Sexual hormone abnormalities in male patients with renal failure

Testosterone deficiency and chronic kidney disease

Testosterone's biological functions are extensive, influencing reproductive and systemic health. It plays a vital role in sexual functions, muscle protein synthesis, bone metabolism, fat distribution, and cardiovascular health. The hormone also affects mood, cognitive function, and erythropoiesis, underscoring its importance in both physical and mental health. Testosterone deficiency, or male male hypogonadism, is increasingly recognized as a significant health issue affecting various bodily systems, also in the context of chronic kidney disease (CKD). Recent research indicates a complex interplay between testosterone levels and renal health, suggesting that male male hypogonadism may both impact and be impacted by CKD. The latter is characterized by a gradual loss of kidney function, affects millions globally and is often associated with diabetes mellitus, arterial hypertension, and autoimmune diseases. Men with CKD frequently experience lower testosterone levels, which can exacerbate muscle wasting, reduce quality of life, and increase cardiovascular risk. Overall, low testosterone levels in CKD patients are associated with increased morbidity and mortality. Several mechanisms explain the relationship between CKD and testosterone deficiency. The uremic environment in CKD disrupts the hypothalamic-pituitary-gonadal axis, impairing hormone production. Nutritional deficiencies and chronic inflammation common in CKD patients further suppress gonadal function. The consequences of low testosterone in CKD are profound, with studies suggesting that testosterone replacement therapy (TRT) might improve clinical outcomes, though the long-term effects and causal relationships remain under investigation. The potential benefits of TRT in CKD patients might be significant. TRT can enhance muscle mass and strength, address anemia by stimulating erythropoiesis, improve bone density, and possibly offer cardiovascular benefits by improving body composition and insulin sensitivity. General symptoms of male hypogonadism, such as deteriorated psychological, sexual and physical wellbeing, can be improved by TRT. However, these benefits must be weighed against potential risks. TRT may exacerbate fluid retention, arterial hypertension, or exacerbate existing heart failure, particularly in CKD patients with pre-existing cardiovascular comorbidities. Additionally, concerns about the progression of renal disease via several testosterone affected pathways involving renal tubular integrity exist, highlighting the need for careful patient selection and monitoring. Understanding this relationship is crucial for developing comprehensive treatment strategies that address both renal and endocrine dysfunctions, highlighting the need for integrated patient care, which means good collaboration between subspecialists like nephrologists, endocrinologists, urologists and primary care providers, aiming to improve outcomes and quality of life while mitigating adverse effects.

Chronic Kidney Disease and Growth Failure in Children

Chronic kidney disease (CKD) is a significant challenge for pediatric endocrinologists, as children with CKD may present a variety of endocrine complications. Growth failure is common in CKD, and its severity is correlated with the degree of renal insufficiency. Management strategies include addressing reversible comorbidities, optimizing nutrition, and ensuring metabolic control. Kidney replacement therapy, including transplantation, determines a significant improvement in growth. According to a recent Consensus Statement, children with CKD stage 3-or on dialysis older >6 months-are eligible for treatment with recombinant growth hormone (rGH) in the case of persistent growth failure. Treatment with rGH may be considered for those with height between the 3rd and 10th percentile and persistent growth deceleration. In children who received kidney transplantation but continue to experience growth failure, initiation of GH therapy is recommended one year post-transplantation if spontaneous catch-up growth does not occur and steroid-free immunosuppression is not an option. In children with CKD, due to nephropathic cystinosis and persistent growth failure, GH therapy should be considered at all stages of CKD. Potential adverse effects and benefits must be regularly assessed during therapy. Treatment with GH is safe in children with CKD. However, its general efficacy is still controversial. All possible problems with a negative impact on growth should be timely addressed and resolved, whenever possible with a personalized approach to the patient. GH therapy may be useful in promoting catch-up growth in children with residual growth potential. Future research should focus on refining effective therapeutic strategies and establishing consensus guidelines to optimize growth outcomes in this population.

[Pituitary disorders in patients with end-stage chronic renal failure]

Disorders in the kidneys lead to disturbance of homeostasis. As the glomerular filtration rate decreases, the metabolism of numerous biologically active substances, including pituitary hormones, decreases. The article presents an overview of pituitary dysfunction in patients with chronic kidney disease (CKD) and discusses the possible reasons of the pathogenetic mechanisms. Particular focus is being given to the assessment of changes in the concentration of pituitary hormones in patients with end-stage chronic kidney disease (CKD) and discusses the pathogenetic mechanisms of their formation. Particular attention is paid to the assessment of changes in the concentration of pituitary hormones in patients receiving renal replacement therapy (RRT). CKD leads to an increase in the level of prolactin, luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Concentrations of growth hormone (GH), isulin-like growth factor-1 (IGF-1), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH) and vasopressin may remain within normal values or increase in this group of patients. RRT does not reduce the levels of prolactin, LH, FSH, while the concentration of growth hormone, IGF-1, TSH tends to normalize. The content of ACTH and vasopressin may remain unchanged or decrease. Kidney transplantation in most cases corrects hormonal disorders. Correction of hormonal changes can improve the clinical outcome and quality of life of patients with end stage CKD.

Testosterone Deficiency as One of the Major Endocrine Disorders in Chronic Kidney Disease

Reduced testosterone concentration is nowadays thought to be one of the main endocrine disorders in chronic kidney disease (CKD). It is caused by the dysfunction of the hypothalamic-pituitary-gonadal axis. The role of testosterone is multifactorial. Testosterone is responsible not only for reproductive processes, but it is a hormone which increases bone and muscle mass, improves lipid profile, insulin sensitivity, erythropoiesis, reduces blood pressure, and ameliorates mood and perception. The implications of hypogonadism in CKD are infertility and loss of libido, reduction of muscle mass and strength, disorders in bone mineralization, the development of sarcopenia and protein energy wasting (PEW), progression of atherosclerosis, increased visceral adiposity, insulin resistance, and anaemia. Reduced testosterone serum concentrations in CKD are associated with increased mortality rate. Testosterone supplementation improves sexual functions, reduces the level of inflammatory markers and blood pressure, stimulates muscle protein synthesis, improves insulin sensitivity and lipid profile, and increases muscle mass, bone mineral density, and haemoglobin concentration. It positively affects mood and well-being. The modes of testosterone supplementation are intramuscular injections, subcutaneous pellets, and percutaneous methods—patches and gels. Successful kidney transplantation may improve gonadal function and testosterone production, however, half of men with low testosterone concentrations before kidney transplantation do not restore hormonal function.

Hypogonadism and urologic surgeries: a narrative review

Background and Objective

Previous studies indicated that the treatment of male hypogonadism can be beneficial for intraoperative and postsurgical outcomes. In this study, we aimed to determine the impact of male hypogonadism on urologic surgeries. We provided an overview of the key studies in the field with the focus on the outcomes of urologic surgeries in hypogonadal men with/without testosterone replacement therapy (TRT).

Methods

We performed a literature review in PubMed and Google Scholar databases for the most relevant articles pertaining to the outlined topics without placing any limitations on publication years or study designs. We included full-text English articles published in peer reviewed journals between January 1970 and March 2022.

Key Content and Findings

Androgen deficiency is a common finding after major urologic surgeries. Although guidelines recommend against TRT in men with prostate carcinoma, recent investigations showed no association between TRT and disease progression and recurrence. Indeed, recent evidence suggested that low androgen levels could be related to high grade prostate carcinoma and increased risk of upgrading from low to high grade disease. Investigations on the application of TRT in benign prostatic hyperplasia (BPH) patients also revealed contrasting results. While some studies suggested higher rates of prostate-related events in men who received TRT, others showed that TRT could alleviate urinary symptoms in hypogonadal men with BPH. Decreased testosterone level is commonly seen in bladder cancer patients. The treatment of perioperative androgen deficiency can reduce postoperative morbidities and lower the risk of recurrence in these patients. Low testosterone levels are observed in approximately half of the men who undergo artificial urinary sphincter (AUS) placement and can increase the risk of complications.

