Sexual function: a comparison between male renal transplant recipients and hemodialysis patients

Comparison of erectile function in patients with end-stage renal disease receiving haemodialysis and kidney transplantation

To investigate the frequency and risk factors of ED in haemodialysis patients (HDps) and kidney transplantation (KTx) recipients (KTxRs). HDps and KTxRs between the ages of 18-65 were compared in terms of ED. IEFF-15 (International Index of Erectile Function) score was used to evaluation of ED. Fifty-seven male HDps and 52 male KTxRs with a mean age of 45.6 ± 10.4 years were included in our study. DM, CAD, hyperlipidaemia, smoking and beta blocker use were higher HDps (p = 0.037, p < 0.001, p = 0.001, p = 0.001 and p = 0.031 respectively). There was no ED in five (8.8%) HDps and 27(51.9%) KTxRx. Severity of ED was significantly higher in HDps (p < 0.001). In multiple logistic regression analysis, KTx was found the most relevant associated factor with ED. KTxRs had decreased risk for ED (OR = 0.09, 95% CI 0.02-0.30, p < 0.001). ED is significantly more common in HDps than KTxRs. Known risk factors for ED, HT, DM, CAD, HL, smoking, obesity and beta-blocker use were not related to ED in the HDps and KTxRs, and the KTx was positively effective for ED in patients undergoing renal replacement therapy.

Erectile function after kidney transplantation: a meta-analysis

Background

Erectile dysfunction (ED) is common in patients with end-stage renal disease (ESRD). Whether kidney transplantation can improve erectile function in patients with ESRD is still controversial. We conducted a meta-analysis on the relationship between kidney transplantation and erectile function.

Methods

A literature search was conducted on PubMed, Embase, Cochrane Library, and Web of Science until May 31, 2019. Primary outcomes were ED prevalence and each domain score of the International Index of Erectile Function (IIEF) questionnaire. We used age-matched dialysis patients or patients before kidney transplantation as a control group and compared them to kidney transplant recipients.

Results

A total of 9 articles were finally enrolled in the study. Compared with the control group, the kidney transplantation group had a lower prevalence of ED (OR 0.49, 95% CI: 0.28–0.86) and higher domain scores for erectile function (SMD 0.53, 95% CI: 0.12–0.94) and sexual desire (SMD 1.19, 95% CI: 0.11–2.27). While there were no significant variations in domain scores for orgasmic function (SMD 0.27, 95% CI: −0.10–0.63), intercourse satisfaction (SMD 0.26, 95% CI: −0.10–0.61), and overall satisfaction (SMD 0.17, 95% CI: −0.21–0.56). Patients in the kidney transplantation group had higher serum testosterone (SMD 1.20, 95% CI: 0.86–1.54) and lower prolactin (SMD −1.46, 95% CI: −2.22 to −0.69) and luteinizing hormone (SMD −0.97, 95% CI: −1.39 to −0.55).

Conclusions

Kidney transplantation may be associated with improved erectile function in patients with ESRD. This may be attributable to the correction of endocrine hormone disorders in patients after kidney transplantation.

Improving Sexual Function in People With Chronic Kidney Disease: A Narrative Review of an Unmet Need in Nephrology Research

Purpose of review:

Sexual dysfunction occurs commonly in people with chronic kidney disease (CKD) and has been recognized as a research priority. We sought to evaluate the current state of the literature addressing sexual dysfunction in people with CKD and identify barriers and strategies to improve our management of this important symptom.

Sources of information:

OVID Medline and Google Scholar were searched for English, peer-reviewed studies using keywords and terms related to “Chronic Kidney Disease,” “sexuality,” and “sexual dysfunction OR function.”

Methods:

In this narrative review, we describe definitions of sexual dysfunction and contributors exacerbated by CKD, barriers to researching sexual dysfunction in people with CKD, and possible avenues for future research.

Key findings:

Sexual dysfunction is common in people with CKD and results from a combination of kidney disease itself, as well as its associated physical (ie, comorbidities) and nonphysical factors. Barriers to the study of sexual dysfunction in CKD include inconsistent disease definitions, stigma, variable efficacy and safety of established therapies, and evolving gender roles in sexual function. Potential avenues for future research to improve the sexual function in people with CKD may include evaluating the safety and efficacy of established therapies in people with CKD using a variety of observational and interventional study designs, engaging people with CKD and multidisciplinary team members in research, and using implementation science methods to translate what is known about sexual function into clinical practice. Concerted efforts are required to break down barriers and improve sexual function in people with CKD. Patients have identified this as an important research priority, and national networks need to direct efforts to reduce symptom burden.

