Sexual dysfunction in uremia

Better renal replacement therapy to improve sexual function in female patients with end-stage renal disease: A cross-sectional study

Background

Sexual dysfunction is commonly observed in patients with end-stage renal disease (ESRD). Sexual dysfunction in correlation with ESRD is associated with physiological and psychological problems resulting in low sexual desire, arousal, difficulties in achieving orgasm, and pain during intercourse. Studies on female sexual dysfunction (FSD) in correlation with renal replacement therapy are limited, and previous studies reporting contradictive results have indicated that the best modality for providing better outcomes (especially on FSD) remains unclear. Thus, this study aimed to compare the sexual function between female patients with ESRD who were on continuous ambulatory peritoneal dialysis (CAPD) and those on hemodialysis (HD).

Materials and methods

This study enrolled female patients who were randomly selected from the urology and renal division of the Internal Medicine Outpatient Clinic of our hospital from January 2020 to August 2021 and divided into the following groups: predialysis, HD, CAPD, and control groups. The participants were asked to fill out the Female Sexual Function Index (FSFI) questionnaires, and their data were recorded and analyzed using GraphPad Prism 9.0.0.

Results

Of the 280 patients, 200 female patients were included in this study. The rate of FSD (cutoff: 26.55) was 42% in the control group, 72% in the predialysis group, 62% in the CAPD group, and 66% the in HD group. The control group had a higher mean score in all parameters (p < 0.05). The total FSFI mean score indicated no significant difference (p > 0.05) between the patients on HD and those on CAPD; the mean of each point was almost identical except for satisfaction, which was higher among patients on CAPD (p < 0.05). Significant differences in the components of desire, arousal, orgasm, and satisfaction were observed between the groups.

Conclusions

Patients on CAPD had better FSFI scores than the female patients with ESRD who were on HD, and the scores of both groups of patients were better than those of the predialysis group.

Renal Transplantation Enhances the Sildenafil Citrate Effectiveness in Patients with Erectile Dysfunction. A Single-Center Perspective

OBJECTIVE

To assess the efficacy and safety of Sildenafil citrate in the treatment of ED in (HD) compared to post-RT patients.

PATIENTS AND METHODS

A concurrent cohort prospective study to evaluate the efficacy of Sildenafil in the treatment of ED in 24 HD patients (Group A) and 13 patients with persistent ED one-year post-RT (Group B). The initial dose of Sildenafil was 25 mg, increased to 50 mg if there is an adequate response. An Arabic-translated International Index of Erectile Function (IIEF) questionnaire was completed one week before and after Sildenafil treatment. An IIEF erectile function score of 26 or an improvement of at least 10 points for the total IIEF score was considered a favorable response to Sildenafil.

RESULTS

Group A included 22 patients with a mean age of 47.32 ± 7.013 years, whereas Group B included 13 patients with a mean age of 56.87 ± 9.612 years. The overall efficacy rate of Sildenafil was 40.9% and 76.9% in groups A and B, respectively. The post-treatment IIEF5-15 score increased from 11.1 ± 5.99 to 12.5 ± 6.41 (p = .458) and from 11.82 ± 7.534 to 21.91 ± 5.700 (p = .002) in groups A and B, respectively. In both groups, the duration of HD had no impact on ED improvement except in the post-RT non-responder subgroup. Hypertension, gastrointestinal symptoms, and flushing were both groups' most common side effects.

CONCLUSION

RT could enhance the response to sildenafil in treating patients with ED. The outcome is better in younger post-RT patients with moderate and severe erectile dysfunction and shorter dialysis duration.

Sexual dysfunction in female and male patients undergoing chronic ambulatory peritoneal dialysis

BACKGROUND

To prolong survival and to provide a better quality of life (QoL) are two aims at the forefront in the care of peritoneal dialysis (PD) patients. In this study we aimed to determine frequency of sexual dysfunction (SD) and influencing factors in PD patients.

METHODS

Of the 201 patients, 114 under 65 years and on chronic ambulatory PD for at least 3 months were enrolled. Forty-nine females and 65 males completed the study. Survey forms were applied using face-to-face interview method. Female Sexual Function Index (FSFI) was used to assess SD in women; International Index for Erectile Function (IIEF) was used to assess erectile dysfunction (ED) in men. All patients completed SF-36 and Beck Depression Inventory (BDI) forms.

