDS (r = 0.41, p = 0.01). Wt SDS at EDD correlated with AUC IGF-I, IGFBP-3 and leptin (birth-EDD), but leptin was the best predictor in multiple regression (r = 0.65, p < 0.0001). Wt at EDD + 700 d correlated with AUC leptin (EDD-700 d) (r = 0.62, p = 0.002). CHL SDS at EDD correlated with AUC IGFBP-3 and leptin (birth-EDD), but IGFBP-3 was the best predictor (r = 0.55, p < 0.0001). CHL at EDD + 700 d correlated with AUC IGF-I and IGFBP-3 (EDD-700 d), but IGFBP-3 was the best predictor (r = 0.47, p = 0.01). Wt and CHL at birth were associated with IGFBP-3 levels in these infants. Wt at EDD and EDD + 700 d was predicted by concurrent leptin output while linear growth at EDD and EDD + 700 d was predicted by IGFBP-3 output.

Phenotypic variation in constitutional delay of growth and puberty: relationship to specific leptin and leptin receptor gene polymorphisms

OBJECTIVES

Constitutional delay of growth and puberty (CDGP) is a variant of normal pubertal timing and progress, often with dominant inheritance. It is likely that one or more genes will be associated with CDGP. Possible candidates are the leptin (L) and the leptin receptor (LR) genes, as the leptin axis links nutritional status to pubertal development. This study has assessed whether a) L or LR gene polymorphisms were associated with CDGP and b) the CDGP phenotype was influenced by these polymorphisms.

DESIGN

Case-control and transmission disequilibrium tests were used to test genetic association of L and LR polymorphisms with CDGP.

METHODS

We genotyped L (3'CTTT repeat) and LR polymorphisms (Gln > Arg substitution, exon 6) in 81 CDGP children and 94 controls in the UK and 88 CDGP children from the US and assessed the effect of genotype on their anthropometric characteristics.

RESULTS

There was no association of these L or LR gene polymorphisms with CDGP. There was no difference in height or bone age delay within L or LR genotypes. However, UK CDGP children homozygous for the L short allele were heavier than heterozygotes and long allele homozygotes, with a similar trend in the US cohort. UK CDGP children with severe pubertal delay, who were thin, had significantly greater bone age delay and an increased frequency of parental pubertal delay than other groups and were less likely to be L short allele homozygotes.

CONCLUSIONS

There was no association of specific L or LR polymorphisms with CDGP, but L short allele carriage influenced the phenotype within CDGP.

Variability in anterior pituitary size within members of a family with GH deficiency due to a new splice mutation in the GHRH receptor gene

OBJECTIVE

Mutations in the GHRH receptor (GHRHR) gene (GHRHR) cause autosomal recessive isolated GH deficiency (IGHD), and are usually associated with anterior pituitary hypoplasia (APH) (defined as pituitary height more than 2 SDS below normal). We searched for GHRHR mutations and studied pituitary morphology in three prepubertal sibs with severe IGHD, who were born from consanguineous parents.

DESIGN

We sequenced the 13 exons and the intron-exon boundaries of the GHRHR of the index patient. After identifying a novel mutation, we sequenced the same area in the other family members. In addition, we performed magnetic resonance imaging (MRI) study of the pituitary (at age 8, 4 and 3 years) in the three affected subjects.

RESULTS

The three children were homozygous for a new GHRHR mutation that alters the second base of the invariant 5' splice site (GT) of intron 12 [IVS12 + 2T-->A]. The parents and an unaffected sibling were heterozygous for the same change. MRI did not show frank APH (by height criteria) in any of the subjects: pituitary height was normal (5.6 mm, +1.8 SDS) in the oldest sibling, and it was low but not below 2 SDS by age-adjusted criteria in the second (3 mm, -1.4 SDS), and third sibling (2.8 mm, -1.7 SDS). Calculated pituitary volume was below -2 SDS in the youngest patient.

CONCLUSIONS

These data demonstrate that pituitary height may fall within 2 SDS from the norm in patients with severe IGHD due to a homozygous GHRHR mutation, and that pituitary size may vary within patients with identical mutations who belong to the same family.

Ghrelin concentrations in healthy children and adolescents

OBJECTIVE

In addition to its regulation by GH releasing hormone (GHRH) and somatostatin, release of GH from the pituitary is modulated by a third factor, ghrelin, which is expressed in high concentration in the stomach and is present in the circulation. Ghrelin has also been shown to cause weight gain by increasing food intake and decreasing fat utilization. Ghrelin is a potential candidate hormone to influence nutrient intake and growth. Its role through normal childhood and adolescence has not been fully defined.

DESIGN

Cross-sectional study in 121 healthy children (65 male, 56 female) aged 5-18 years, in whom height, weight, body mass index (BMI), pubertal status and measurements of IGF-I, IGFBP-3, IGFBP-1 and leptin were available.

METHODS

Serum ghrelin concentrations have been measured in radioimmunoassay (RIA; Phoenix, AZ, USA) that detects active and inactive human ghrelin. Relationships between ghrelin and anthropometric data and growth factors were assessed by correlation and regression analyses.