Conclusions

The role of testosterone treatment in patients with urologic diseases such as prostate carcinoma and BPH is controversial. Further investigations are needed to determine the impact of hypogonadism and TRT on the outcomes of urologic surgeries in patients with androgen deficiency.

Testosterone deficiency and the aging male

Testosterone deficiency (TD), also known as male hypogonadism, is a complex syndrome encompassing physical, biochemical, and social aspects that increasingly affects the aging population. TD has been analyzed over recent decades, with an enhanced focus on etiologies relating to aging males. There is debate whether testosterone decline leading to hypogonadism is directly and primarily related to age-specific processes or if it is the subsequent result of accumulating comorbidities throughout a lifetime. Several studies have been done to further characterize this distinction. Chronic comorbidities that have commonly been associated with TD include hypertension (HTN), cardiovascular disease (CVD), diabetes mellitus (DM), obesity, metabolic syndrome (MetS), chronic kidney disease (CKD), and tobacco use. Although clear associations between hypogonadism and aging have been biochemically demonstrated, many large studies have illustrated the concomitant effects of highly prevalent chronic diseases and social behaviors in aging men. Given the significant impact of hypogonadism on the physical and mental health of men, this paper aims to delve into these studies and further define the complex relationship of testosterone deficiency in the aging male.

Is erectile dysfunction an early clinical symptom of chronic kidney disease?

OBJECTIVES

Erectile dysfunction (ED) is the persistent inability to attain and/or maintain erection sufficient for satisfactory sexual performance. Chronic kidney disease (CKD) is a problem with increasing incidence every day which disrupts quality of life significantly. We aimed to research whether ED is a warning symptom for the early stages of CKD or not.

MATERIALS AND METHODS

The records of 639 patients attending Ordu University due to ED were retrospectively investigated. According to International Index of Erectile Function (IIEF) scores and degree of ED, patients were compared in terms of GFR values.

RESULTS

In 92.8% of patients, serum creatinine values were within normal limits (<1 mg/dL), while 30.5% of patients were observed to have GFR below 80. While stage 2 CKD was identified in 1% of the control group, this rate was calculated as 8% in the group with severe ED. In stage 1 and stage 2 CKD, IIEF scores were identified to be low by clear degree.

CONCLUSIONS

Results confirm that it was identified that the incidence of stage 1 and stage 2 CKD was higher among patients attending with ED compared to the control group. Just as ED may be an early clinical marker of coronary artery disease, it may be early warning symptom for CKD.

Implications of renal transplantation on serum testosterone and preoperative factors affecting its levels in the post-transplant period

Objective:

Low serum testosterone is highly prevalent in chronic kidney disease patients. The objective of the study was to determine levels of serum testosterone at the time of transplantation, the prevalence of testosterone deficiency/insufficiency in the pre- and post-transplant periods, and its correlation with patients’ age, serum creatinine, duration of preoperative dialysis, human leukocyte antigen (HLA) matching, and graft outcomes.

Methods:

The study was conducted from January 2019 to April 2020. Forty-five male renal transplant patients were evaluated before and at one and six months following transplant for changes in testosterone and creatinine levels. Six-month follow-up was possible for 28 patients.

Result:

Renal transplantation resulted in significant improvement in testosterone levels as early as one month after transplantation. The duration of preoperative dialysis and HLA match had a negative and positive impact on postoperative serum testosterone levels, respectively. We did not find any impact of testosterone levels on graft function.

Conclusion:

Successful transplantation among the study population produced a positive impact on serum testosterone levels. The duration of preoperative dialysis and HLA match had a negative and positive impact on postoperative serum testosterone levels, respectively.

Level of evidence:

XXX.

Effects of Testosterone Treatment on Quality of Life in Patients With Chronic Kidney Disease

Testosterone deficiency (TD) is common and impairs quality of life (QoL) in patients with chronic kidney disease (CKD). However, there are no studies about whether testosterone replacement therapy (TRT) can improve QoL in patients with CKD. Therefore, we investigated the effect of TRT on the QoL of patients with CKD and confirmed the safety of TRT. Twenty-five male patients with stages III–IV CKD whose serum testosterone levels were <350 ng/dl (TD) were enrolled and treated with testosterone gel for 3 months (group II). Age-matched controls with stages III–IV CKD and TD (group I) were recommended to exercise for the same period. Before and after the treatment, the BMI and handgrip strength were checked, serological tests were performed, and questionnaires were administered in both groups. Compared to baseline, there was no significant difference in serum testosterone levels, scores of the 36-Item Short Form Health Survey (SF-36), Aging Males’ Symptoms Scale (AMS), and International Prostate Symptom Score (IPSS), and grip strength in group I after 3 months. In group II, a significant increase in testosterone, hemoglobin (Hb), and hematocrit (Hct) was observed, and grip strength significantly increased after TRT. Significant improvement in scores of SF-36, AMS, and IPSS was also confirmed after TRT in group II. There was a significant difference in testosterone, Hb, Hct, grip strength, and scores of SF-36, AMS, and IPSS between the two groups after 3 months. The patients in group II showed positive results and continued with TRT. Therefore, we conclude that TRT safely improves the QoL and TD symptoms in patients with moderate-to-severe CKD.

Echinochrome Pigment Improves Male Rats' Fertility

Background::

Infertility is the first-rate public health trouble affecting one in five married couples globally, male causes embody a significant proportion. Natural products could be an alternative or complementary inexpensive treatment for such matters. Echinochrome (Ech) is a natural quinone pigment obtained from sea urchin, and it was confirmed to possess many pharmacological properties due to its chemical activity.

Objective::

The current research paper was targeted to evaluate the potential effects of Ech on male fertility, and to highlight the possible involved mechanisms.

Methods::

Eighteen adult male rats were randomly distributed into three groups: control (1 ml of 2% DMSO, p.o.), low dose Ech (0.1 mg/kg, p.o.), and high dose Ech (1 mg/kg p.o.).

Results::

The high dose Ech caused a significant decline in the levels of glucose, ALT, AST, ALP, urea, Cr, uric acid, TG, TC and LDL-C and testicular tissue MDA, while it caused a significant rise in the levels of albumin, TP, HDL-C, FSH, LH, testosterone and testicular tissue GSH activity. Moreover, it showed a significant positive effect on the testis weight, caudal epididymis weight, sperm count, sperm motility, sperm morphology, fructose concentration, and α-glucosidase activity. However, no significant changes were observed in histological examination of testicular tissue among all groups.

Conclusion::

High dose Ech improved male rat-fertility either directly by activating the pituitary gonadal axis, and or indirectly via enhancing: the renal and hepatic functions, the lipid profile and or the antioxidant pathways.

Sexual Dysfunction in Women With Kidney Disease

Sexual health is inversely associated with estimated glomerular filtration rate and is associated with adverse cardiovascular outcomes, depression, poor self-image, and impaired quality of life. Many women with chronic kidney disease (CKD) and ESKD experience symptoms of sexual dysfunction which is underrecognized secondary to a variety of factors including physicians' discomfort in discussing sexual health, patients' reluctance to bring up sexual health, difficulty in the assessment of sexual health in comparison to men, and the overall lack of well-conducted clinical studies in women. The pathophysiology is not fully understood but likely involves changes in sex hormones throughout the hypothalamic-pituitary-ovarian axis. Proper evaluation of this axis is necessary as treatment is tailored to these findings and can improve outcomes. A comprehensive assessment of sexual dysfunction inclusive of women with varying gender identification and sexual orientation, partnered with recognition and treatment of contributing factors as well as identifying the underlying cause, is paramount. With the lack of studies, particularly in women with CKD, treatment options, in some cases, can be considered unchartered territory. In this article, we will review available evidence on the pathophysiology, clinical manifestations, and treatment for sexual dysfunction in women with CKD and ESKD.

