More restrictive growth hormone policies translate into shorter children

By Will Boggs MD

NEW YORK (Reuters Health) - European countries with more restrictive reimbursement for growth hormone use in pediatric end-stage renal disease (ESRD) end up with shorter children, according to a report from the ESPN/ERA-EDTA registry.

More than 40% of children with ESRD do not achieve normal adult height, but there are no general European guidelines on recombinant growth hormone (rGH) use in pediatric ESRD.

Dr. Marjolein Bonthuis from the ESPN/ERA-EDTA Registry, Academic Medical Center, Amsterdam, The Netherlands and colleagues examined the variation in growth hormone policies in pediatric nephrology patients across European countries and related these policies to outcomes.

Of the 28 countries that completed their questionnaire, 21 reimbursed rGH for children with chronic kidney disease. Fifteen of these 21 countries had national policies on its use in this setting.

Mean height standard deviation scores (SDS) were significantly higher in countries where rGH was reimbursed (-1.80) than in countries where rGH was not reimbursed (-2.34; p<0.001), according to a report online April 28th in Nephrology Dialysis Transplantation.

Age limitations, height criteria, and specific chronic kidney disease stage limitations across various countries had a smaller impact on final height.

Although 45.9% of dialysis and 38.9% of transplant patients had height SDS below -2, and were therefore eligible for receiving rGH, only 21.7% of dialysis patients and 5.5% of transplant patients actually received rGH treatment.

"In all countries," the researchers say, "the actual use of rGH was lower than the number of children eligible for rGH: only 26.0% of short dialysis and 8.9% of short transplant patients actually received rGH."

"Physicians stated that the difference between actual rGH use and percentage of children eligible for rGH was due to several factors: patients refused treatment, improving nutritional intake and metabolic bone disease had priority over starting rGH, dialysis adequacy was sub-optimal, and patients were suffering from severe uncontrolled hyperparathyroidism," they explain. "In addition, physicians stated that delayed prescription could occur when the responsibility for prescribing rGH was under control of the endocrinologist."

Both doctor- and patient-related obstacles "are amenable for interventions in order to improve the use of rGH in children with ESRD and offer those children a chance to achieve more beneficial health outcomes," the authors conclude.

Dr. Doaa Youssef Mohammed El Sheikh, a pediatric nephrologist from Zagazig University in Egypt, told Reuters Health he was surprised by the findings.

"We have to try convince endocrinologists with these results and previous publications about this subject," he said in an email. "Also, an effort has to be made to convince both caregivers and health insurance companies about the cost benefit effect of its usage."

"The main message taken from this report is that it is not enough to build a guideline, but it's also important to follow its applications, restrictions, and actual outcomes which might change the guidelines again," Dr. El Sheikh said. "I would suggest a completion of this report including main side effects, factors affecting drug discontinuation, and a financial report about cost of usage."

Dr. Bonthuis was not able to comment for Reuters Health by deadline.

SOURCE: http://bit.ly/1IymHDx

Nephrol Dial Transplant 2015.

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