RESULTS

Ghrelin was detected in all samples, with a median concentration of 162 pg/ml, range 60-493 pg/ml. Prepubertal children had higher ghrelin concentrations than those in puberty [218 pg/ml (n = 42) and 157 pg/ml (n = 79), P < 0.001], with significant negative correlations between ghrelin and age (rs = -0.39, P < 0.001) and pubertal stage (rs = -0.42, P < 0.001). The decrease in ghrelin with advancing pubertal stage/age was more marked in boys than girls. In the whole group, ghrelin was negatively correlated to BMI SD (rs = -0.24, P = 0.006) and to weight SD (rs = -0.24, P = 0.008) but not height sds. Ghrelin was also negatively correlated to IGF-I (rs = -0.48, P < 0.001), IGFBP-3 (rs = -0.32, P < 0.001) and leptin (rs = -0.22, P = 0.02) but not IGF-II. It was positively related to IGFBP-1 (rs = +0.46, P < 0.001). In stepwise multiple regression, 30% of the variability in ghrelin through childhood could be accounted for by log IGF-I (24%) and log IGFBP-1 (6%).

CONCLUSIONS

The fall in ghrelin over childhood and with puberty does not suggest that it is a direct growth-promoting hormone. However in view of the negative relationship with IGF-I and the positive relationship with IGFBP-1, this fall in ghrelin could facilitate growth acceleration over puberty.

IGF-I and IGF-binding protein-3 measurements on filter paper blood spots in children and adolescents on GH treatment: use in monitoring and as markers of growth performance

BACKGROUND/AIM

In childhood an appropriate response to GH treatment is achieved by titration of growth response against dose administered, with careful observation for side-effects. In order to evaluate the potential use of IGF monitoring in children treated with GH, a cross-sectional study has been carried in 215 children and adolescents (134 with GH deficiency (GHD), 54 with Turner syndrome (TS) and 27 with non-GHD growth disorders) treated with GH for 0.2-13.7 years.

METHODS

IGF-I and IGF-binding protein-3 (IGFBP-3) were measured in ELISAs, using dried capillary blood collected onto filter papers. Results were expressed as the mean S.D. range (SDS). Values of either analyte < -2 or > +2 SDS were considered abnormal.

RESULTS

IGF-I and IGFBP-3 SDS were higher in the TS and non-GHD groups (mean +0.01 and +0.1 respectively) than in those with GHD (mean value -0.6). Nineteen per cent of the IGF-I values (13% low, 6% high) and 12% of IGFBP-3 values were abnormal (10% low, 2% high). Abnormalities, either low or high, were most common in the GHD group. There was a weak but significant relationship between change in height SDS over the Year up to the time of sampling in the whole group and IGF-I SDS. Satisfactory growth performance (+0.5>change in height SDS> -0.5) was found in those with high (7.2%), normal (60%) and low (9.3%) IGF-I levels. Overall, it was estimated that 26% of the tests would indicate that an adjustment to GH dose (up in 18% and down in 8%) could be considered.

CONCLUSIONS

From this cross-sectional study of IGF monitoring across a broad range of diagnoses and ages, it can be concluded that the majority of children on GH have normal levels of IGF-I and IGFBP-3, but 26% of tests could suggest that a change of GH dose should be considered. Regular monitoring of IGF-I and IGFBP-3 should be considered in any child on GH treatment.

The effect of pegvisomant-induced serum IGF-I normalization on serum leptin levels in patients with acromegaly

BACKGROUND

In humans, serum leptin correlates positively with fat mass. GH is lipolytic and patients with active acromegaly have lowered serum leptin compared to age, sex and body mass index (BMI)-matched controls, but a direct influence of GH on serum leptin remains unclear. In patients with acromegaly, total leptin increases following successful pituitary surgery and during somatostatin (SMS) analogue therapy (despite no change in BMI) but whether this represents changes in soluble leptin receptor, bound or free leptin is unclear. Pegvisomant, a GH receptor antagonist capable of normalizing serum IGF-I in over 97% of patients, represents a novel treatment strategy in acromegaly and its effect on leptin has not previously been reported.

PATIENTS

Sixteen patients (nine male (M), seven female (F), median age 52 years, range 27-78 years) with active acromegaly (serum IGF-I at least 30% above the upper limit of an age-related reference range) were studied. Serum IGF-I was normalized in all subjects with pegvisomant [mean duration 7 months (range 3-11 months), median dose 20 mg/day (range 10-40 mg/day)]. A single batch measurement of leptin, bound leptin (BL), soluble leptin receptor (SLR), insulin and glucose were performed on samples from baseline and first occurrence of serum IGF-I normalization.