Effects of Dietary or Supplementary Micronutrients on Sex Hormones and IGF-1 in Middle and Older Age: A Systematic Review and Meta-Analysis

Observational research suggests that micronutrients may be protective for sarcopenia, a key health issue during ageing, potentially via effects on hormone synthesis and metabolism. We aimed to carry out a systematic review of RCTs investigating effects of increasing dietary or supplemental micronutrient intake on sex hormones and IGF-1 in individuals aged 45 years or older. We searched MEDLINE, EMBASE and Cochrane databases for RCTs reporting the effects of different micronutrients (vitamins A, C, D, or E; carotenoids; iron; copper; zinc; magnesium; selenium; and potassium) on sex hormones or IGF-1. Of the 26 RCTs identified, nine examined effects of vitamin D, nine of multi-nutrients, four of carotenoids, two of selenium, one of zinc, and one of vitamin E. For IGF-1 increasing vitamin D (MD: -0.53 nmol/L, 95% CI: -1.58, 0.52), multi-nutrients (MD: 0.60 nmol/L, 95% CI -1.12 to 2.33) and carotenoids (MD -1.32 nmol/L; 95% CI -2.76 to 0.11) had no significant effect on circulating concentrations. No significant effects on sex hormones of other micronutrients were found, but data were very limited. All trials had significant methodological limitations making effects of micronutrient supplementation on sex hormones unclear. Further high quality RCTs with physiological doses of micronutrients in people with low baseline intakes or circulating concentrations, using robust methodology, are required to assess effects of supplementation adequately.

Incidental Gynecomastia on Thoracic Computed Tomography in Clinical Practice: Characteristics, Radiologic Features, and Correlation With Possible Causes in South Korean Men

Gynecomastia is a common incidental finding on thoracic computed tomography (CT). This study aimed to retrospectively determine the prevalence, imaging characteristics, and possible causes of incidental gynecomastia on thoracic CT. Records of male patients who underwent thoracic CT in 2015 were reviewed. The size and morphologic types (nodular, dendritic, and diffuse) were recorded for patients with breast glandular tissue larger than 1 cm, and the cutoff value of gynecomastia was defined as 2 cm. Additionally, the possible causes of gynecomastia obtained by reviewing patients' charts were recorded. CT-depicted gynecomastia was identified in 12.7% (650 of 5,501) of patients. The median size of the breast glandular tissue was 2.5 cm (interquartile range 2.2-3.1), and 36.8% of patients (239 of 650) had unilateral gynecomastia. The age distribution provided a bimodal pattern with two peaks in the age groups from 20 to 29 years old and greater than 70 years old. Chronic liver disease (CLD; p < .001), all stages of chronic kidney disease (CKD; p < .001), and medications (p = .002) were significantly associated with gynecomastia. Gynecomastia did not correlate with body mass index (p = .962). The size of breast glandular tissue was identified to be correlated with the morphologic type of breast tissue and the severity of CLD or CKD. The prevalence of incidental gynecomastia seen on thoracic CT was 12.7%. CT-depicted gynecomastia is not associated with obesity but with CLD, CKD, and medications. When gynecomastia is detected on CT, further evaluations and management might be required for patients with a treatable cause.

The renal molecular clock: broken by aging and restored by exercise

The mammalian circadian clock governs physiological, endocrine, and metabolic responses coordinated in a 24-h rhythmic pattern by the suprachiasmatic nucleus (SCN) of the anterior hypothalamus. The SCN also dictates circadian rhythms in peripheral tissues like the kidney. The kidney has several important physiological functions, including removing waste and filtering the blood and regulating fluid volume, blood osmolarity, blood pressure, and Ca²⁺ metabolism, all of which are under tight control of the molecular/circadian clock. Normal aging has a profound influence on renal function, central and peripheral circadian rhythms, and the sleep-wake cycle. Disrupted circadian rhythms in the kidney as a result of increased age likely contribute to adverse health outcomes such as nocturia, hypertension, and increased risk for stroke, cardiovascular disease, and end organ failure. Regular physical activity improves circadian misalignment in both young and old mammals, although the precise mechanisms for this protection remain poorly described. Recent advances in the heart and skeletal muscle literature suggest that regular endurance exercise entrains peripheral clocks, and we propose that similar beneficial adaptations occur in the kidney through regulation of renal blood flow and fluid balance.

Dietary patterns in relation to testosterone levels and severity of impaired kidney function among middle-aged and elderly men in Taiwan: a cross-sectional study

Background

Chronic Kidney Disease (CKD), characterized by an impaired kidney function, is associated with low testosterone levels. This study investigated the association between dietary patterns, testosterone levels, and severity of impaired kidney function among middle-aged and elderly men.

Methods

This cross-sectional study used the database from a private health-screening institute in Taiwan between 2008 and 2010. Men aged 40 years old and older (n = 21,376) with estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m² and proteinuria were selected. Among 21,376 men, 256 men had available measurements of testosterone levels. Dietary assessment was conducted using a food frequency questionnaire and three dietary patterns (fried-processed, vege-seafood, and dairy-grain dietary patterns) were identified using principal component analysis.

Results

Men in the lower tertiles (T1 and T2) of eGFR had significantly decreased testosterone levels by 0.8 (95% CI: − 1.40, − 0.20) and 0.9 nmol/L (95% CI: − 1.43, − 0.33). Furthermore, serum triglycerides (TG) levels were inversely associated with testosterone levels (β = − 0.51, 95% CI: − 0.77, − 0.24). Men in the higher tertile of fried-processed dietary pattern scores were associated with decreased testosterone levels by 0.8 nmol/L (95% CI: − 1.40, − 0.16), reduced testosterone-to-TG (T/TG) ratio by 1.8 units (95% CI: − 2.99, − 0.53), and increased risk of moderate/severe impaired kidney function (eGFR < 60 mL/min/1.73 m²) and proteinuria severity by 1.35 (95% CI: 1.15, 1.58) and 1.18 (95% CI: 1.02, 1.37) times respectively. In contrast, the vege-seafood dietary pattern was negatively associated with severity of impaired kidney function and proteinuria after multivariable adjustment, but had no association with testosterone levels and T/TG ratio.

Conclusions

The fried-processed dietary pattern is negatively associated with testosterone levels but positively associated with the severity of impaired kidney function. However, the vege-seafood and dairy-grain dietary patterns appear to have beneficial effects.

Electronic supplementary material

The online version of this article (10.1186/s12937-019-0467-x) contains supplementary material, which is available to authorized users.

Sex hormones and their influence on chronic kidney disease

PURPOSE OF REVIEW

The majority of end-stage renal disease including dialysis and kidney transplant patients are men. In contrast, the incidence of chronic kidney disease (CKD) is higher in women compared with men. In this review, we dissect the sex hormone levels and its effects on experimental models and patients with CKD.