RESULTS

While SD was evident in 89.8% of female patients (FSFI score:10.4 ± 9.7), ED was present in 87.7% of males (IIEF score:13.8 ± 7.9). Depression rates were 65.3% and 49.2% in female and male patients, respectively. BDI scores were 21.6 ± 10.4 and 17.1 ± 9.5; physical component scores, 52.6 ± 20.4 and 55.2 ± 20.2; mental component scores, 45.2 ± 19.8 and 49.9 ± 22, in female and male patients, respectively. FSFI was correlated with age (β = -0.53 p < 0.001) and BDI score (β = -0.23 p = 0.04), (R² = 0.64). ED showed correlation with age (β = -0.36 p < 0.001), BDI score (β = -0.57 p < 0.001), and hemoglobin level (β = 0.26 p = 0.003), (R² = 0.74).

CONCLUSION

SD, often overlooked and not discussed by both patients and physicians, is encountered relatively frequently among PD patients. Left not discussed and untreated SD may adversely affect QoL.

Depression and anxiety symptoms among patients receiving maintenance hemodialysis: a single center cross-sectional study

BACKGROUND

To investigate depression and anxiety and related factors among patients receiving maintenance hemodialysis (MHD).

METHODS

This cross-sectional study included patients underwent MHD in 3/2022 at Jinshan Hospital affiliated to Fudan University. Depression and anxiety levels of patients were assessed using Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), respectively. SF-36 was used to assess patients' quality of life. Multiple linear regression analysis was used to determine the variables associated with the scores of BDI/BAI.

RESULTS

A total of 103 patients were included, 71 cases (68.93%) and 38 cases (36.89%) with depression and anxiety, respectively. The scores of almost all domains of the SF-36 showed a declining trend with increasing depression or anxiety among patients on MHD. Higher Charlson Comorbidity Index (CCI) (β =0.066, 95%CI: 0.016-0.116, P = 0.010), lower educational status (β = - 0.139, 95%CI: - 0.243- -0.036, P = 0.009), and number of oral medications (β =0.177, 95%CI: 0.031-0.324, P = 0.018) were significantly associated with higher BDI scores. Longer dialysis duration (β =0.098, 95%CI: 0.003-0.193, P = 0.044) and number of oral medications (β =4.714, 95%CI: 1.837-7.590, P = 0.002) were significantly associated with higher BAI scores.

CONCLUSIONS

Depression and anxiety may be likely to occur among patients undergoing MHD and impact their quality of life. Higher CCI, lower educational status and usage of multiple oral medications may be associated with depression, whereas longer dialysis duration and multiple oral medications may be associated with anxiety in MHD patients.

Associations of impaired grip strength and gait function with the severity of erectile dysfunction in men undergoing dialysis: a cross-sectional study

OBJECTIVE

To investigate the associations of impaired muscle strength and gait function with the severity of erectile dysfunction (ED) in men undergoing dialysis.

METHODS

This cross-sectional study included 63 men undergoing dialysis. ED was assessed with the Sexual Health Inventory for Men (SHIM). Patients were divided into the mild/moderate (SHIM score ≥8) and severe ED groups (SHIM score ≤7). Correlations between variables were analyzed using Spearman's rank correlation coefficient. Multivariable logistic regression analyses were performed to evaluate the impact of impaired grip strength and gait function on the severity of ED.

RESULTS

The median age of the study participants was 62 years; all had ED, with 67% having severe ED. Spearman's rank correlation test demonstrated significant negative and positive correlations between gait function and SHIM score (ρ = -0.257, p = 0.042) and between grip strength and SHIM score (ρ = 0.305, p = 0.015), respectively. In the multivariable analyses, impaired grip strength was significantly associated with severe ED (odds ratio [OR]: 4.965, p = 0.017), whereas gait function was not (OR: 3.147, p = 0.064).

CONCLUSION

Impaired muscle strength was significantly associated with severe ED, whereas impaired gait function had a marginal effect on this erectile condition.