RESULTS

As in normal subjects, females with acromegaly had higher baseline serum leptin [median M = 6.1 (range 1.6-58.7), F = 25.9 (range 3.19-54.1) ng/ml; P = 0.04], which correlated positively with BMI (R = 0.78, P = 0.0004). Forward step-wise regression analysis demonstrated that BMI and gender accounted for 90% of the variance in mean serum log10 leptin. Pegvisomant-induced serum IGF-I normalization was associated with a rise in serum leptin [8.9 (range 1.6-58.3) to 12.7 (range 2.3-90.8) ng/ml, P < 0.0001]. Although the absolute increase was not significantly different, mean percentage increase was greater in men (M = 66.6 +/- 51%, F = 11.8 +/- 16%, P = 0.017) despite similar serum IGF-I and BMI in male and female subjects at baseline. No change in BL or SLR accompanied serum IGF-I normalization [0.27 (range 0.15-1.26) to 0.27 (range 0.14-1.2) nmol/l, P = 0.27 and 3.2 (range 1.2-6.8) to 2.7 (range 1-7.4) nmol/l, P = 0.5, respectively]. After normalization of serum IGF-I, a correlation between BMI and leptin remained (R = 0.86, P < 0.0001) and together BMI and gender accounted for 87% of the variance in mean log10 serum leptin (P = 0.0002).

CONCLUSION

Pegvisomant-induced serum IGF-I normalization in patients with active acromegaly is associated with a significant increase in total, and by implication, free leptin.

Leptin measurement in urine in children and its relationship to other growth peptides in serum and urine

OBJECTIVE

Leptin has been implicated in the interaction between nutrition, energy balance and sexual maturation in humans. A non-invasive method of measuring leptin would greatly facilitate longitudinal studies of changes in leptin in normal children. The aim of this study was to evaluate the use of urinary leptin as a surrogate for serum leptin measurements.

DESIGN

We have modified and validated a serum immunoradiometric assay (IRMA) kit for the measurement of leptin in urine, and subsequently investigated the relationship between urinary leptin and other growth-related proteins.

METHODS

Cross-sectional study: urinary leptin, measured in the first morning urine voided and expressed as ng excreted overnight, and serum concentrations of leptin, IGF-I, IGF-II, IGFBP-3 and IGFBP-1 were determined in a cohort of 188 healthy schoolchildren aged 5-19 years (88 males, 100 females). Height, weight and pubertal status were assessed in all children. Longitudinal study: urinary levels of leptin, IGF-I and GH were measured daily in two adults (one male, one female) over a period of 6 weeks.

RESULTS

The detection limit of this modified assay was 0.59 ng/L. The intra- and interassay coefficients of variation range was 4-8% and 4-9%, respectively. The recovery of recombinant leptin added to urine was 98-108%, and the assay had a recovery rate for serial dilution in the range of 106-112%. Urinary leptin correlated significantly with serum leptin (r = +0.65, P < 0.01). Urinary leptin showed similar changes through puberty to those of serum leptin, with levels rising in females throughout puberty, whereas in males levels peaked at G2/G3 then decreased. BMI SDS was the main determinant of urinary leptin, as it was for serum leptin. In the cross-sectional study urinary leptin correlated significantly with serum IGF-I (r = +0.41, P = 0.001), IGF-II (r = +0.19, P = 0.05), IGFBP-3 (r = +0.29, P = 0.001) and IGFBP-1 (r = -0.25, P = 0.001). In the adult study, leptin was also detected in urine with similar night-to-night variability to that found for IGF-I and GH.

CONCLUSION

Urinary leptin is a valid marker of serum leptin concentrations, and therefore this non-invasive assay would be a useful tool for longitudinal assessment of changes in leptin in children.

A new missense mutation in the growth hormone-releasing hormone receptor gene in familial isolated GH deficiency

OBJECTIVE

Mutations in the GH-releasing hormone (GHRH) receptor (GHRHR) gene (GHRHR) cause autosomal recessive familial isolated GH deficiency (IGHD). We searched for GHRHR mutations in two siblings with IGHD type IB and a history of parental consanguinity.

DESIGN

We analyzed peripheral genomic DNA of an index patient. After identifying a novel mutation in the GHRHR, we performed functional studies in order to confirm that the mutation causes receptor malfunction.

METHODS

The entire GHRHR was analyzed in the index case by denaturing gradient gel electrophoresis. Abnormally migrating bands were isolated and sequenced. The mutated area was then sequenced in all family members whose DNA was available. The newly found mutation was inserted into a GHRHR cDNA. Wild-type and mutant cDNAs were expressed into CHO cells and the cyclic AMP (cAMP) response to GHRH was measured. In order to determine whether the mutant receptor was properly expressed on the cell membrane surface, CHO cells were transfected with wild-type or mutant GHRHR cDNA containing a FLAG epitope tag in the extracellular N-terminus.

RESULTS

Both patients were homozygous for a new missense mutation in codon 176, corresponding to the second transmembrane domain of the receptor protein that replaces alanine with valine (A176V). The mother and three unaffected siblings were heterozygous for the mutation; DNA from the father was not available. Cells expressing the A176V receptor had a significantly reduced cAMP response to GHRH, despite appropriate expression on the cell surface.

CONCLUSIONS

We describe two siblings with IGHD due to a new mutation in the GHRHR that disrupts GHRH signaling and leads to GHRH resistance.