RECENT FINDINGS

Sex hormones are clearly involved in CKD progression to end-stage renal disease (ESRD). A significant reduction in lipid peroxidation as a mechanism of renoprotection has been observed in kidneys of streptozotocin (STZ)-diabetic ovariectomized rats after estradiol administration. Furthermore, a G-protein-coupled estrogen receptor inhibits podocyte oxidative stress maintaining the integrity of the mitochondrial membrane. Sex hormone depletion has been shown to modulate RAS system and protect against kidney injury in the male STZ-diabetic model. In human primary proximal tubular epithelial cells, a proteomic study showed that dihydrotestosterone dysregulated metabolic, suggesting that the deleterious effect of androgens within the kidney maybe related to altered energy metabolism in renal tubules.

SUMMARY

Male gender is associated with worse CKD progression and this fact may be ascribed to sex hormone. Although male hormones exert a deleterious effect in terms of increasing oxidative stress, activating RAS system, and worsening fibrosis within the damaged kidney, female hormones exert a renoprotective effect.

Finasteride-Induced Inhibition of 5α-Reductase Type 2 Could Lead to Kidney Damage-Animal, Experimental Study

In the pharmacological treatment of prostate cancer, benign prostatic hyperplasia and androgenetic alopecia finasteride is commonly used. This drug inhibits 5α-reductase type 2, which is why finasteride affects androgen homeostasis, since testosterone (T) cannot be reduced to dihydrotestosterone (DHT). As studies on sex-related renal injuries suggest a high probability of androgen-induced renal dysfunction, the aim of this study was to determine the potential harmful effects of finasteride on the kidneys of rats. The study was performed on sexually mature male Wistar rats given finasteride. Histological sections of the kidneys were used for immunohistochemical visualization of the androgen receptor (AR), junctional proteins (occluding (Occ); E-cad, N-cad, E-/N-cadherin; β-cat, β-catenin; connexin 43 (Cx43)), proliferating cell nuclear antigen (PCNA), IL-6, and lymphocyte markers (CD3 for T cell, CD19 for B cell). The TUNEL method was used for cell apoptosis identification, and picro sirius red staining was used to assess collagen fibers thickness. The levels of T, DHT and estradiol (E2) were determined in blood serum. It was shown that finasteride treatment affected steroid hormone homeostasis, altered the expression of AR and intracellular junction proteins, changed the ratio between cell apoptosis and proliferation, and caused lymphocyte infiltration and an increase of IL-6. The thickening of collagen fibers was observed as tubular fibrosis and glomerulosclerosis. Summarizing, finasteride-induced hormonal imbalance impaired the morphology (i.e., dysplastic glomeruli, swollen proximal convoluted tubules) and physiology (changed level of detected proteins/markers expression) of the kidneys. Therefore, it is suggested that patients with renal dysfunction or following renal transplantation, with androgen or antiandrogen supplementation, should be under special control and covered by extended diagnostics, because the adverse negative effect of DHT deficiency on the progression of kidney disease cannot be ignored.

Hand-Grip Strength Is Associated With Serum Testosterone and Albumin Levels in Male Kidney Transplant Recipients

OBJECTIVES

In kidney transplant recipients, reduced muscle mass and hand-grip strength are associated with impaired nutritional status. Serum testosterone is highly associated with muscle strength in the general population. Here, we aimed to determine the associations among serum testosterone, hand-grip strength, and nutritional and inflammatory parameters, as well as graft function.

MATERIALS AND METHODS

Our study included 144 stable male kidney transplant recipients from our renal transplant outpatient clinic. All patients were evaluated for clinical parameters (age, duration of hemodialysis, and posttransplant time), biochemical parameters (calcium, phosphorus, parathyroid hormone, C-reactive protein, albumin, creatinine), and serum testosterone levels. Body composition was analyzed with the bioimpedance spectroscopy analysis technique using a body composition monitor that estimates body mass index and percent fat. Hand-grip strength was analyzed by using a dynamometer (ProHealthcareProducts.com, Park City, UT, USA). We calculated estimated glomerular filtration rate using the Modification of Diet in Renal Disease-4 equation.

RESULTS

Demographic characteristics, duration of dialysis before transplant, biochemical parameters, and estimated glomerular filtration rates were similar among study patients. Mean (standard deviation) serum testosterone was 588.0 (55.5) ng/dL, mean body mass index was 26.8 (0.6) kg/m2, and mean hand-grip strength was 42.2 (1.7) mm2. Serum testosterone levels were positively correlated with hand-grip strength (r = 0.445; P = .033) and serum albumin (r = 0.399; P = .05) and negatively correlated with serum C-reactive protein (r = -0.454; P = .05) and age. In linear multiple regression analysis, serum albumin (P = .033) and testosterone levels (P = .038) were shown to be predictors of hand-grip strength. However, we could not show a significant correlation between graft function and testosterone.

CONCLUSIONS

Serum testosterone level is correlated with hand-grip strength and C-reactive protein and albumin levels, which may indicate that testosterone affects nutritional status and inflammation in male renal transplant recipients.

Bioavailable Testosterone Is Positively Associated With Bone Mineral Density in Male Kidney Transplantation Candidates

Introduction

Low levels of sex hormones are common in patients with chronic kidney disease (CKD) and may be a contributing factor to bone fragility. We investigated associations between levels of sex hormones and bone mineral density (BMD) in adult kidney transplantation candidates.

Methods

Volumetric BMD of spine and hip were measured by computed tomography. Parathyroid hormone (PTH), testosterone (T), estradiol (E), and sex hormone–binding globulin were measured from fasting morning blood samples. Bioavailable (Bio) T and E were calculated based on constants for protein binding.

Results

A total of 146 patients (102 men and 44 women) were included in the analyses. The median age was 54 years (range, 32−72 years); 32% were diabetic; and 36% received maintenance dialysis therapy. In men, Bio T was positively associated with BMD at the lumbar spine (β = 5.02, P = 0.002), total hip (β = 6.35, P = 0.001), and femoral neck (β = 13.9, P = 0.002), independently of age, body mass index, dialysis, diabetes type 1 and 2, parathyroid hormone, and steroid exposure. Bio E was positively associated with BMD at the lumbar spine (β = 0.23, P = 0.03) and femoral neck (β = 0.61, P = 0.04) using the same fully adjusted model. In postmenopausal women, Bio T was positively correlated with lumbar spine BMD (r = 0.46, P = 0.02).

Conclusion

High endogenous levels of sex hormones are associated with greater BMD in male kidney transplantation candidates. Disturbances in the gonadal axis may contribute to skeletal fragility in men with late-stage CKD.

Association between Testosterone and Mortality Risk among U.S. Males Receiving Dialysis

BACKGROUND

Among the general population, low circulating testosterone levels are associated with higher risk of cardiovascular disease and death. While testosterone deficiency is common in dialysis patients, studies of testosterone and mortality in this population are ambiguous and overlapping. We hypothesized that lower testosterone levels are associated with higher mortality in male dialysis patients.

METHODS

We examined a nationally representative cohort of male dialysis patients from a large US dialysis organization who underwent one or more total testosterone measurements from 1/2007 to 12/2011. The association between total testosterone categorized as quartiles and all-cause mortality was studied using Cox models adjusted for expanded case-mix and laboratory covariates. We also examined total testosterone as a continuous predictor of all-cause mortality using restricted cubic splines.

RESULTS

Among 624 male dialysis patients, 51% of patients demonstrated testosterone deficiency (total testosterone <300 ng/dL); median (IQR) total testosterone levels were 297 (190-424) ng/mL. In expanded case-mix + laboratory adjusted Cox analyses, we observed a graded association between lower testosterone levels and higher mortality risk (ref: quartile 3): adjusted hazard ratios (95% CI) 2.32 (1.33-4.06), 1.80 (0.99-3.28), and 0.68 (0.32-1.42) for Quartiles 1, 2, and 4, respectively. In adjusted spline analyses, the lower testosterone-higher mortality risk association declined with higher testosterone levels until the value reached a threshold of 400 ng/dL above which risk plateaued.

