Androgen therapy in hemodialysis patients: I. Effects on red cell oxygen transport

Endocrine manifestations of chronic kidney disease and their evolving management: A systematic review

BACKGROUND

Chronic Kidney Disease (CKD) shows a wide range of renal abnormalities including the excretory, metabolic, endocrine, and homeostatic function of the kidney. The prognostic impact of the 'endocrine manifestations' which are often overlooked by clinicians cannot be overstated.

METHODS AND OBJECTIVES

A systematic review was attempted to provide a comprehensive overview of all endocrine abnormalities of CKD and their evolving principles of management, searching databases of PubMed, Embase, and Scopus and covering the literature between 2002 and 2022.

RESULTS

The endocrine derangements in CKD can be attributed to a myriad of pathologic processes, in particular decreased clearance, impaired endogenous hormone production, uremia-induced cellular dysfunction, and activation of systemic inflammatory pathways. The major disorders include anemia, hyperprolactinemia, insulin resistance, reproductive hormone deficiency, thyroid hormone deficiency, and serum FGF (Fibroblast Growth Factor) alteration. Long-term effects of CKD also include malnutrition and increased cardiovascular risk. The recent times have unveiled their detailed pathogenesis and have seen an evolution in the principles of management which necessitates a revision of current guidelines.

CONCLUSION

Increased advertence regarding the pathology, impact, and management of these endocrine derangements can help in reducing morbidity as well as mortality in the CKD patients by allowing prompt individualized treatment. Moreover, with timely and appropriate intervention, a long-term reduction in complications, as well as an enhanced quality of life, can be achieved in patients with CKD.

Use of androgens in patients with renal failure

Anabolic steroids have been used for the treatment of the anemia of chronic renal failure for more than 25 years. Due to concerns over adverse effects, their use historically has been limited to nandrolone decanoate given to men, usually over age 50, who have intact kidneys. The introduction of epoetin alfa in 1989 has led to reduced androgen use for the treatment of anemia. Nevertheless, there continues to be scientific investigation into the possible role that androgens may play in combination with or as an alternative to erythropoietin. Whether combination therapy will prove to be useful remains to be determined in a large, prospective, randomized trial. There is little likelihood, based on present literature, that androgen therapy alone will replace epoetin alfa in U.S. dialysis units. This topic was addressed recently by the Anemia Work Group of the National Kidney Foundation Dialysis Outcomes Quality Initiative (27). While acknowledging androgen treatment may be less expensive than epoetin alfa, the group stated that the potential risks of primary androgen therapy alone make this form of treatment "unacceptable." The work group did not offer any recommendations on the combined use of erythropoietin and androgens, stating that published data are inconclusive. If future reimbursement policies are changed to include epoetin alfa within a capitated rate, economic incentives may lead to increased use of androgens to achieve targeted hematocrit values. The potential value of anabolic steroids for treating malnutrition in dialysis patients is an intriguing idea. Very little has been done to explore this issue, and this clinical practice has not become widespread nor universally recommended (28). Prospective clinical trials in this area may be warranted as well.