GH and epidermal growth factor signaling in normal and Laron syndrome fibroblasts

We have investigated and compared GH and epidermal growth factor (EGF) signaling in primary human skin fibroblasts from normal subjects and subjects with GH-binding protein-positive Laron syndrome (LS). In normal human fibroblasts, GH and EGF activate the tyrosine phosphorylation of signal transducer and activator of transcription (STAT)1 and STAT5b; in LS fibroblasts, EGF does, but GH does not. GH also activates the tyrosine phosphorylation of Janus kinase (JAK)2 in normal, but not LS, fibroblasts. Similarly, both GH and EGF activate MAPK in normal fibroblasts, but only EGF does in the LS fibroblasts. As in the 3T3-F442A mouse preadipocyte cell line, GH signaling to mitogen-activated protein kinase is partially inhibited by wortmannin treatment, indicating a role for phosphatidylinositol 3-kinase (PI3K) in this signaling pathway. The exogenous expression of the GH receptor in one family of LS fibroblasts (H1) but not the other (M) restores signaling to a STAT5 reporter element. Together, these results indicate that the mechanism of defective GH signaling in two families of LS fibroblasts are different but that both occur at a level close to, and specific for, the GH receptor.

Monitoring serum insulin-like growth factor-I (IGF-I), IGF binding protein-3 (IGFBP-3), IGF-I/IGFBP-3 molar ratio and leptin during growth hormone treatment for disordered growth

OBJECTIVE

Serum IGF-I levels are monitored during GH replacement treatment in adults with GH deficiency (GHD) to guide GH dose adjustment and to minimize occurrence of GH-related side-effects. This is not routine practice in children treated with GH. The aim of this study was to evaluate changes in (1) serum IGF-I, IGFBP-3 and IGF-I/IGFBP-3 molar ratio, and (2) serum leptin, an indirect marker of GH response, during the first year of GH treatment in children with disordered growth.

DESIGN

An observational prospective longitudinal study with serial measurements at five time points during the first year of GH treatment was carried out. Each patient served as his/her own control.

PATIENTS

The study included 31 patients, grouped as (1) GHD (n = 20) and (2) non-GHD (Turner syndrome n = 7; Noonan syndrome n = 4), who had not previously received GH treatment.

MEASUREMENTS

Serum IGF-I, IGFBP-3 and leptin levels were measured before treatment and after 6 weeks, 3 months, 6 months and 12 months of GH treatment, with a mean dose of 0.5 IU/kg/wk in GHD and 0.7 IU/kg/wk in non-GHD groups. IGF-I, IGFBP-3 and the calculated IGF-I/IGFBP-3 molar ratio were expressed as SD scores using reference values from the local population.

RESULTS

In the GHD group, IGF-I SDS before treatment was lower compared with the non-GHD (-5.4+/-2.5 vs. -1.8+/-1.0; P<0.001). IGF-I (-1.8 SDS +/- 2.2) and IGFBP-3 (-1.1 SDS +/- 0.6) levels and their molar ratios were highest at 6 weeks and remained relatively constant thereafter. In the non-GHD group, IGF-I levels increased throughout the year and were maximum at 12 months (0.3 SDS +/- 1.4) while IGFBP-3 (1.1 SDS +/- 0.9) and IGF-I/IGFBP-3 molar ratio peaked at 6 months. In both groups, IGF-I SDS and IGF-I/IGFBP-3 during treatment correlated with the dose of GH expressed as IU/m2/week (r-values 0. 77 to 0.89; P = 0.005) but not as IU/kg/week. Serum leptin levels decreased significantly during GH treatment in the GHD (median before treatment 4.0 microg/l; median after 12 months treatment 2.4 microg/l; P = 0.02) but not the non-GHD (median before treatment 3.0 microg/l; median after 12 months treatment 2.6 microg/l). In the GHD group, serum leptin before treatment correlated with 12 month change in height SDS (r = 0.70, P = 0.02).

CONCLUSIONS

The pattern of IGF-I, IGFBP-3 and their molar ratio during the first year of GH treatment differed between the GHD and non-GHD groups. Calculation of GH dose by surface area may be preferable to calculating by body weight. As a GH dose-dependent increase in serum IGF-I and IGF-I/IGFBP-3 may be associated with adverse effects, serum IGF-I and IGFBP-3 should be monitored routinely during long-term GH treatment. Serum leptin was the only variable that correlated with first year growth response in GHD.

Serum insulin-like growth factor-I, IGF binding protein-3 and IGFBP-3 protease activity after cranial irradiation

The relationship between peak growth hormone (GH), insulin-like growth factor I (IGF-I), IGF-I binding protein 3 (IGFBP-3) and IGFBP-3 protease activity was studied in 28 children and adolescents undergoing investigation of pituitary function 0.4-14.2 years after cranial or craniospinal irradiation for the treatment of CNS tumours distant from the hypothalamic-pituitary axis (n = 16) or prophylaxis against CNS leukaemia (n = 12). Seven out of 15 patients with GH deficiency (GHD) (defined as a peak GH concentration <7.5 ng/ml in a stimulation test) had IGF-I <-2 standard deviation score (SDS). None of the 28 patients had serum IGFBP-3 concentrations measured by radioimmunoassay (RIA) <-1.5 SDS with no difference between those with and without GHD. IGFBP-3 concentrations measured by RIA were strongly correlated to IGFBP-3 band density on Western ligand blot (WLB) (r = 0.71; p < 0.0001). IGFBP-3 protease activity was negatively correlated to IGFBP-3 by RIA (r = -0.55; p < 0.01) and to IGFBP-3 by WLB (r = -0.51; p < 0.01). Twenty-two patients had normal IGFBP-3 protease activity (<30% of the activity in pregnancy serum) indicating that serum IGFBP-3 protease activity does not account for the normal levels of IGFBP-3 in RIA. Low serum IGF-I but normal IGFBP-3 concentrations and in the majority normal IGFBP-3 protease activity was found in patients in the years after CNS irradiation. Neither serum IGF-I nor IGFBP-3 can be used as a reliable index of the development of radiation-induced GHD.