CONCLUSION

Lower testosterone levels were independently associated with higher mortality risk in male dialysis patients. Further studies are needed to determine underlying mechanisms, and whether testosterone replacement ameliorates death risk in this population.

A case series of the safety and efficacy of testosterone replacement therapy in renal failure and kidney transplant patients

Background

Hypogonadism is common in patients with renal dysfunction and does not always correct following transplantation. Recent studies show increased mortality for dialysis and transplant patients with low testosterone (T). These patients are often not treated due to concerns over efficacy and complications (both real and imagined). There is surprisingly scant literature supporting the use of T therapy in these patients. We wished to examine the results of T therapy in our patients with renal failure or following transplant.

Methods

We identified 15 men in our Men’s Health Registry treated with T who either were on dialysis or had a functioning transplant at time of therapy. Demographic, laboratory and clinical outcome data were collected from the electronic medical record.

Results

There were 3 men on dialysis and 12 with a functioning transplant. Mean age was 53.7 years (range, 39–71 years) and mean total serum T was 207.9 ng/mL (range, 45–330 ng/mL). All had bothersome symptoms including fatigue (15/15) and erectile dysfunction (ED) (14/15). Mean hematocrit was 35.8% and 9/15 were anemic. Therapy included patches in 1, topical gels in 6 and testopel pellets in 8. With a mean follow-up of 22.7 months (range, 11–58 months), mean T post therapy was 528 (range, 226–869). Mean hematocrit improved to 42.6% and 7/9 anemic patients improved out of the anemic range. There were no cardiovascular or infectious complications.

Conclusions

Symptomatic hypogonadism is common in dialysis and transplant patients and T replacement therapy can be safely given with improvement in T values and symptoms in most patients. Anemia is usually improved. Testopel pellets can be used in immunosuppressed transplant recipients without infectious complications.

Effect of ADMA levels on severity of erectile dysfunction in chronic kidney disease and other risk factors

INTRODUCTION

Hormonal, neurogenic, vasculogenic, and psychogenic impairments, as well as endothelial dysfunction may play a role in erectile dysfunction (ED) in patients with chronic kidney disease (CKD). Asymmetrical dimethylarginine (ADMA) is an inhibitor of nitric oxide, which is the key element of ED. ADMA levels are increased in CKD. We aimed to evaluate the effect of serum ADMA, prolactin, testosterone, and hemoglobin levels on erectile function of patients with CKD and control subjects.

METHODS

A total of 42 men with CKD and 25 age-matched controls were enrolled. The patients with CKD were categorized into group 1 and group 2 based on whether they had ED according to their response to International Index of Erectile Function questionnaire (IIEF-EFD). Group 3 was a control group. Serum ADMA, total testosterone prolactin, and hemoglobin levels of the patients were evaluated.

RESULTS

Serum ADMA, testosterone, and hemoglobin levels were similar between group 1 and 2, serum prolactin level was significantly high in group 1 than in group 2 or 3 (control group). There was no correlation between ADMA levels and IIEF-EFD scores of patients with CKD.

CONCLUSIONS

The results of this study suggest serum ADMA level is not related with ED in patients with CKD. Also, low testosterone and hemoglobin levels were not significant factors. High levels of serum prolactin are related with ED in patients with CKD.

Hypogonadism and renal failure: An update

The prevalence of both hypogonadism and renal failure is increasing. Hypogonadism in men with renal failure carries with it significant morbidity, including anemia and premature cardiovascular disease. It remains unclear whether testosterone therapy can affect the morbidity and mortality associated with renal failure. As such, in this review, we sought to evaluate the current literature addressing hypogonadism and testosterone replacement, specifically in men with renal failure. The articles chosen for this review were selected by performing a broad search using Pubmed, Embase and Scopus including the terms hypogonadism and renal failure from 1990 to the present. This review is based on both primary sources as well as review articles. Hypogonadism in renal failure has a multifactorial etiology, including co-morbid conditions such as diabetes, hypertension, old age and obesity. Renal failure can lead to decreased luteinizing hormone production and decreased prolactin clearance that could impair testosterone production. Given the increasing prevalence of hypogonadism and the potential morbidity associated with hypogonadism in men with renal failure, careful evaluation of serum testosterone would be valuable. Testosterone replacement therapy should be considered in men with symptomatic hypogonadism and renal failure, and may ameliorate some of the morbidity associated with renal failure. Patients with all stages of renal disease are at an increased risk of hypogonadism that could be associated with significant morbidity. Testosterone replacement therapy may reduce some of the morbidity of renal failure, although it carries risk.

[Impact of end-stage renal disease and kidney transplantation on the reproductive system]

Chronic renal failure leads to many metabolic disorders affecting reproductive function. For men, hypergonadotropic hypogonadism, hyperprolactinemia, spermatic alterations, decreased libido and erectile dysfunction are described. Kidney transplantation improves sperm parameters and hormonal function within 2 years. But sperm alterations may persist with the use of immunosuppressive drugs. In women, hypothalamic-pituitary-ovarian axis dysfunction due to chronic renal failure results in menstrual irregularities, anovulation and infertility. After kidney transplantation, regular menstruations usually start 1 to 12 months after transplantation. Fertility can be restored but luteal insufficiency can persist. Moreover, 4 to 20% of women with renal transplantation suffer from premature ovarian failure syndrome. In some cases, assisted reproductive technologies can be required and imply risks of ovarian hyperstimulation syndrome and must be performed with caution. Pregnancy risks for mother, fetus and transplant are added to assisted reproductive technologies ones. Only 7 authors have described assisted reproductive technologies for patients with kidney transplantation. No cases of haemodialysis patients have been described yet. So, assisted reproductive technologies management requires a multidisciplinary approach with obstetrics, nephrology and reproductive medicine teams' agreement.

A prospective study in male recipients of kidney transplantation reveals divergent patterns for inhibin B and testosterone secretions

Background

Male patients with chronic kidney disease often exhibit the biological and clinical hallmarks of an abnormal hypothalamo–pituitary–gonadal axis. It is known that dialysis does not reverse this impaired endocrine status; however, the impact of kidney transplantation (KT) is still controversial. The aim of our study was to investigate the levels of serum gonadotropins, testosterone, and inhibin B during dialysis and after KT.

Methods

A longitudinal and prospective single center study was led in an academic setting. Blood hormones levels were assayed by immunoassays in 53 men (mean age: 37 years) receiving dialysis (T₀) and at 6 months post-KT (T₁₈₀). These data were compared with those from 46 fertile semen donors (mean age: 37 years). The main outcome measure was the between-groups differences in hormones levels. A second criterion was the comparison of T₀ and T₁₈₀ hormones levels according to the immunosuppressive regimen.

Results

For patients ongoing dialysis, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) mean levels were high, whereas testosterone and inhibin B mean levels remained normal. After KT, LH levels returned to normal whereas FSH was significantly increased. Testosterone levels remained normal whereas inhibin B levels significantly decreased. We found that the combination tacrolimus plus mycophenolic acid significantly decreased post-KT inhibin B levels. Moreover, we found that pre-graft inhibin-B level was independent of testosterone and could predict low post-operative inhibin B level with a sensitivity of 77% and a specificity of 92%.

Conclusions

Our study suggests that endocrine secretions of Leydig and Sertoli cells are differently impacted by dialysis, KT and immunosuppressive regimen raising new issues to explore.

Resistance training and testosterone levels in male patients with chronic kidney disease undergoing dialysis

BACKGROUND

We investigated serum testosterone and insulin-like growth factor 1 (IGF-1) levels' associations with muscle fibre size and resistance training in male dialysis patients.