Limitations:

This narrative review was limited by a paucity of high-quality studies examining sexual dysfunction specifically in people with kidney disease.

Erectile Dysfunction after Kidney Transplantation

Patients with kidney transplantation often have a worse quality of life than the general population. One of the reasons for this, in male patients, is the high prevalence of erectile dysfunction. This is mainly due to the presence of comorbidities, surgery for kidney transplantation, adverse drug effects, psychological changes related to chronic disease, as well as hyperprolactinemia and hypogonadism. Whenever these endocrine dysfunctions occur after kidney transplantation, they must be corrected with appropriate treatment, i.e., testosterone replacement therapy. Administration of the phosphodiesterase-5 inhibitor (PDE5i) sildenafil at the recommended posology does not significantly alter the pharmacokinetics of the calcineurin inhibitors cyclosporin A or tacrolimus and does not impair kidney allograft function. Tacrolimus increases the peak concentration and prolongs the half-life of PDE5i in kidney transplant patients and, therefore, daily administration cannot be recommended due to the significant drop in blood pressure. Intracavernous injection or topical application of alprostadil can be a second-line option for the treatment of erectile dysfunction after kidney transplantation, which does not alter cyclosporine concentrations and does not deteriorate kidney function. Finally, penile prostheses can be successfully implanted following pelvic organ transplantation after eliminating the risk of infection associated with surgery.

Male Sexual Dysfunction and Chronic Kidney Disease

Male sexual dysfunction is common in chronic kidney disease (CKD), particularly in end-stage renal disease. Historically, this cause of considerable morbidity has been under-reported and under-recognized. The ideal approach to diagnosis and management remains unclear due to a paucity of good quality data, but an understanding of the pathophysiology is necessary in order to address the burden of this important complication of CKD. This paper will review the endocrine dysfunction that occurs in renal disease, particularly the hypothalamic–pituitary–gonadal axis, discuss the causes of erectile dysfunction, infertility, and altered body image and libido in these patients and suggest appropriate treatment interventions.

Chronic administration of sildenafil improves erectile function in a rat model of chronic renal failure

The relationship between erectile dysfunction (ED) and chronic renal failure (CRF) has been reported in several studies. This study aimed to investigate whether the chronic use of sildenafil could enhance the erectile capacity in CRF-induced rats. In addition, we assessed the effect of that treatment on certain molecules, which have been suggested to play crucial roles in erectile physiology and CRF-related ED as well. Three groups of animals were utilized: (1) age-matched control rats, (2) CRF-induced rats, (3) CRF-induced rats treated with chronic administration of sildenafil (5 mg kg⁻¹ p.o. for 6 weeks [treatment started after 6 weeks of CRF induction]). At 3 months, all animals underwent cavernosal nerve stimulation (CNS) to assess erectile function. Penile tissue advanced glycation end products (AGE's)/5-hydroxymethyl-2-furaldehyde, malondialdehyde (MDA), cGMP (ELISA), inducible nitric oxide synthase (iNOS) and neuronal NOS (nNOS) (Western blot) analyses were performed in all rat groups. CRF-induced rats had a significant decrease in erectile function when compared to control rats (P < 0.05). The increase in both intracavernosal pressure (ICP) and area under the curve of CRF-induced rats treated with sildenafil (Group 3) was greater than CRF-induced rats (Group 2). Additionally, sildenafil treatment decreased AGE, MDA and iNOS levels, while it preserved nNOS and cGMP contents in CRF-induced penile tissue. Decreased AGE, MDA, iNOS and increased nNOS, cGMP levels at the sildenafil-treated group increased both ICP and Total ICP to CNS, which led to improve erectile function in CRF-induced rats. The results of the present study revealed the therapeutic effect of chronic sildenafil administration on erectile function in CRF-induced rats.

Psychosocial Correlates of Body Mass Index in the United States: Intersection of Race, Gender and Age

BACKGROUND

Studies on the association between psychosocial factors and obesity have provided mixed findings.

OBJECTIVES

Current study used a nationally representative sample of U.S. adults to investigate how intersection of race, gender and age alters the psychosocial correlates of body mass index (BMI).

MATERIALS AND METHODS

Data came from the national health measurement study (NHMS), a cross-sectional study with nationally representative sample of Black and White (n = 3,648) adults ages 35 - 89. We tested bivariate correlations between BMI and physical and mental quality of life, purpose in life, number of chronic medical conditions, and discrimination across race × gender × age groups.

