Articoli in pubblicazione

Over 15% of couples worldwide suffer from infertility and in 50% of cases a male factor is found. According to the World Health Organization, sperm analysis is the most appropriate test to assess male infertility. Since quite often, the conventional semen parameters are related to sperm DNA damage, the integration of this evaluation with sperm DNA fragmentation (SDF) could independently predict the sperm reproductive potential. Unfortunately, this analysis has not entered into routine clinical practice. The aim of this review is to discuss the importance of the SDF analysis and its clinical implication and to evaluate the extrinsic and intrinsic factors that affect the DNA fragmentation. In addition, principles and protocols of different methods used to evaluate and quantify the SDF are reviewed; advantages and disadvantages of different methods are reported.

The most recent international guidelines recommend that high-sensitivity (hs) methods should be preferred for the measurement of cardiac troponin I (cTnI) and T (cTnT) for the detection of myocardial injury and the differential diagnosis of acute coronary syndromes. Furthermore, these guidelines state that there is no significant difference in accuracy among hs cTnI and cTnT methods for diagnosis of acute myocardial infarction. Myocardial injury is a prerequisite for the diagnosis of acute myocardial infarction, but it is also a distinct entity. The 2018 Fourth Universal Definition of Myocardial Infarction states that myocardial injury is detected when at least one value above the 99th percentile upper reference limit is measured in a patient by high-sensitivity methods for cTnI or cTnT. Occasionally, discrepancies between hs-cTnI and hs-cTnT test results can be found, when tested in the same blood sample. Several studies have reported discrepancies between hs-cTnI and hs-cTnT test results in some clinical conditions (especially chronic neuromuscular diseases) or even in apparently healthy subjects. This review, summarizes and discusses the biochemical, pathophysiological and analytical possible mechanisms causing discrepancies between hs-cTnI and hs-cTnT test results.

Background: monoclonal gammopathies include a broad spectrum of pathologies, and free light chains (FLC) measurement is recommended by guidelines for the diagnosis, follow up and prognosis of plasma cell dyscrasia. The aim of the study is to compare the measurement of FLC performed with two different analytical platforms, a nephelometer and a turbidimeter, in order to assess the analytical and diagnostic agreement.
Methods: 87 consecutive samples received by the laboratory with a request of FLC measurement were analyzed on nephelometer Immage 800 (Beckman Coulter, USA) and turbidimeter Optilite (The Binding Site, UK), using the same antibodies (Freelite, The Binding Site, UK).
Results: by applying the Passing-Bablok regression and the Bland-Altman analysis, a proportional and constant systematic error but non-significant bias for FLC ratio (rFLC) has been observed. By applying the Weighted Cohen’s Kappa (WK) test to the rFLC values, an excellent diagnostic agreement between the two instruments has been shown, considering both the normal range (0.26 – 1.65) (WK=0.87) and the diagnostic range for multiple myeloma (<0.01 or >100) (WK=0.84).
Conclusions: Although there are statistical differences between the measurements performed by the two instruments, these do not affect the diagnostic agreement, that is excellent. Nevertheless, the turbidimeter is provided with a software that can automatically detect the antigen excess; by diluting further the samples automatically, it performs fewer dilutions than the nephelometer and provides a wider range of measurement, especially for low concentrations. These characteristics assist the operator both during the analysis and the validation phases of the results, saving time and resources. On the basis of the results of the study, it can be concluded that the turbidimeter shows better performances compared to the nephelometer.