Signal transduction defects in growth hormone insensitivity

Growth hormone (GH) insensitivity is a heterogeneous condition that can result from mutations within the GH receptor (GHR) and that can be inherited as both an autosomal recessive and a dominant trait. However, evidence from a small number of growth hormone binding protein (GHBP)-positive families indicates that their GH insensitivity is independent of GHR mutations. Two of these families appear to have distinct abnormalities in GH signal transduction. Studies suggest that one family (classic Laron syndrome phenotype; designated family H) have a signalling defect close to the GHR, preventing activation of both the STAT and MAPK pathways, whereas the other family (less marked phenotype; family M) have a defect in activating MAPK but not the STAT pathway. The children studied here are specifically insensitive to GH and their defect must be exclusive to this signalling system. Thus, families with GHBP-positive GH insensitivity without GHR mutations are likely to be important models in which to study the specificity of GH signal transduction and the relationship between GH insensitive phenotype and signalling defect.

Growth hormone stimulation of the mitogen-activated protein kinase pathway is cell type specific

The GH receptor is a member of the cytokine receptor superfamily. Studies in the 3T3-F442A mouse preadipocyte have shown that GH activates the Janus kinase (JAK2), the signal transducers and activators of transcription (STAT1, -3, and -5), and mitogen-activated protein (MAP) kinase. Our previous studies in the human IM-9 lymphocyte have shown that GH activates JAK2 and only STAT5 (not STAT1 or -3). In the studies presented here, we have investigated activation of the MAP kinase (MAPK) pathway in the IM-9 lymphocyte. Western blotting with antiphosphotyrosine-, anti-MAPK-, and anti-phospho-MAPK-specific antibodies as well in vitro kinase assays using a synthetic peptide substrate demonstrate that although GH (200 ng/ml) activates MAPK in 3T3-F442A cells (at 5 and 10 min of treatment), it does not activate MAPK in IM-9 lymphocytes at time points ranging from 5-60 min. Nevertheless, the phorbol ester phorbol 12-myristate 13-acetate (50 ng/ml) does activate MAPK in the IM-9 cell, and immunoprecipitation with specific antibodies indicates that this activation occurs through c-Raf-1. Although the 52- and 66-kDa forms of the adapter protein Shc are tyrosine phosphorylated in response to GH treatment in 3T3-F442A cells, we demonstrate that the predominant forms in IM-9 cells are the 52- and 46-kDa forms, and neither is tyrosine phosphorylated in response to GH. These studies further elucidate the differential signaling by GH in two cell types.

Activation of the signal transducers and activators of transcription signaling pathway by growth hormone (GH) in skin fibroblasts from normal and GH binding protein-positive Laron Syndrome children

We have previously described two families (H and M) with GH binding protein-positive Laron Syndrome (LS), proposed to have one or more post GHR signaling defects. In the present study, we have examined whether the signal transducers and activators of transcription (STAT) pathway is activated by GH in skin fibroblast cultures established from these LS children, to determine the level(s) at which GH insensitivity has occurred. On immunoblots, both normal and LS fibroblasts express JAK2 and STATs 1, 3, and 5. GH induced rapid tyrosine phosphorylation of a protein at approximately 93 kDa in normal fibroblasts, and Western blotting with STAT-specific antibodies revealed STAT5 activation (phosphorylation) by GH. To determine further the identity and the DNA binding characteristics of the STAT proteins that were activated by GH, EMSAs were performed using three DNA elements known to bind STAT proteins; m67, the high affinity c-sis-inducible element (SIE), the interferon response element (IRE), and the lactogenic hormone-responsive region (LHRR). GH failed to induce protein binding to the SIE or IRE in normal skin fibroblasts but did induce the formation of a specific complex with the LHRR. Induction by GH of this LHRR/protein complex, which could be supershifted partially by anti-STAT1 antisera and completely by anti-STAT5 antisera, was transient, maximal between 10 and 30 min and reduced by 60 min. GH also induced distinct LHRR/protein complexes in mouse 3T3-F442A fibroblasts and in human IM-9 lymphocytes, but supershift analysis revealed that these complexes contained STAT5 but not STAT1. Whereas no binding to the LHRR was observed in GH-treated H fibroblasts, GH induced binding to this element in M fibroblasts. These results demonstrate that 1) the JAK-STAT pathway is activated by GH in normal fibroblasts and that STATs 1 and 5 have a role in GH-dependent signaling in these cells; 2) GH activation of DNA/STAT binding is cell type- and species-specific; and 3) GH failed to activate the STAT pathway in H fibroblasts but induced STAT signaling in M fibroblasts, indicating that the site of GH resistance in the latter is likely to be located within another GH signaling pathway. These fibroblast cultures therefore provide unique models with which to further our understanding of the mechanisms of human GH signaling.