RESULTS

Higher purpose in life was associated with lower BMI among middle aged and older White women, middle aged Black men, middle aged Black women, and older Black women but not middle aged or older White men and older Black men. There was a positive association between multi-morbidity and BMI in all groups other than older White men. High BMI was associated with poor mental quality of life among older White women, older Black men and women, but not any of middle aged groups, and older White men. High BMI was associated with poor physical quality of life among all groups. Everyday discrimination was positively associated with BMI among older White women but not any other group. Lifetime discrimination was not associated with BMI among any of the groups.

CONCLUSIONS

Race, gender, and age shape psychosocial and health related correlates of BMI. There is a need for further research on group differences in psychosocial correlates of obesity.

Sexually transmitted infection screening and reproductive health counseling in adolescent renal transplant recipients: Perceptions and practice patterns. A study from the Midwest Pediatric Nephrology Consortium

We wanted to identify practice patterns and perceived barriers among pediatric nephrologists regarding STI screening and reproductive health counseling in adolescent renal transplant recipients. We created an online Likert-scaled survey. Response rate was 54%. The majority (83%) believed STI risk in their patients was similar to or higher than healthy teens. Interestingly, while 67% felt moderately or very confident in asking about sexual activity and counseling about safer sex, only 43% routinely or always inquired about sexual activity, and only 42% routinely or always counseled about safer sex. Fifty-four percent routinely or always discussed contraceptive options and implications of unintentional pregnancy. Fifty-one percent routinely or always referred patients to a gynecologist or adolescent provider for contraception prescription. The most common counseling mechanism was informal discussions in clinic (87%). Ten percent had no mechanism in place. Major barriers included time limitations, adolescents' fear regarding confidentiality, and lack of professional training. This is the first report of perceptions and practice patterns of pediatric nephrologists regarding STI screening and reproductive health counseling. Providers seem to recognize the importance of counseling; however, translation into practice remains low. Professional training in this area and increased encounter time could improve counseling delivery and thereby reduce risk in this population.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Sexual function in patients supported with left ventricular assist device and with heart transplant

AIMS

Sexual dysfunction is common among patients with heart failure (HF) and considered an important hamper to quality of life. While implantation of left ventricular assist device (LVAD) may prolong and improve life in advanced HF, limited data are available on its impact on sexual function. The aim of this study is to evaluate sexual function in LVAD patients and compare this with patients after heart transplantation (HTx).

METHODS AND RESULTS

Sexual activity and satisfaction of stable patients with durable LVAD or after HTx were evaluated using a validated questionnaire and visual analogue scale from 0 to 10. Data were collected from 31 patients (mean age 59 ± 12 years, 87% male), 17 after HTx and 14 with LVAD. Pleasure or satisfaction with sex was significantly higher in HTx patients (P = 0.0005). In total, 29% LVAD patients and 71% HTx patients reported content with sexual activity. Recalled satisfaction with sex life pre-operation was comparable between the groups. During support, satisfaction with sex life using visual analogue scale was 7.6 ± 3.1 for HTx versus 3.9 ± 4.0 for LVAD patients (P = 0.017). In total, 11 LVAD patients (79%) reported specific problems in sexual function including erectile dysfunction or vaginal dryness (8, 57%); problems with the LVAD, cable, or batteries (5, 36%); problems with orgasm (4,29%); and other problems such as fear of injury, feeling depressed, partner issues, self-image, and pain (1, 7% each).

CONCLUSION

Sexual dysfunction occurs in patients with LVAD support and may be more prominent than after HTx. Problems limiting sexual function related to physiological, psychological, and equipment merit consideration during follow-up.

Chronic kidney disease and erectile dysfunction

Erectile dysfunction (ED) is a common condition among male chronic kidney disease (CKD) patients. Its prevalence is estimated to be approximately 80% among these patients. It has been well established that the production of nitric oxide from the cavernous nerve and vascular endothelium and the subsequent production of cyclic GMP are critically important in initiating and maintaining erection. Factors affecting these pathways can induce ED. The etiology of ED in CKD patients is multifactorial. Factors including abnormalities in gonadal-pituitary system, disturbance in autonomic nervous system, endothelial dysfunction, anemia (and erythropoietin deficiency), secondary hyperparathyroidism, drugs, zinc deficiency, and psychological problems are implicated in the occurrence of ED. An improvement of general conditions is the first step of treatment. Sufficient dialysis and adequate nutritional intake are necessary. In addition, control of anemia and secondary hyperparathyroidism is required. Changes of drugs that potentially affect erectile function may be necessary. Further, zinc supplementation may be necessary when zinc deficiency is suspected. Phosphodiesterase type 5 inhibitors (PDE5Is) are commonly used for treating ED in CKD patients, and their efficacy was confirmed by many studies. Testosterone replacement therapy in addition to PDE5Is may be useful, particularly for CKD patients with hypogonadism. Renal transplantation may restore erectile function. ED is an early marker of cardiovascular disease (CVD), which it frequently precedes; therefore, it is crucial to examine the presence of ED in CKD patients not only for the improvement of the quality of life but also for the prevention of CVD attack.

