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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">We present a new case that illustrates the difficulty in differentiating between a growth hormone &#40;GH&#41; secretion disorder and acromegaly in a patient with chronic kidney disease &#40;CKD&#41; due to changes in growth hormone levels caused by uraemia&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">A 48-year old patient was referred to hospital after the outpatient clinic detected a serum creatinine of 7&#46;56mg&#47;dL&#46;</p><p class="elsevierStylePara">Significant exam findings included blood pressure&#58; 163&#47;111mmHg&#44; Weight&#58; 105kg&#44; Height&#58; 190cm&#44; Body mass index&#58; 29kg&#47;m<span class="elsevierStyleSup">2</span>&#46; Slight cognitive deficit&#46; Corpulent body phenotype&#46; Facies with prognathism and macroglossia&#44; thick lips&#44; prominent brow ridges &#40;Figure 1&#41;&#44; deep voice&#46; Normal on auscultation&#46; Normal fundoscopy&#46; The patient reported no changes in body morphology&#46;</p><p class="elsevierStylePara">Ultrasound imaging showed kidneys of a size at the lower limit of normal&#44; with markedly thinned bilateral renal parenchyma&#44; almost non-existent&#46;</p><p class="elsevierStylePara">Laboratory tests on admission showed characteristic uraemia biochemical parameters with negative viral serology and normal immunologic tests&#46; Hormone determinations were also performed&#58;</p><p class="elsevierStylePara">- Cortisol&#58; 23mcg&#47;dL &#40;6-28&#41; TSH&#58; 1&#46;01mcIU&#47;mL &#40;0&#46;27 to 4&#46;2&#41;&#46;</p><p class="elsevierStylePara">- Renin&#58; 29&#46;7micro IU&#47;mL &#40;2&#46;8 to 39&#46;9&#41;&#46;</p><p class="elsevierStylePara">- Aldosterone&#58; 4&#46;24ng&#47;mL &#40;10-160&#41;&#46;</p><p class="elsevierStylePara">- FSH&#58; 12&#46;4mIU&#47;ml &#40;1&#46;5 to 12&#46;4&#41; LH&#58; 8&#46;4mIU&#47;mL &#40;1&#46;7 to 8&#46;6&#41;&#46;</p><p class="elsevierStylePara">- Prolactin&#58; 553mIU&#47;L &#40;86-324&#41;&#44; total testosterone&#58; 1&#46;99ng&#47;mL &#40;2&#46;5-8&#46;4&#41;&#46;</p><p class="elsevierStylePara">- GH&#58; 4&#46;24ng&#47;mL &#40;0-1&#41;&#46;</p><p class="elsevierStylePara">- Somatomedin C &#40;IGF1&#41;&#58; 670ng&#47;mL &#40;100-358&#41;&#46;</p><p class="elsevierStylePara">- IGF1-BP3&#58; 7&#46;59micro&#47;mL &#40;3&#46;3 to 6&#46;7&#41;&#46;</p><p class="elsevierStylePara">- ACTH&#58; 39pg&#47;mL &#40;8-46&#41;&#46;</p><p class="elsevierStylePara">Hypertension was controlled with medical treatment&#46; Due to renal function deterioration of unknown etiology&#44; treatment was begun with chronic HD&#46;</p><p class="elsevierStylePara">An oral glucose overload test &#40;OGOT&#41; was performed &#40;Figure 2&#41;&#46;</p><p class="elsevierStylePara">At this point&#44; we suspected acromegaly&#44; based on phenotype and hormone profile &#40;increase in GH&#44; IGF-1 and IGF1-BP3&#59; OGOT with no clear suppression of GH&#41;&#46; It was not possible to perform magnetic resonance imaging &#40;MRI&#41; of the pituitary due to patient and family refusal&#46;</p><p class="elsevierStylePara">Four months later&#44; an MRI was finally performed without paramagnetic contrast&#46; The size of the pituitary was within normal limits&#44; and the pituitary stalk was centred&#46; A new OGOT was performed&#44; showing normal baseline GH with paradoxical increase at 30 minutes&#44; but with adequate suppression within two hours &#40;Figure 2&#41;&#46;</p><p class="elsevierStylePara">At that time&#44; the levels of IGF-1 &#40;340ng&#47;mL&#41; and IGF1-BP3 &#40;6&#46;3mcg&#47;mL&#41; were also normal&#46; Prolactin continued to be high and testosterone was normal&#46; Currently&#44; the patient undergoes regular endocrinology check-ups and continues on haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Appearances can be deceiving when it comes to diagnosing acromegaly in uraemic patients&#46; Our patient did not suffer from acromegaly&#44; in spite of the fact that his morphological features and first hormone determinations were compatible with this condition&#46;</p><p class="elsevierStylePara">After reviewing the literature&#44; we found two similar cases<span class="elsevierStyleSup">1&#44;2</span>&#46; In the case of our patient&#44; we were uncertain until we had the MRI results&#46;</p><p class="elsevierStylePara">Repeated functional tests after several months on haemodialysis showed normal values&#46;</p><p class="elsevierStylePara">Hyperprolactinemia&#44; also seen in our patient&#44; is a common finding in CKD in both sexes<span class="elsevierStyleSup">3</span>&#46;</p><p class="elsevierStylePara">Acromegaly is a rare condition in Spain&#44; with an estimated incidence of 3-4 cases per million inhabitants a year and a prevalence of 36 cases per million<span class="elsevierStyleSup">4</span>&#46; OGOT is the test that confirms diagnosis&#46; In healthy individuals&#44; it leads to suppression&#44; within two hours&#44; of serum GH values below 1ng&#47;mL&#46; Furthermore&#44; it has been reported that several disorders&#44; including renal failure&#44; can lead to OGOT false positives&#46;</p><p class="elsevierStylePara">There are not many studies that have assessed renal function in acromegaly&#46; In a recent study&#44; a large series of patients was analysed&#44; concluding that acromegaly is characterised by significant changes in renal structure and function<span class="elsevierStyleSup">6</span>&#46; It may be assumed that perhaps through a hyperfiltration mechanism&#44; renal function could eventually deteriorate in these individuals&#46;</p><p class="elsevierStylePara">Often studies of GH secretion in CKD have been inconclusive or have produced conflicting results&#44; possibly due to the pulsatile nature of GH&#44; increased retention and catabolism in uraemia&#44; variable activity of transporter proteins and the effects of stress&#44; malnutrition and other unknown factors<span class="elsevierStyleSup">7</span>&#46; There is evidence that uraemia causes a state of resistance to growth hormone<span class="elsevierStyleSup">3&#44;8&#44;9</span> and this would explain why acromegaly is so rare in renal patients&#46; Some studies have shown that dialysis can significantly reduce GH levels to normal levels<span class="elsevierStyleSup">9&#44;10</span>&#44; as occurred in our patient&#46;</p><p class="elsevierStylePara">In conclusion&#44; our case illustrates the difficulty of interpreting GH&#47;IGF-1 axis results in uraemia&#46; We should remind doctors of these alterations when assessing probable acromegaly in a patient with CKD&#46; A complete hormone study&#44; including imaging&#44; and monitoring of hormone levels after starting dialysis&#44; will help establish the correct diagnosis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12000&#95;16025&#95;64433&#95;en&#95;f112000&#46;jpg" class="elsevierStyleCrossRefs"><img src="12000_16025_64433_en_f112000.jpg" alt="Patient whose phenotype on admission led to suspicion of acromegaly"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Patient whose phenotype on admission led to suspicion of acromegaly</p><p class="elsevierStylePara"><a href="grande&#47;12000&#95;16025&#95;64434&#95;en&#95;f212000&#46;jpg" class="elsevierStyleCrossRefs"><img src="12000_16025_64434_en_f212000.jpg" alt="Changes in levels of growth hormone in ng&#47;ml of patient at rest with an oral glucose load of 75g "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Changes in levels of growth hormone in ng&#47;ml of patient at rest with an oral glucose load of 75g </p>"
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