METHODS

Male patients were included in a 16-week control period followed by 16 weeks of resistance training thrice weekly. Blood samples were obtained to analyse testosterone, luteinizing hormone (LH), IGF-1, and IGF-binding protein 3. Muscle fibres' size was analysed in biopsies from m. vastus lateralis.

RESULTS

The patients' testosterone levels were within the normal range at baseline (n = 20) (19.5 (8.2-52.1) nmol/L versus 17.6 (16.1-18.0), resp.) whereas LH levels were higher (13.0 (5.5-82.8) U/L versus 4.3 (3.3-4.6), P < 0.001, resp.). IGF-1 and IGF-binding protein 3 levels were higher in the patients compared with reference values (203 (59-590) ng/mL versus 151 (128-276), P = 0.014, and 5045 (3370-9370) ng/mL versus 3244 (3020-3983), P < 0.001, resp.). All hormone levels and muscle fibre size (n = 12) remained stable throughout the study. Age-adjusted IGF-1 was associated with type 1 and 2 fibre sizes (P < 0.05).

CONCLUSION

Patients' total testosterone values were normal due to markedly increased LH values, which suggest a compensated primary insufficiency of the testosterone producing Leydig cell. Even though testosterone values were normal, resistance training was not associated with muscle hypertrophy. This trial is registered with ISRCTN72099857.

Role of testosterone in the pathogenesis, progression, prognosis and comorbidity of men with chronic kidney disease

Testosterone deficiency and hypogonadism are common conditions in men with chronic kidney disease (CKD). A disturbed hypothalamic-pituitary-gonadal axis due to CKD is thought to contribute to androgen deficiency. Data from experimental studies support the hypothesis that exogenous administration of testosterone may induce the activation of the renin-angiotensin system (RAS), the production of endothelin and the regulation of anti- or/and proinflammatory cytokines involved in the pathogenesis of hypertension and kidney damage. On the other hand, low testosterone levels in male patients with CKD are paradoxically associated with a higher risk of morbidity and mortality, possibly explained by anemia, osteoporosis and cardiovascular disease. In this article, we present an overview of clinical and experimental studies of the impact of testosterone on the progression and prognosis of male patients with CKD; even today, this remains a controversial issue.

The vulnerable man: impact of testosterone deficiency on the uraemic phenotype

Testosterone deficiency or hypogonadism is a common finding in men undergoing dialysis, to a great extent a consequence of the failing kidney per se. Testosterone restoration in hypogonadism is common practice among endocrinologists. However, there is currently little awareness of this condition among both uremic patients and nephrologists, and in many cases, testosterone deficiency remains unscreened and untreated. This review article summarizes our current understanding of the role of testosterone deficiency at the crossroad of cardiometabolic complications of patients with chronic kidney disease. Pathways discussed include, among others, the plausible role of testosterone deficiency in the development of anaemia and ESA hyporesponsiveness, muscle catabolism, endothelial dysfunction, cognitive dysfunction, decreased libido, cardiovascular disease and mortality. As there are limited sources to guide decision-making, we also review existing testosterone replacement therapy studies in the context of CKD as well as considerations for side and adverse effects. This review makes a case for consideration of screening and better management of hypogonadism in men undergoing dialysis.

[Falsely elevated testosterone in a type 1 diabetes patients with acne and chronic renal failure on dialysis]

The purpose of this report is to present the case of a patient with type 1 diabetes with acne and chronic renal failure on dialysis admitted to the hospital with high total total and free testosterone (612 ng/dL, normal < 90 ng/dL; 255 pMol/L, normal: 20-45 pMol/L). On clinical evaluation, she presented facial acne, and no other signs of hyperandrogenism. As this result was confirmed, she underwent adrenal and ovary morphological assessment (adrenal CT and pelvic ultrasound), which yielded normal results. Due to divergence between clinical and laboratory findings, we considered other possibilities that could explain the elevation of testosterone, including the presence of comorbidities (diabetes and chronic renal failure) and failure of the testosterone assay. Testosterone levels were determined again by high performance liquid chromatography, as a preparative method, and tandem mass spectrometry, yielding normal results (21 ng/dL), which were compatible with a falsely elevated total testosterone level caused by the presence of factors that intereferred with the assay.

Testosterone supplementation in male obese Zucker rats reduces body weight and improves insulin sensitivity but increases blood pressure

Androgen levels are lower in obese men as compared with normal weight individuals. However, there are no safety data regarding the chronic use of androgen supplements in middle-aged men. The present study was undertaken to determine the cardiovascular and metabolic effects of chronic (10 weeks) testosterone treatment in male obese Zucker rats, starting at 22 weeks of age, when testosterone levels were significantly decreased. Testosterone supplements increased plasma levels, 10-fold in both obese Zucker rats and lean Zucker rats. In obese Zucker rats, testosterone supplements reduced body weight, plasma insulin, and cholesterol levels and improved the oral glucose tolerance test. None of these parameters were affected in lean Zucker rats. Mean arterial pressure was significantly increased in obese Zucker rats but not lean Zucker rats. Testosterone supplements increased proteinuria and accelerated renal injury in lean Zucker rats only. Thus, treatment of obese men with chronic testosterone supplements should be done with careful monitoring of blood pressure.

Endogenous testosterone, endothelial dysfunction, and cardiovascular events in men with nondialysis chronic kidney disease

BACKGROUND AND OBJECTIVES

Deterioration of kidney function impairs testosterone production, with hypogonadism being common in men with chronic kidney disease (CKD). In nonrenal populations, testosterone is suggested to participate in the atherosclerotic process. In male dialysis patients, we showed that low testosterone increases the risk of mortality. We here studied plausible links among testosterone levels, vascular derangements, and cardiovascular events in nondialysis CKD men.

DESIGN, SETTING, PARTICIPANTS, & METHODS

This was a cross-sectional analysis in which flow-mediated dilation (FMD) was assessed in 239 CKD male patients (stages 1 to 5; mean age 52 ± 12 years), together with routine measurements, serum total and free testosterone, and follow-up for cardiovascular outcomes.

RESULTS

Total and free testosterone levels decreased in parallel with the reduction of kidney function. Multiple regression analyses showed that total and free testosterone significantly and independently contributed to explain the variance of FMD. After a median follow-up of 31 months (range 8 to 35 months), 22 fatal and 50 nonfatal cardiovascular events occurred. In Cox analysis, the risk of cardiovascular events was reduced by 22% for each nanomole-per-liter increment of total testosterone. This reduced risk persisted after adjustment for age, renal function, diabetes mellitus, previous cardiovascular history, C-reactive protein, albumin, and FMD. The same was true for free testosterone concentrations.

CONCLUSIONS

The reduction in endogenous testosterone levels observed with progressive CKD was inversely associated with endothelial dysfunction and exacerbated the risk of future cardiovascular events in nondialysis male CKD patients.

Low serum testosterone, arterial stiffness and mortality in male haemodialysis patients

BACKGROUND

In the general population, accumulating data support a link between low testosterone levels and mortality by all causes, but especially by cardiovascular disease (CVD). Also, accelerated arterial stiffness has been recognized as an important cardiovascular risk factor. Here, we explored the association between testosterone levels and risk of death in male haemodialysis (HD) patients, whose arterial system is characterized by generalized stiffening.

METHODS

In this three-centre prospective observational study, 111 male HD patients after completion of baseline assessment, including measurement of male sex hormones and pulse wave velocity (PWV), were followed up for CVD and all-cause mortality.