Background: Gestational Diabetes Mellitus (GDM) is diagnosed by the oral glucose tolerance test (OGTT) using Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study-derived definite cut-off values, where reference glucose is determined in sodium fluoride (NaF) containing tubes immediately centrifuged. The aim of the present study is to evaluate the effect of the use of the recommended citrate containing tubes, as immediate glycolisis inhibitor, for OGTT as screening for GDM, comparing them with NaF containing tubes, used in routine laboratory conditions.
Methods: a total of 83 pregnant women were enrolled in the study; OGTT (75 g) was carried out in the Clinical Laboratories of Brescia and Vicenza in all the subjects for screening of GDM. All subjects signed written informed consent to participate in the study. Glucose determination was performed using three different types of glycolysis inhibitor: [sodium fluoride (NaF, in both laboratories), a lyophilized acidified mixture (FC-MIX, in Vicenza), and a liquid acidified mixture (GlucoEXACT, in Brescia)]. The glucose concentration was measured by an hexochinase method on Dimension Vista systems from Siemens Healtheers. The International Association of Diabetes and Pregnancy Study Groups (IAPDGS) criteria, derived from the HAPO study, were used for the diagnosis of GDM.
Results: Using NaF and FC-mix tubes, 6/51 (11.8%) and 12/51 (23.5%) women respectively, were diagnosed having GDM in Vicenza. Using NaF and GlucoEXACT tubes 2/31 (6.5%) and 6/31 (18.8%) women respectively, were diagnosed having GDM in Brescia. There was a statistically significant difference (p<0.05) between NaF and citrate acidified mixture in the glucose measurements at all time points.
Conclusions: The use of the tubes containing a mixture of NaF, EDTA and citrate is a useful and necessary pre-analytical tool for an accurate OGTT, when utilized for the screening of GDM. Tubes containing NaF alone should no longer be used for screening of GDM because their use results in underdiagnosis of GDM.

Background: this article provides an updated overview on the current epidemiologic burden of ischemic heart disease (IHD) in Italy.
Methods: an electronic search was carried out in the Global Health Data Exchange (GHDx) registry, using the keyword “ischemic heart disease”, for retrieving recent information (year 2017) on incidence, prevalence, health loss (expressed as disability-adjusted life year, DALYs) and mortality of IHD in Italy.
Results: the cumulative incidence, prevalence and mortality of IHD in Italy are 0.38%, 3.47% and 0.16% respectively, whilst the impact on health loss is 1.11 million DALYs (6.73% of total DALYs). Incidence, prevalence and DALYs are higher in men than in women, whilst mortality is only marginally higher in males. Overall, IHD is the first cause of death in Italy (15.5% of all deaths). During the last three decades the incidence has constantly increased (+30%), whilst DALYs have declined in both sexes by ~30%. Mortality for IHD steadily decreased in men (-13%), whilst it remained almost unchanged in women. The curve of incidence of IHD in Italy peaks between 60-84 years in men and between 75-94 years in women. The mortality curve of IHD in Italy peaks in both sexes between 85-94 years. Hypertension, hypercholesterolemia and diabetes are the leading risk factors for IHD in Italy.
Conclusions: IHD still poses a substantial clinical, social and economic burden in Italy.

Introduction: this study compares the cardiac troponin I (cTnI) values measured with three high-sensitivity (hs) different methods in apparently healthy volunteers enrolled in a multicenter study.
Methods: heparinized plasma samples were collected from 1511 volunteers in 8 Italian clinical institutions (mean age 51.5 years, SD 14.2, range 18-86, female to male ratio 0.94). All volunteers denied chronic or acute diseases and had normal values of routine laboratory tests and ECG. The reference laboratory of the study (Laboratorio Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy) assayed all plasma samples with three hs-methods: Architect hs-cTnI, Access hs-cTnIand ADVIA Centaur XPT hs-cTnI. After the exclusion of outlier values, calculation of 99th percentile (Upper Reference Limit, URL) values was performed using both robust nonparametric and bias corrected and accelerated bootstrap methods.
Results: large between-method differences were found. ADVIA Centaur measured higher cTnI values (up to 2-fold) than the two other methods. cTnI values were significantly higher in men than in women, and progressively increased with age over 55 years. Moreover, 99th percentile URL values also depended on the statistical approach used for calculation (robust non-parametric versusbootstrap). All 99th percentile URL values calculated with non-parametric robust method were on average slightly lower than those suggested by manufacturers (mean difference 4.2 ng/L, standard error 1.7, p=0.0273).
Conclusion: clinicians should be advised that plasma samples from the same patient should be measured for hs-cTnI in the same laboratory. Specific clinical studies are needed to establish the most appropriate statistical approach to calculate 99th percentile URL values for hs-cTnI methods.