Gender Differences in the Association between Lipid Profile and Sexual Function among Patients with Coronary Artery Disease

BACKGROUND

Although several studies have been conducted on the association between lipid profile and sexual function among men with coronary artery disease, there is a paucity of knowledge about this association among women with coronary artery disease.

OBJECTIVES

Our study aimed to evaluate the link between lipid profile and sexual function in men and women with coronary artery disease.

METHODS

One hundred and twenty patients with documented coronary artery disease were consecutively sampled from an outpatient cardiovascular clinic. The patients were assessed for lipid profile and sexual relationship using the Relation and Sexuality Scale (RSS). In addition, the Hospital Anxiety and Depression Scale (HADS) was used to measure the symptoms of anxiety and depression. The characteristics of chest pain were also measured using the Rose Angina Questionnaire. The data were analyzed through linear regression analysis.

RESULTS

This study was conducted on 91 males (75.8%) and 29 females (24.2%). Multivariate analysis showed that low-density lipoprotein cholesterol was correlated with sexual function (B = 0.01, P = 0.010) and total sexual relationship (B = 0.01, P = 0.050). A correlation was also observed between the level of high-density lipoprotein and sexual frequency score (B = -0.02, P = 0.040). Gender moderated these correlations. Among males, serum cholesterol (r = 0.193, P = 0.047) and low-density lipoprotein (r = 0.224, P = 0.037) were correlated to sexual function. In females, however, low-density lipoprotein was correlated to the total sexual relationship (r = 0.426, P = 0.021) and high-density lipoprotein was correlated to sexual frequency (r = -0.334, P = 0.046).

CONCLUSIONS

The findings of this study showed a relationship between lipid profile and sexual relationship among both male and female patients with coronary artery disease. The link between lipid profile and sexual function of the patients with coronary artery disease is thus beyond just the effect of lipid profile on erectile dysfunction.

Depression and sexual dysfunction in chronic kidney disease: a narrative review of the evidence in areas of significant unmet need

People with chronic kidney disease (CKD) have a high symptom burden and experience poorer quality of life than the general population. People with CKD frequently report fatigue, anorexia, pain, sleep disturbance, itching and restless legs. Depression and sexual dysfunction may also be common in CKD, although questions about optimal diagnosis and treatment remain unanswered. People with kidney disease identify lifestyle and the impact of CKD on family and psychosocial supports as key priorities and rate symptoms such as sexual dysfunction and psychological distress as severe. Here, we outline the current state of research underlying depression and sexual dysfunction in this population focusing on prevalence, diagnosis, screening, outcomes and interventions and suggest areas requiring additional specific research.

Phosphodiesterase type 5 inhibitor treatment for erectile dysfunction in patients with end-stage renal disease receiving dialysis or after renal transplantation

INTRODUCTION

The phosphodiesterase type 5 (PDE5) inhibitors are generally well tolerated and effective for treating erectile dysfunction (ED), including in patients with significant comorbidity. Because of this benign safety profile, investigators have used PDE5 inhibitors to treat patients with ED and severe renal disease or those who have received renal transplants.

AIM

To assess safety and efficacy of PDE5 inhibitors in patients receiving dialysis or renal transplants.

MAIN OUTCOME MEASURES

Erectile function as assessed by the International Index of Erectile Function (IIEF) and Global Assessment Questions; adverse events (AEs).

METHODS

We reviewed published studies of PDE5 inhibitors in patients receiving dialysis or renal transplants.

RESULTS

In double-blind, placebo-controlled studies in patients receiving dialysis or renal transplants, sildenafil significantly improved erectile function as assessed by the IIEF, and 75-85% of patients reported improved erectile function on Global Assessment Questions; efficacy was more variable in less well-controlled studies. In >260 patients undergoing dialysis who received sildenafil in clinical studies, there were only six reported discontinuations because of AEs (headache [N=3], headache and nausea [N=1], gastrointestinal [N=1], and symptomatic blood pressure decrease [N=1]). In approximately 400 patients with renal transplants who received sildenafil, only three patients discontinued because of AEs. Vardenafil improved IIEF scores of up to 82% of renal transplant recipients in randomized, controlled studies (N=59, total), with no reported discontinuations because of AEs. Limited data also suggest benefit with tadalafil.