RESULTS

Of the 111 patients studied, 54 were found with and 57 without testosterone deficiency, defined as testosterone levels <8 nmol/L. During a median follow-up period of 37 months, 49 deaths occurred, 28 (57%) of which were caused by CVD. Testosterone deficiency patients had increased CVD and all-cause mortality {crude hazard ratio: 3.14 [95% confidence interval (CI), 1.21-8.16] and 3.09 (95% CI, 1.53-6.25), respectively}, even after adjustment for age, body mass index, serum albumin and C-reactive protein, prevalent CVD and HD vintage. The association of testosterone with CVD mortality, but not with all-cause mortality, was lost after adjusting for PWV, an index of arterial stiffness. Testosterone levels were inversely related to PWV (r = -0.441; P < 0.001).

CONCLUSION

We showed that testosterone deficiency in male HD patients is associated with increased CVD and all-cause mortality and that increased arterial stiffness may be a possible mechanism explaining this association.

Analyse du statut spermatique, érectile et hormonal chez des patients hémodialysés

But

Le but de notre travail était d’établir le profil hormonal, érectile et spermatique chez les patients hémodialysés et de rechercher l’impact des perturbations hormonales sur la fonction érectile (FE) et les paramètres spermatiques.

Patients et méthodes

Nous avons réalisé une étude transversale chez 30 sujets hémodialysés chez qui un spermogramme a été réalisé parallèlement à un bilan hormonal qui incluait le dosage sérique de FSH (follicle-stimulating hormone) et la testostérone totale. La FE a été évaluée par l’étude de l’indice international de la FE dans sa version française (IIEF-5). Le dosage des hormones sexuelles a été fait par la technique radio-immunologique, et la pratique du spermogramme a été faite selon les recommandations de l’OMS.

Résultats

Deux patients seulement avaient un spermogramme et un bilan hormonal normaux, l’IIEF était normal chez un seul patient.

Les patients azoospermiques (16 %) présentaient un eugonadisme hypergonadotrophique. Quarante pour cent des patients avaient une hypospermie. Un tiers des patients présentait une oligozoospermie sévère associée à un taux élevé de FSH dans 77 % des cas.

La mobilité et la morphologie spermatique étaient altérées dans respectivement 96 et 50 % des cas. Le bilan hormonal montrait une élévation de la FSH (> 8,5 mUI/ml) chez 40 % des patients, et la testostéronémie était diminuée (< 3,2 ng/ml) chez 25 % des patients. Deux patients présentaient un hypogonadisme franc (testostérone < 2 ng /ml).

Discussion

Le volume de sperme était diminué de façon significative chez les patients de plus de 30 ans. La FE était perturbée dans 73 % des cas avec un IIEF moyen de 15 (IIEF normal > 20). Plusieurs auteurs ont mis en évidence une corrélation entre le dysfonctionnement gonadique et les taux élevés de gonadotrophines chez l’homme présentant une insuffisance rénale chronique, avec ou sans atrophie testiculaire. Dans notre série, la testostéronémie était normale chez nos patients malgré l’absence de prise d’androgène. Les séances d’hémodialyses permettent-elles de préserver la fonction endocrine des testicules ?

Conclusion

Les patients au stade d’hémodialyse chronique d’une durée supérieure à un an présentaient un eugonadisme hypergonadotrophique ainsi qu’une insuffisance érectile. L’ancienneté de l’hémodialyse n’altère pas de manière significative les paramètres spermatiques ni la FE. Les patients d’un âge supérieur à 30 ans présentaient une diminution significative du volume spermatique qui pourrait être un marqueur déterminant de l’atteinte de la FE et de la fonction reproductive.

Urinary proteomics based on capillary electrophoresis-coupled mass spectrometry in kidney disease: discovery and validation of biomarkers, and clinical application

Use of capillary electrophoresis coupled to mass spectrometry (CE-MS) technology in proteome analysis has increased, with a focus on the identification of biomarker peptides in clinical proteomics. Among the reported applications, the main focus is on the urinary biomarkers for kidney disease. In this review, we discuss the principal, theoretical, and practical obstacles that are encountered when using CE-MS for the analysis of body fluids for biomarker discovery. We present several examples of a successful application of CE-MS for biomarker discovery in kidney disease, implications for disease diagnosis, prognosis, and therapy evaluation, and will also discuss current challenges and possible future improvements.

Prevalence and clinical implications of testosterone deficiency in men with end-stage renal disease

BACKGROUND

Abnormally low serum testosterone levels were recently associated with an increased mortality risk in male dialysis patients. However, the prevalence of testosterone deficiency in end-stage renal disease (ESRD) is not well defined. We hereby explore the prevalence and correlates of clinical testosterone deficiency in a large cohort of ESRD male patients.

METHODS

Two hundred and sixty ESRD men [median age 59 (25th-75th percentile 48-67)  years] were included. Testosterone concentration and testosterone deficiency (<10 nmol/L) were studied in relation to clinically evident cardiovascular disease and markers of inflammation at baseline as well as deaths registered during the following 36 months.

RESULTS

Testosterone deficiency was present in 44% of the patients, while 33% showed testosterone insufficiency (10-14 nmol/L), and only 23% had normal testosterone values (>14 nmol/L). Testosterone was strongly and inversely correlated to inflammatory markers (CRP, IL-6 and fibrinogen), even after correction for age and sex hormone-binding globulin. In a crude spline curve, low testosterone concentrations were associated with worse outcome. A clinical condition of testosterone deficiency was independently associated with cardiovascular co-morbidity [odds ratio (OR) 2.51; 95% confidence interval (CI) 1.32-4.76] and death (OR 2.00; 95% CI 1.01-3.97) in logistic regression analyses.

CONCLUSIONS

Testosterone deficiency is a common finding among male ESRD patients, and it is independently associated with inflammation, cardiovascular co-morbidity and outcome. Future studies are needed to determine the potential adverse effects of male hypogonadism in ESRD and the possibility of improving risk profile, quality of life, and ultimately outcome with testosterone supplementation in these patients.

Low Plasma Dehydroepiandrosterone Sulfate Level and its Relationship to Adiponectin in Hemodialysis Patients

The aim of the present study was to assess the relationship between plasma DHEA-S and adiponectin concentrations in hemodialyses patients (HD). Plasma adiponectin, DHEA-S, cholesterol, and albumin levels were estimated in 94 HD and 46 healthy subjects (HS). In HD, a significantly lower plasma DHEA-S concentration (2.5+/-0.2 vs. 4.7+/-0.4 micromol/L respectively; p = 0.002) but significantly higher plasma adiponectin level (15.0+/-0.7 vs. 8.7+/-0.8 microg/mL respectively; p = 0.004) than in HS were found. Only in uremic patients was a significant negative correlation found between plasma adiponectin and DHEA-S concentrations (tau = -0.210; p = 0.001). Decreased plasma DHEA-S level is associated with increased adiponectinemia in uremic patients.

Imbalance in sex hormone levels exacerbates diabetic renal disease

Studies suggest that the presence of testosterone exacerbates, whereas the absence of testosterone attenuates, the development of nondiabetic renal disease. However, the effects of the absence of testosterone in diabetic renal disease have not been studied. The study was performed in male Sprague-Dawley nondiabetic, streptozotocin-induced diabetic, and streptozotocin-induced castrated rats (n=10 to 11 per group) for 14 weeks. Diabetes was associated with the following increases: 3.2-fold in urine albumin excretion, 6.3-fold in glomerulosclerosis, 6.0-fold in tubulointerstitial fibrosis, 1.6-fold in collagen type I, 1.2-fold in collagen type IV, 1.3-fold in transforming growth factor-beta protein expression, and 32.7-fold in CD68-positive cell abundance. Diabetes was also associated with a 1.3-fold decrease in matrix metalloproteinase protein expression and activity. Castration further exacerbated all of these parameters. Diabetes was also associated with a 4.7-fold decrease in plasma testosterone, 2.9-fold increase in estradiol, and 2.1-fold decrease in plasma progesterone levels. Castration further decreased plasma testosterone levels but had no additional effects on plasma estradiol and progesterone. These data suggest that diabetes is associated with abnormal sex hormone levels that correlate with the progression of diabetic renal disease. Most importantly, our results suggest an important role for sex hormones in the pathophysiology of diabetic renal complications.