Serum leptin through childhood and adolescence

OBJECTIVE

Leptin is the protein product of the recently cloned ob gene, that has been implicated in the control of body weight and thermogenesis, but also independently stimulates the reproductive axis. As major changes in body composition and gonadal function occur during human adolescence, we have assessed serum leptin concentration through childhood.

SUBJECTS AND MEASUREMENTS

Serum leptin was measured in a radioimmunoassay in samples from 235 healthy children from 5 to 18 years of age. Its relationship to body mass index (BMI) (expressed as standard deviation score (SDS)) and the changes in concentration both within and between sexes over the stages of puberty were analysed.

RESULTS

Serum leptin was present at similar concentrations in both sexes over the prepubertal years and increased in parallel into early puberty (breast stage (B) 2, genital stage (G) 2). Thereafter serum leptin in the boys declined to a nadir in G5. In contrast in girls, leptin remained constant in mid-puberty rising to a peak at B5. Factors influencing leptin (BMI SDS, age and testicular volume) were assessed therefore in the pre- and peripubertal stages (B1-2, G1-2) compared to the later pubertal stages (B3-5, G3-5). In all groups, leptin was positively correlated to BMI SDS (r2 = 38-41% in girls, r2 = 31-35% in boys). However in B1-2 and G1-2, leptin was also positively related to age, which contributed a further 27% and 20% respectively to the variability. In B3-5, age only accounted for an additional 5% in leptin variability. In contrast in G3-5, leptin was related positively to BMI SDS (r2 = 35%) and negatively to testicular volume (r2 = 24%).

CONCLUSIONS

The influence of BMI on leptin is a significant factor throughout the prepubertal and pubertal years of both sexes. The additional negative effect of testicular volume in the boys contributes to the sexual dichotomy in leptin concentration at the completion of puberty. The similar rise in leptin over the prepubertal years into early puberty in both sexes, related not only to BMI SDS but also independently to age, would suggest that leptin may have a facilitatory role in human pubertal development.

Urinary IGF and IGF binding protein-3 in children with disordered growth. The North West Paediatric Endocrine Group

OBJECTIVE

Both IGF-I and IGFBP-3 reflect spontaneous GH secretion in healthy individuals. We have evaluated the clinical usefulness of urinary IGF-I and IGFBP-3 measurements in the diagnosis of children with disordered growth.

DESIGN

Serum IGF-I and IGFBP-3 radioimmunoassays (RIA) were developed, and modified for quantitation in urine. The relationship between serum and urine levels, and the performance of these tests in the diagnosis of GH deficiency (GHD) were examined.

PATIENTS

Sixty-nine children (age 9.5 +/- 3.6 years; 37 boys, 32 girls) provided a timed overnight urine collection and a serum sample collected on the same morning. Subjects were defined as GHD (n = 22) or short normal (SN; n = 47) on the basis of medical history, clinical examination, auxology and peak response to a GH stimulation test (< 20 mU/L in GHD patients).

MEASUREMENTS

IGF-I and IGFBP-3 in serum and urine were measured by RIA, urinary GH (uGH) by immunoradiometric assay (IRMA) after dialysis and urinary creatinine by the alkaline picrate method. Urine results were expressed as total amount excreted (tulGFBP-3 (microgram), tulGF-1 (ng), tuGH (ng), tuCrt (mmol).

RESULTS

Urine IGF-I and IGFBP-3 excretion correlated significantly to serum levels of IGF-I and IGFBP-3 and also to tuGH excretion. There was a strong positive relationship between both urinary peptides and tuCrt, which suggested that renal filtration was the source of these peptides in urine. In addition, there were significant correlations with age, bone age and height SD score, of similar magnitude to those for tuGH. In prepubertal children, serum IGF-I and IGFBP-3 were significantly lower in GHD compared with SN children, while in puberty only serum IGFBP-3 was significantly lower in GHD. There was no difference however, in tulGF-I or tulGFBP-3 between GHD and SN children either prepubertally or in puberty with near complete overlap of the values between groups.

CONCLUSIONS

Measurements of tulGF-I and tulGFBP-3 have no place in the diagnosis of childhood GHD. Nonetheless, the significant correlations between serum and urinary IGF-I and IGFBP-3 levels and their correlation to uGH indicate that these peptides could be used as non-invasive physiological markers of the GH-IGF axis.