CONCLUSIONS

ED is common in patients undergoing renal dialysis or postrenal transplant and substantially affects patient quality of life. Sildenafil and vardenafil appear to be efficacious and well tolerated in patients receiving renal dialysis or transplant.

Erectile dysfunction in hemodialysis: A systematic review

Men with chronic renal failure (CRF) on hemodialysis have been frequently associated with erectile dysfunction (ED), with an of between 20% to 87.7%. As a result of the multi-system disease processes present in many uremic men, it is apparent that the pathogenesis of ED is most probably multifactorial. Factors to be considered include peripheral vascular disease, neurogenic abnormalities, hormonal disturbances and medications used for treatment of conditions associated with CRF. These physiological abnormalities may be supplemented by significant psychological stresses and abnormalities resulting from chronic illness. Treatment must start with the determination and treatment of the underlying causes. In addition to psychological treatment, further lines of treatment of ED in CRF can be classified as 1st line (medical treatment which includes oral phosphodiesterase-5 inhibitors and hormone regulation), 2nd line (intracavernosal injection, vacuum constriction devices and alprostadil urethral suppositories) or 3rd line (surgical treatment). Renal transplantation improves the quality of life for some patients with CRF and subsequently it may improve erectile function in a significant number of them, however still there is high incidence of ED after transplantation.

Does kidney transplantation onto the external iliac artery affect the haemodynamic parameters of the cavernosal arteries?

Reduced cavernosal arterial inflow has been hypothesized to be the likely cause of erectile dysfunction after kidney transplants in recipients revascularized through end-to-end anastomosis to the internal iliac artery, suggesting that end-to-side anastomosis at the external iliac artery is preferable. The aim of this study was to prospectively evaluate the effect of the use of the external iliac artery on erectile function, hormone profiles and penile blood flow by evaluating changes in penile colour Doppler ultrasound parameters in a consecutive series of 22 recipients before and after end-to-side external iliac artery transplantation. The mean International Index of Erectile Function-Erectile Function (IIEF-EF) domain score decreased significantly 3 months after transplant (18.09±6.33 vs. 22.50±7.09, P=0.01). The reduction in peak systolic velocity (PSV) was significant for the cavernous artery homolateral to the side of transplant (42.60±18.77 vs. 52.01±19.91, P=0.01). The mean postoperative end diastolic velocity (EDV) did not differ significantly from the preoperative value (P=0.74). No statistical differences were found in the serum levels of testosterone or prolactin. Kidney grafts anastomosed at the external iliac artery produced significant (P=0.01) reductions in arterial inflow at the homolateral cavernosal artery that remained above the normal threshold. Whether these haemodynamic changes can explain the worsening of postoperative erectile function remains to be proven.

The impact of erectile dysfunction on the quality of life of men undergoing hemodialysis and its association with depression

INTRODUCTION

Erectile dysfunction (ED) is highly prevalent among men undergoing hemodialysis.

AIM

This study was performed to identify the influence of ED on the patient's quality of life (QoL) and to evaluate the influence of depression on erectile function of these patients.

MAIN OUTCOME MEASURES

For this multicenter cross-sectional study, 275 patients were interviewed through questionnaires: the five-item version of the International Index of Erectile Function was used for diagnosing and classifying ED; the Medical Outcomes Study Questionnaire 36-Item Short Form Health Survey (SF-36) for scoring QoL; and the Hospital Anxiety and Depression Scale (HADS) to evaluate depressive symptoms. Linear regression was used to examine the associations between some of the variables and ED. Predialytic biochemical and hematological parameters were determined during the longer interdialytic period.

RESULTS

Patients had a mean age of 48.6 ± 12.8 years, and the ED prevalence was 72.3%. Advanced age, diabetes and depression score were independent risk factors for the development of ED as confirmed by linear regression (P < 0.001, P = 0.002, and P < 0.001, respectively). QoL was worse among patients with any degree of ED, and the scores were statistically significant for overall health rating (P = 0.016), physical composite score (P = 0.003), bodily pain (P = 0.042), physical functioning (P < 0.001), and vitality (P = 0.005). Furthermore, more severe forms of ED were associated with a lower QoL. After adjustment for some variables, such as age, time under dialysis, hemoglobin, albumin, parathyroid hormone, Kt/V, and depression, linear regression showed that domains related to poorer physical functioning (P = 0.047) and decreased vitality (P = 0.009) were significantly related to ED.

CONCLUSION

Depression is an important trigger for the development of ED in hemodialysis patients, and this sexual condition is an independent risk factor for their poor QoL.