Transplant recipient renal function is donor renal mass- and recipient gender-dependent

The effect of both donor renal mass and gender on renal function, in both gender recipients, was examined. Qualifying consecutive living-donor renal transplants (n = 730) were stratified into 4 donor-recipient groups: female-female (n = 177), male-female (n = 151), female-male (n = 240), male-male (n = 162). Groups were equivalent in age, race, body mass index (BMI), match, ischemia time, operative time, and estimated glomerular filtration rate (eGFR). Female recipients had lower serum creatinine (Cr(s)). Male recipients had higher Cr(s) wherever they received a female allograft. Male recipients of male kidneys had a higher eGFR than all other groups for 3 years. Renal function of the recipient correlated with the renal mass of the donor within each group. Male and female kidneys functioned equivalently in the female-recipient environment. Large nephron-mass male donor kidneys function more poorly in female recipients. The male kidney loses 15-20 ml/min eGFR in the female host. The diminished graft function may be related to androgen deprivation. Female and male donor kidneys function equivalently in the male recipient if adjusted for renal mass transplanted. Female kidneys improve eGFR by 7-10 ml/min by being transplanted into a male environment. Donor renal mass and gender affect recipient graft function Expectations of ultimate recipient renal function should take into account both the gender and mass disparity of the donor-recipient pair.

Therapy Insight: sexual dysfunction in patients with chronic kidney disease

Sexual dysfunction is common in people with chronic kidney disease (CKD). Sexual dysfunction in these patients should be thought of as a multifactorial problem that is affected by a variety of physiological and psychological factors, as well as by comorbid conditions. Assessment of sexual difficulties in patients with CKD, therefore, involves a careful investigation of a variety of domains. The development of treatment strategies presents challenges as it is often difficult to determine the primary factor(s) responsible for the sexual dysfunction. It is important to think of the treatment in the overall context of the management of various medical problems presented by patients with CKD. It must be remembered that the design of therapeutic approaches for each patient is dependent on the systematic evaluation of the functional and psychosocial problems presented, and assessment of the cause(s) of sexual dysfunction.

Transdermal androgen therapy to augment EPO in the treatment of anemia of chronic renal disease

BACKGROUND

Hypogonadism and anemia are common comorbid conditions in dialysis patients. Testosterone replacement may improve such clinical parameters as anemia, sarcopenia, and low libido. Additionally, by increasing hemoglobin levels, testosterone replacement may allow for a dose reduction in recombinant human erythropoietin (rHuEPO), thereby reducing cost.

METHODS

This phase IV, single-center, placebo-controlled, double-blind study assessed the effect of transdermal testosterone on serum testosterone levels, rHuEPO dose required to maintain hemoglobin level, bone mineral content, lean body mass and fat content, cholesterol level, sexual function, and mood. Forty hypogonadal male hemodialysis patients who were administered rHuEPO were randomly assigned to 100 mg of topical 1% testosterone gel (Testim; Auxilium Pharmaceuticals, Norristown, PA) or placebo, applied daily for 6 months.

RESULTS

Forty men with a mean age of 56 years and baseline serum testosterone level less than 300 ng/dL (< 10.4 nmol/L) participated in this trial. In men assigned to administration of transdermal testosterone, there was an increase beyond that in the placebo group in mean serum testosterone (77.1 ng/dL [2.7 nmol/L]), dihydrotestosterone (DHT; 0.8 nmol/L), and estradiol levels (6.3 pg/mL [23.0 pmol/L]) and a decrease in mean serum luteinizing hormone levels (-3.1 IU/L). Compared with subjects administered placebo, participants on testosterone replacement therapy did not show an appreciable change in rHuEPO dose (mean difference adjusted for baseline values, 12.6 U/kg/wk; P = 0.73), bone mineral density, lean body mass or fat content, cholesterol level, sexual function, or mood.

CONCLUSION

Daily administration of 100 mg of topical 1% testosterone gel for 6 months failed to significantly increase serum testosterone or DHT levels in hypogonadal men with end-stage renal disease. Treatment with transdermal testosterone did not impact on rHuEPO requirement or clinical parameters in this small placebo-controlled study. Greater serum testosterone levels may be required to show clinical benefit in men with end-stage renal disease.

Testosterone supplementation in aging men and women: possible impact on cardiovascular-renal disease

Treatment of aging men and women with testosterone supplements is increasing. The supplements are given to postmenopausal women mainly to improve their libido and to aging men to improve muscle mass and bone strength, to improve libido and quality of life, to prevent and treat osteoporosis, and, with the phosphodiesterase-5 inhibitors, such as sildenafil, to treat erectile dysfunction. The increased use of testosterone supplements in aging individuals has occurred despite the fact that there have been no rigorous clinical trials examining the effects of chronic testosterone on the cardiovascular-renal disease risk. Studies in humans and animals have suggested that androgens can increase blood pressure and compromise renal function. Androgens have been shown to increase tubular sodium and water reabsorption and activate various vasoconstrictor systems in the kidney, such as the renin-angiotensin system and endothelin. There is also evidence that androgens may increase oxidative stress. Furthermore, the kidney contains the enzymes necessary to produce androgens de novo. This review presents an overview of the data from human and animal studies in which the role of androgens in promoting renal and cardiovascular diseases has been investigated.

Testosterone metabolism and replacement therapy in patients with end-stage renal disease

Hypogonadism is common among men with end-stage renal disease (ESRD), beginning before the need for dialysis and not improved with the initiation of dialysis. Many of the manifestations of hypogonadism, such as bone disease and muscle wasting, are also frequently seen among dialysis patients. There have been few studies of testosterone replacement therapy in this patient population, but available data suggest that testosterone can be administered without adjustment of the doses used in hypogonadal men with normal renal function. Extrapolation from results of treatment of hypogonadal older men with normal renal function suggests that testosterone replacement could improve libido and could have salutary effects on muscle mass and bone mineral density in patients with kidney disease. However, caution is warranted because of the potential side effects of testosterone therapy, and further research is needed to more precisely define the balance of risk and benefit in patients with chronic kidney disease. Specifically it will be important to determine the prevalence and clinical significance of hypogonadism in ESRD patients in the modern era and to measure the effects of replacement therapy on various symptoms of hypogonadism as well as on overall quality of life, physical functioning, and survival.

Effects of different calcineurin inhibitors on sex hormone levels in transplanted male patients

Hormonal abnormalities in male patients with end-stage renal diseases are primarily organic and related to uremia as well as the other comorbid factors that frequently contribute to chronic renal failure and concomitant drug administration. The restoration of hormonal profiles after successful renal transplantation is still controversial. Immunosuppressive drugs may influence hormonal profiles. Our cross-sectional study of 37 male kidney transplant recipients investigated two groups according to their calcineurin inhibitor therapy, namely 21 cyclosporine versus 16 tacrolimus patients. The two groups were matched for age, graft function, mean duration of dialysis before transplantation, and duration of follow-up after transplantation. There was no statistical significant difference in baseline circulating levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone (TTE), and prolactin (PRL) between the two groups. We found that calcineurin inhibitors have favorable effects on sexual hormone levels of male renal transplant patients and that there is no difference in baseline hormone levels between cyclosporine- and tacrolimus-treated male patients.