Introduction: the Working Groups “Hematology” and “Extra-Analytical Variability” of the Italian Society of Clinical Biochemistry (SIBioC) promoted a survey investigating the quality of the complete blood count reporting among Italian Laboratories.
Methods: the survey included 36 questions and was sent to all the SIBioC members. 251 laboratories participated in the survey.
Results: there is a full concordance in reporting the traditional parameters (leukocytes, erythrocytes and platelet count, hemoglobin, hematocrit and the calculated indices, plus the leukocytes differential count), while other relatively new parameters, like the mean platelet volume (MPV) and the platelet distribution width (PDW) are reported by 70% of the laboratories. A low percentage of laboratories (20-30%) do not report the presence of abnormal cell populations, if detected (blasts, immature granulocytes, plasma cells, prolymphocytes and erythroblasts). 70% of laboratories do not report the erythrocyte and leukocyte related parameters available on the new analyzers. Specific reference intervals for gender and age are adopted by 68% of the laboratories, but only 50% have instrument-specific intervals. 83% of the laboratories include interpretative comments in the report, but only in less than half of them these are harmonized according to the recent available recommendations. 83% of the laboratories have a shared document to manage critical values, that are communicated to the requesting physician by 90% of the laboratories.
Discussion: activities promoted by the SIBioC Hematology working group to harmonize the hematological report have been effective on traditional parameters reporting with a substantial improvement compared to the 2014 survey. Two issues remain however unresolved: the inclusion of interpretative comments and of the recent available parameters in the report.

Introduction: oncololytic adenoviruses (OAds), viruses constructed to replicate in tumor cells, improve the outcome of cancer therapy in some cases, such as sarcomas. However, the molecular heterogeneity of tumors requires specific and personalized cancer treatments in order to set up more adequate and effective therapies.
Methods: by using the array Comparative Genomic Hybridization (array-CGH), a molecular approach method, we aimed to identify chromosomal aberrations or Copy Number Variants (CNVs) in three different tumor cell lines: HCT116, SW872 and A2058 selected for their Coxsackievirus and Adenovirus receptor (CAR) expression profile.
Results: the cells showed several duplications of genes involved in replicative Adenovirus cycle (binding, internalization, escape) in the core transport, and in the escape of the viral DNA from the capsid.
Conclusion: in this study, our aim was to identify chromosomal alterations in genes involved in the OAd replication cycle process. Array-CGH method could be useful to design a platform for a screening analysis in order to identify mutations that can contribute to oncolytic virotherapy approach generating a personalized strategy for tumor suppression.

Introduction: immune-checkpoint inhibition using programmed cell death-1 and its ligand drug inhibitors have improved survival, among patients with advanced non-small-cell lung cancer (NSCLC): nivolumab is one of the last approved. Vitamin D deficiency (<20 ng/mL) is frequent in lung cancer patients and studies showed this pre-hormone modulates the expression of genes involved in drug pathway and in the immune system regulation. Furthermore, not many biomarkers related to nivolumab therapy are present in literature. The aim of this study was to understand which factors were able to predict nivolumab concentrations and its anti-antibody levels in patients’ plasma at 15, 45 and 60 days of therapy.
Methods: forty-five patients with advanced NSCLC were enrolled to receive nivolumab. Enzyme-linked immunosorbent assay was used for drug and vitamin D quantification.
Results: Median nivolumab plasma levels were 12.5, 22.3 and 27.1 μg/mL respectively at 15, 45 and 60 days (p<0.001). No anti-nivolumab antibodies have been detected. 25-hydroxyvitamin D median concentrations were 12.8 ng/mL at baseline, 13.6 ng/mL at 15 days, 11.8 ng/mL at 45 days and 12.9 ng/mL at 60 days. Gender significantly affected nivolumab concentrations (p=0.010 at 15 days, p=0.033 at 45 days and p=0.006 at 60 days). In linear regression analyses, 25-hydroxyvitamin D <20 ng/mL before starting therapy, gender and 25-hydroxyvitamin D <20 ng/mL at 15 days were able to predict nivolumab concentrations respectively at 15, 45 and 60 days of treatment.
Conclusions: for the first time, this study shows factors able to predict nivolumab exposure at different timings, but further, studies in bigger and different cohorts are needed to clarify these data.