Biochemical tests in the diagnosis of childhood growth hormone deficiency

GH stimulation tests are widely used in the diagnosis of GH deficiency (GHD), although they are associated with a high false positive rate. We have examined, therefore, the performance of other tests of the GH axis [urinary GH excretion, serum insulin-like growth factor I(IGF-I), and IGF-binding protein-3 (IGFBP-3) levels] compared with GH stimulation tests in identifying children defined clinically as GH deficient. Group I comprised 60 children (mean age, 10.3 +/- 4.8 yr) whose diagnosis of GHD was based on a medical history indicative of pituitary dysfunction (n = 43) or on the typical phenotypic features and appropriate auxological characteristics of isolated GHD (n = 17). Group II comprised 110 short children (mean age, 9.8 +/- 4 yr) in whom GHD was not suspected, but needed exclusion. The best sensitivity for a single GH test was 85% at a peak GH cut-off level of 10 ng/mL, whereas the best specificity was 92% at 5 ng/mL. The sensitivities of IGF-I, IGFBP-3, and urinary GH, using a cut-off of -2 SD score were poor at 34%, 22%, and 25%, respectively, with specificities of 72%, 92%, and 76% respectively. Only 2 of 21 pubertal children in group I and none of the 27 subjects with radiation-induced GHD had an IGFBP-3 SD score less than -1.5. We devised a scoring system based on the positive predictive value of each test, incorporating data from the GH test and the IGF-I and IGFBP-3 levels. A specificity of 94% could be achieved with a score of 10 or more (maximum 17) (sensitivity 34%). The latter could not be improved above 81% with a score of 5 points or more (specificity, 69%). A high score was, therefore, highly indicative of GHD, but was achieved by few patients. A normal IGFBP-3 level, however, did not exclude GHD, particularly in patients with radiation-induced GHD and those in puberty. A GH test with a peak level more than 10 ng/mL was the most useful single investigation to exclude a diagnosis of GHD.

Human skin fibroblasts as a model of growth hormone (GH) action in GH receptor-positive Laron's syndrome

Congenital GH insensitivity (Laron's syndrome, LS) is often associated with a dysfunctional GH receptor (GHR) causing complete insensitivity to GH and absent serum GH-binding protein (GHBP). However, a proportion of children with LS have normal GHBP levels. We have identified four girls from two families with this condition (height SD score, -3.4 to -6.8) and undertaken studies on 1) their GHR genes and 2) their GH responses in cultured skin fibroblasts to define the etiology of their GH insensitivities. No GHR gene mutations were identified in one family. In the other family, the affected siblings, an unaffected brother, and the father were heterozygous for a point mutation within exon 6 (D152H). In addition, use of intron 9 haplotypes to determine linkage to the GHR gene implied inheritance of different maternal GHR alleles in the two affected girls of the latter family. It is unlikely, therefore, that the D152H mutation alone could account for the LS phenotype. End points of GH action [DNA synthesis, insulin-like growth factor-binding protein-3 (IGFBP-3) messenger RNA (mRNA) and peptide production] in skin fibroblast cultures established from three of the LS subjects and four normal children were examined. Whereas normal fibroblasts incorporated [3H]thymidine dose dependently in response to 10-1000 ng/ml GH (increment at 1000 ng/ml, 77 +/- 19%), LS fibroblasts failed to respond significantly above basal levels (P < 0.01). In normal fibroblasts, IGFBP-3 mRNA and peptide increased maximally at 48 h in response to 200 ng/ml GH, as determined by ribonuclease protection assay, Western ligand blotting, and RIA. In comparison, LS fibroblasts produced significantly less IGFBP-3 peptide than normal fibroblasts in response to GH, whereas IGFBP-3 mRNA failed to increase above basal levels. These studies have shown that 1) cultured human skin fibroblasts can be used to define the end points of GH action; 2) fibroblast cultures from the LS children show absent or reduced responses to GH; and 3) GH insensitivity in these children does not appear to be caused exclusively by GHR mutations, but is probably due to dysfunctional GHR signalling. Such patients may prove particularly important to elucidation of the key events in GH signaling.

Insulin-like growth factor binding protein-3 generation: an index of growth hormone insensitivity

GH insensitivity may be an inherited condition or may arise as a consequence of disease of malnutrition. Laron syndrome is the most severe form of GH insensitivity, arising from an absent or defective GH receptor. Less severe forms of GH insensitivity, however, may exist, resulting in short stature but in few other features of Laron syndrome. We have identified a heterogeneous group of children with short stature and either high basal (> 10 mU/L) or high peak GH levels (> 40 mU/L) on GH provocation testing, to examine biochemical markers of GH sensitivity. These children received 4 d of GH (0.1 U/kg) and the increment in IGF-I, IGF binding protein (BP)-3, and GHBP was determined. Eight GHD children, commencing GH therapy, were recruited as positive controls. The two groups could not be differentiated by age, height SDS (SD score), height velocity SDS, or body mass index. IGF-I and IGFBP-3 generation were correlated in all children (delta SDS IGF-I versus delta SDS IGFBP-3, r = 0.49, p = 0.03). Neither basal GHBP levels or the increment in GHBP were predictive of the IGF-I or IGFBP-3 response to GH. The GHI group had a significantly reduced IGFBP-3 response to stimulation with 4 d of GH (median percent increment in IGFBP-3, 26%, versus 72% in the GHD group, P = 0.03); their IGF-I response to GH was also reduced (median % increment in IGF-I 75% versus 144% in the GH deficient group), but this did not achieve significance, p = 0.06. In all children, the percentage rise or delta SDS in both IGF-I and IGFBP-3 inversely correlated with the GH peak obtained on provocation testing, the latter being the most significant determinant of GH peak. We propose that the "IGF generation test", in particular IGFBP-3 generation, can be used in the investigation of partial GH insensitivity. Further work, however, is required to establish diagnostic criteria for partial GH insensitivity.