Insuline-Naaïve type 2 diabetic patients: a multidimensional evaluation on the role of glycated albumin Introduction: glycated Albumin (GA) is an innovative glycemic marker, that could be used in the clinical practice, as an add-on strategy, to the traditional glycemic monitoring systems, such as glycated haemoglobin (Hb1Ac) and fasting plasma glucose (FPG). The study aims at presenting the results of a multidimensional analysis conducted in Italy, exploring the main clinical, economic, ethical, social and organizational implications, related to the introduction of GA. Methods: an Health Technology Assessment (HTA) approach was implemented. The analysis considered the Italian National Healthcare Service (NHS) perspective, and assumed a 12-month time horizon, focusing on type 2 diabetes patients insulin-naïve, assuming oral therapy. The 9 HTA dimensions (derived from the Core Model developed by the European Network of HTA – EUnetHTA) were deployed, considering scientific evidence, health economics tools and qualitative approaches, through the administration of specific questionnaires to 15 diabetes experts. Results: literature reported better GA safety and efficacy profiles, thus being a predictor of the relative risk for diabetes complications development, and increasing the therapeutic success after 3 months of therapy (97.0% versus71.6%). From an economic point of view, GA introduction resulted in an economic advantage of 1.06% and in a better trade-off between costs sustained and efficacy gained. Considering a 7-item Likert Scale (ranging from -3 to +3), negative perceptions emerged with regard to equity aspects (0.13 versus0.72) due to GA limited accessibility, whereas it would improve both patients (2.17 versus1.33) and care givers (1.50 versus0.83) quality of life. In the short term, GA required training courses and equipment update, whereas, in the long term, it could be considered the preferable solution from an organizational perspective (0.30 versus0.01). Conclusions: the results of this study demonstrated GA strategic relevance, its economic sustainability and feasibility, as well as the potential clinical pathway improvement.

Introduction: the development of new technologies in the era of information technology and digitization has certainly influenced the clinical laboratory and quality management system. The aim of this work is to verify the utility of a dedicated software (SNCS - Sysmex, Inc. Kobe, Japan) for the improvement of quality control management procedures of quantitative parameters obtained by the automated cell counting in biological liquids.
Methods: the measurements were performed on the XN "Body Fluid Mode" (XN-BF) analytical system (Sysmex, Inc. Kobe, Japan) according to the manufacturer's specifications. The parameters that can be included in the report using this mode are the total nucleated elements count, the leukocyte count, the differentiation of mononuclear from polymorphonuclear cells and the erythrocyte count.
Results: our study included: a comparative evaluation between the laboratory CVs and the CV of an international homogeneous group; a retroactive evaluation from the SNCS software using the standard deviation index and the precision index used as accuracy and precision measurements. Finally, a daily comparison was made between the Levi-Jennings cards of the instrument and the SNCS intra-day report, to improve the timely evaluation of the random error.
Conclusion: using the SNCS software, the performance of the analyzers can be precisely monitored and compared on an internaional basis. Its utility lies in the possibility of comparing internal performances with those of a group of laboratories using the same instruments and the same controls, allowing the quantification of the analytical bias.

Introduction: aging is regulated by a number of aging genes including sirtuins, linked to redox status and epigenetically controlled. Physical exercise, depending on intensity, type of training and duration, seems to modulate positively the redox state in aging. It was demonstrated an increase in susceptibility to oxidative stress by the depletion of intracellular glutathione (GSH) and total glutathione (tGSH) levels in the muscles of aged animals. Moreover, physical activity, especially if moderate and regular, seems to activate adaptive mechanisms, reducing body's vulnerability to oxidative stress and improving systemic metabolic activities.
Methods: this study is aimed to evaluate the effects of regular exercise (3 times/week for 2 months) on the levels of radical species (d-ROM test), thiol groups (SHp test), plasma antioxidant capacity (BAPtest), 8-OH-guanosine (COMET test) and some redox-related proteins (HSP27, HSP70, Sirt1 and 2) in 40 healthy elderly subjects, aged from 65 to 74 years. In addition, plasma enzymatic activities of superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutathione reductase (GR) were evaluated.
Results: the enrolled subjects showed oxidative stress before exercise with the presence of radical species, oxidation of purine bases and reduced antioxidant capacity. After the scheduled training, a global improvement of oxidative stress markers was observed with an upregulation of HSP27, HSP70, Sirt1 and Sirt2 expression, as adaptive response.
Conclusion: our results underline the importance of these biochemical parameters to monitor oxidative stress in aging and the adaptive redox response to physical exercise in elderly.Therefore, these biomarkers may be routinely used in order to identify individuals at risk for developing oxidative stress related pathologies as well as in personalized physical therapy.

Only very recently the set-up of some immunoassay methods with high-sensitivity analytical performance allowed the accurate detection of cardiac troponin I (cTnI) and T (cTnT) levels in healthy adult subjects. Several studies have demonstrated the association between the risk of major cardiovascular events and cardiac troponin concentrations even for biomarker values within the reference intervals. High-sensitivity cTnI and cTnT methods enable to monitor myocardial renewal and remodelling, and to promptly identify patients at highest risk to heart failure development. An early and effective treatment of individuals at higher cardiovascular risk may revert the initial myocardial remodelling and slow down heart failure progression. Dedicated trials are needed also in Italian population to demonstrate the efficiency of general population screening by means of cost benefit analysis for individuals at higher risk for heart failure progression.

The evolution of the biochemical diagnosis of cardiac diseases, represents a paradigm of the laboratory medicine evolution in the recent years.
Starting from the use of poor specific and sensitive biomarkers, the “so-called” cardiac enzymes (aspartate aminotransferase; lactate dehydrogenase; creatine kinase) recommended by World Health Organization for the acute myocardial infarction (AMI) diagnosis, a fundamental development in biochemical knowledge has been obtained, providing new biomarkers (CK-MB, myoglobin) for a more specific and early diagnosis according to the clinical and therapeutic needs. However, the revolutionary biochemical issue has been represented by the discovery of cardiac troponins and by the implementation of methods allowing their measurement in emergency setting in patients with acute chest pain. Cardiac troponins, are characterized by an absolute cardiac specificity and by a high sensitivity that allow to carry out a timely and safe diagnosis of AMI, being recognized as “gold standard” in all clinical and biochemical guidelines. In patients with acute chest pain and in ischemic clinical setting, a typical kinetic release of biomarker concentration may be suggestive of AMI even if ECG typical patterns are lacking. The actual improvement in analytical performance of troponins methods, particularly in the analytical sensitivity, allows to extend the measurement also in diagnosis of minor myocardial damage in patients suffering from different cardiac disease, to monitor the efficacy of therapy, the progression of the disease and to provide prognostic information and risk-stratification in addition to the clinical pathway.

Von Willebrand disease (VWD) is the most common inherited bleeding disorder. Clinically, VWD induces mucosal bleeding caused by a decreased quantity or quality of von Willebrand factor (VWF). Diagnosis of VWD requires careful consideration of patient specific factors, bleeding symptoms, and laboratory results. There is no single diagnostic test for VWD; laboratory diagnosis requires a number of assays of VWF amount and function, and factor VIII activity, with no single straightforward diagnostic test available up to know to either confirm or exclude the diagnosis. The currently available laboratory testing for VWD is imperfect, but if accompanied by an attentive and careful interpretation provides significant clinical utility by categorizing affected patients by type of VWD. As the diagnosis of VWD variants has implications fort reatment, laboratory testing is therefore critical for optimising patient care. Newer assays of VWF function are becoming available and will be of great help in establishing the laboratory diagnosis of VWD.

This document of the Interdisciplinary Urinalysis Group (GIAU) is aimed to provide recommendations on how to improve and standardize the postanalytical approach to physical, chemical and morphological urine examination (ECMU). The main tool to emphasize the value of the ECMU is the development of a laboratory report suitable for the clinical needs. As a consequence, these recommendations are mainly related to the structure and content of the report. They include: the layout, the parameters to be included, the measurement units, the reference values, the inclusion of interpretative comments. Really, an important section of the report is dedicated to the interpretative comments: these are a real add-on value and are tailored on the type of laboratory performing the analysis (general or with a specific section dedicated to the urine examination). The different levels of the laboratory competence determine the category of possible comments. The basic one concerns comments that evaluate the non-conformity of the sample (i.e. presence of urethral, seminal, vaginal, faecal contamination; too concentrated/too diluted samples). The second level of comments is dedicated mainly to the reporting of the discrepancies between the biochemical analysis and the microscopy examination (i.e. presence of haemoglobin and no erythrocyte detection; presence of leucocyte esterase and no leucocyte detection). The third level requires a specific competence of the pathologist together with a strict collaboration with the clinic; these comments are elaborated on the basis of a specific clinical request. The detection of the “decoy cells” in immunosuppressed solid organ transplant recipients, that are typical of a poliomavirus infection, is a good example of the third level of interpretative comments. A final section of the document is dedicated to the opportunity to implement and adopt specific programs of external evaluation of the urinary sediment.
After the issuing of the recommendations dedicated to pre-analytical and analytical phases, this GIAU document gives suggestions for the standardisation and harmonisation of post-analytical phase in the attempt to emphasize the diagnostic importance of ECMU.