Infradian rhythms in urinary growth hormone excretion

All studies of urinary GH excretion in normal and disordered growth have revealed marked day to day (infradian) variation. We used serial overnight urinary GH estimations as an indirect measure of endogenous GH secretion in eight normal prepubertal children (aged 3.6-7.3 yr) over 90-365 days to determine whether longer term rhythms in GH output could exist. This study constitutes a first step in examining the potential relationship between GH excretion and growth. Urinary GH was measured by immunoradiometric assay after dialysis, expressed as the total amount excreted (nanograms per night) or as the GH/creatinine ratio (nanograms per mmol), and assessed by pulse counting techniques and time-series analysis. Variability in urinary GH excretion (median coefficient of variation, 46%) was significantly greater than creatinine (median coefficient of variation, 25%; P = 0.003). Additionally, there was marked month by month variation in baseline urinary GH in all children. High frequency pulses of urinary GH were defined in all children, with periods between 3-5 days. In the two children followed for 7 months or more, time-series analysis was also undertaken on urinary GH data divided into weekly series. This revealed significant rhythms present at 2.6 and 4.1 weeks. There were, therefore, three components to urinary GH excretion: long term basal fluctuation (over months), short term pulses (over days), and intermediate rhythms (over weeks). Further work is required to establish the relationship between these patterns of GH excretion and short term growth.

Effects of okadaic acid on expression of phosphoenolpyruvate carboxykinase in cultured rat hepatocytes

In normal rat hepatocytes in primary culture the level of mRNA encoding the key gluconeogenic enzyme phospho enol pyruvate carboxykinase (PEPCK) is increased by the cyclic AMP analogue, chlorophenylthio cyclic AMP (cpt cAMP), and this response is reversed by insulin. The protein-phosphatase inhibitor okadaic acid diminished the stimulatory effects of cpt cAMP on PEPCK mRNA. Protein kinase A remained fully active in the presence of okadaic acid, therefore, the insulin-mimetic actions of okadaic acid were localised to a site subsequent to initial protein kinase A activation. Insulin produced a decrease in PEPCK mRNA expression which was similar to that of okadaic acid both in extent and mechanism (i.e., lack of change in protein kinase A activation). The effects of okadaic acid on PEPCK mRNA amount were not additive with those of insulin and the effects of insulin were not abolished by okadaic acid. These data suggest that okadaic acid and insulin may interact with the cAMP regulation of the PEPCK gene expression at a common site. The mechanisms by which this may be attained are discussed in relation to what is known about the control of specific protein kinases and protein phosphatases by insulin and okadaic acid and of the importance of protein phosphorylation state to regulation of gene-transcriptional processes.

Glycolipids isolated from cultured rat hepatocytes: analysis of their role in insulin signal transduction

The precise mechanism by which insulin elicits its effects remains to be fully determined. A glycophospholipid, isolated from H35 cells, has been proposed as a possible precursor for an insulin-generated second messenger that mediates the intracellular effects of insulin. This glycolipid contains a hexosamine moiety, inositol, galactose and palmitate. We have isolated a glycolipid from cultured rat hepatocytes that exhibits chromatographic and radiolabelling characteristics similar to this proposed precursor. The glycolipid can be radiolabelled with glucosamine, galactosamine, galactose and palmitate, but not myristate or myoinositol. Incorporation of radiolabel into this glycolipid was insensitive to the presence of either insulin (10(-7) M) or phosphatidylinositol-specific phospholipase C (PI-PLC) in the culture medium. The cultured hepatocytes used exhibited normal insulin responses with respect to glycogen turnover and gene expression. Treatment of partially purified glycolipid with either PI-PLC or nitrous acid did not result in the generation of an aqueous soluble phosphooligosaccharide indicating that the glycolipid was not cleaved by either agent. This is in contrast to the reported cleavage of the glycolipids found in H35 hepatoma and lymphocytes. These results question the role of the putative phosphooligosaccharide mediator in the intracellular transduction system activated by insulin.

Initial characterization of a polyclonal antibody to an insulin-sensitive glycophospholipid

This paper describes the production of a rabbit polyclonal antibody against an insulin-sensitive glycophospholipid from rat liver membranes. The immunogen was a highly purified glycophospholipid-tetanus toxoid conjugate. Immunoglobulin purified from immune serum reacted with a glycophospholipid-ovalbumin conjugate, indicating specificity for the glycophospholipid hapten and not the protein carrier. By radioimmunoassay the antibody recognized the purified glycophospholipid antigen but not other phospholipids including phosphatidylethanolamine, phosphatidylcholine, phosphatidylserine, and phosphatidylinositol. The antigenic site appears to be the carbohydrate portion of the glycophospholipid. The antibody also reacted with glycophospholipid purified from two rat hepatoma cell lines. Analysis of partially purified liver glycophospholipid by thin-layer chromatography revealed over 20 orcinol- or fluorescamine-positive bands, but immunostaining identified only 1 band. The latter had an Rf identical to those of the original glycophospholipid isolated from rat liver and metabolically labeled material isolated from hepatoma cells. The antibody should prove useful in determining the role of the glycophospholipid and its metabolites in insulin action.