A large body of evidence supports that quality improvement efforts tailored to the analytical phase only, are less likely to generate further clinical and economical progresses. Actually, most diagnostic errors made within the laboratory diagnostics emerge in the extra-analytical domains of testing, especially within the preanalytical phase. It is now clear that the underlying causes are most frequently due to system errors or to the implementation of poorly standardized procedures for collection, handling, transportation, preparation and storage of biospecimens. Some of these problems could generate a number of issues related to the quality of clinical samples, ending up with the reception by the laboratory of unsuitable samples. The identification and the management of unsuitable samples represent thus unavoidable practices in clinical laboratories to guarantee the quality of test results throughout the total testing process. Due to the ongoing evolution of the in vitro diagnostic market and the availability of new evidence, this paper provides a revision of the national recommendations issued by the Italian Society of Clinical Biochemistry and Clinical Molecular Biology in 2007 for detection and practical management of unsuitable specimens in clinical laboratories.

Serum monoclonal components, Bence-Jones proteinuria (PBJ) and free light chains (FLC) are clonal biomarkers for diagnosis and response assessment in light chain (AL) amyloidosis. Two clinical reports are presented here toi llustrate the utility of these biomarkers. The first case is a patient with AL κappa renal amyloidosis. Serum and urine immunofixation were negative and the FLC ratio was abnormal. Immunoelectron microscopy on tissue biopsy was negative. Amyloid typing was achieved by mass spectrometry on fat pad aspirate. The second case is a patient with AL cardiac amyloidosis with PBJ lambdaand low concentration of amyloidogenic FLC (32 mg/L). Urine capillary electrophoresis was used to assess response to treatment. The progressive reduction of PBJ after treatment was accompanied by reduction of NT-proBNP and improvement of clinical conditions. Clonal biomarkers are irreplaceable tools in management of AL amyloidosis. There is a need for more sensitive techniques for identification of monoclonal FLC on serum and urine.

Monoclonal gammopathy of renal significance (MGRS) is a condition defined by the presence of a small-B cell clone causing a renal disease trough deposition in renal tissues of the monoclonal component (MC) secreted by the B cells. Since MGRS is associated with several types of renal diseases, characterization of renal damage caused by protein deposition is important to define the correct diagnosis as well as the identification of the MC. Adult Fanconi Syndrome (FS) is characterized by the presence of a MC and damage in the proximal tubule with impaired small molecules transport. We report the case of a 32 years old man with moderate kidney failure, normoglycemic glycosuria and hypouricemia. Further investigations revealed hypophosphoremia and phosphaturia; an IgGκ MC was detected by immunofixation. The kidney biopsy confirmed FS suspect. This case underlines that the results of the biochemical analysis carried on for the diagnosis of FS, need to be confirmed by histopathologic analysis.

The human parechoviruses (HPeV) have recently been recognized as emerging pathogenic microorganisms causing a broad pattern of diseases including sepsis and meningitis in children. A born-at-term, 33-day-old child, was admitted to the hospital with fever, irritability, and loss of appetite. Results of physical examination and routine blood chemistry were unremarkable (no lung rales or skin rashes; normal hemoglobin and leukocyte and platelets counts) with the only exception of an elevated procalcitonin serum level. Examination of the patient’s cerebrospinal fluid (CSF) showed pleocytosis, normal glycorrhachia and a mild increase of proteins. Blood and CSF cultures were negative. When tested with a commercial multiplex PCR technology (FILMARRAY®- Biomerieux), CSF turned out positive for the HPeV. Rapid identification of HPeV may contribute to reduce the laboratory turnaround time and improve clinical management. HPeV should be included in the differential diagnosis of young children with central nervous system symptoms and sepsis-like illness.

Growth hormone deficiency (GHD) is a disorder characterized by the inadequate secretion of GH, which results in short stature reflected by the delay in the bone lengthening, that is inappropriate to the chronological age of the child. Laboratory tests are very important to determine whether the growth-delayed child actually has GHD. These tests are intended to stimulate the pituitary gland to secrete GH, allowing the measuring of its levels in blood at timed intervals. In a 7-year-old child arrived at our attention for deceleration of growth rate, laboratory tests excluded other causes of short stature and the GH measurement confirmed the deficit of this hormone. The patient started the therapy using the recombinant human growth hormone (rhGH). Serum insulin-like growth factor-1 (IGF-1) concentration was monitored during the treatment to help with dose adjustment and to determine the adherence to therapy by the child.