Effects of renal transplantation on erectile dysfunction: a systematic review and meta-analysis

Erectile dysfunction (ED) is a major global health burden commonly observed in patients with end-stage renal disease (ESRD). Although renal transplantation improves the problem in some patients, it persists in ≈20-50% of recipients. Studies regarding the effects of kidney transplantation on ED present contradictory findings. We performed a systematic review to summarise the effects of kidney transplantation on ED. A systematic literature search was performed across PubMed, Cochrane, and Scopus databases in April 2020. We included all prospective studies that investigated the pre and posttransplant international index of erectile function (IIEF-5) scores in recipients with ED. Data search in PubMed and Google Scholar produced 1326 articles; eight were systematically reviewed with a total of 448 subjects. Meta-analysis of IIEF-5 scores showed significant improvements between pre and post transplantation. Our findings confirm that renal transplantation improves erectile function. Furthermore, transplantation also increases testosterone level. However, the evidence is limited because of the small number of studies. Further studies are required to investigate the effects of renal transplantation on erectile function.

Use of Sertraline in Hemodialysis Patients

Depression and anxiety are the most common psychiatric disorders in end-stage renal disease (ESRD) patients treated with hemodialysis (HD) and may correlate with lower quality of life and increased mortality. Depression treatment in HD patients is still a challenge both for nephrologists and psychiatrists. The possible treatment of depressive disorders can be pharmacological and non-pharmacological. In our article, we focus on the use of sertraline, the medication which seems to be relatively safe and efficient in the abovementioned population, taking under consideration several limitations regarding the use of other selective serotonin reuptake inhibitors (SSRIs). In our paper, we discuss different aspects of sertraline use, taking into consideration possible benefits and side effects of drug administration like impact on QTc (corrected QT interval) prolongation, intradialytic hypotension (IDH), chronic kidney disease-associated pruritus (CKD-aP), bleeding, sexual functions, inflammation, or fracture risk. Before administering the medication, one should consider benefits and possible side effects, which are particularly significant in the treatment of ESRD patients; this could help to optimize clinical outcomes. Sertraline seems to be safe in the HD population when provided in proper doses. However, we still need more studies in this field since the ones performed so far were usually based on small samples and lacked placebo control.

Sexual Dysfunction in Women With End-Stage Renal Disease: A Systematic Review and Meta-Analysis

BACKGROUND

In women with end-stage renal disease (ESRD), female sexual dysfunction (SD) remains underestimated.

AIM

To explore the prevalence, correlates, diagnostic approach and treatment modalities of sexual symptoms in females with ESRD.

METHODS

We performed a systematic review and meta-analysis to estimate both the prevalence of SD and the pooled Female Sexual Function Index (FSFI) scores in ESRD females. Similarly, for studies reporting the FSFI score before and after renal transplantation (RT), we estimated the effect of RT on sexual function. Further assessment of heterogeneity was conducted via subgroup and sensitivity analyses, cumulative meta-analysis and univariate meta-regression of important correlates. Records were identified through searching PubMed, Cochrane Library and Scopus databases as well as sources of grey literature until November 2020 (PROSPERO ID: CRD42020215178).

OUTCOMES

We included 47 studies with 61 patient group entries and 3490 ESRD female individuals (median age: 45.2 years, ΙQR: 40.4-50.6).

RESULTS

The SD prevalence in all females with ESRD was 74% (95%CI: 67%-80%, I² = 92%) and the FSFI total score 16.1 points (95%CI: 14.3-17.8, I² = 98%). The female SD prevalence was 63% (95%CI: 43%-81%, I² = 92%) in renal transplant recipients, 80% (95%CI: 72%-87%, I² = 91%) in hemodialysis patients and 67% (95%CI: 46%-84%, I² = 90%) in peritoneal dialysis patients. The total FSFI score improved by 7.5 points (95%CI: 3.9-11.1, I² = 92%) after RT. Older age and menopause were associated with higher SD prevalence.

CLINICAL TRANSLATION

Female SD is highly prevalent in all ESRD women, but renal transplant recipients reported improved sexual function.

STRENGTHS & LIMITATIONS

We provide the first study about SD in females and assessed the role of RT on sexual function. Contrary, none of the included studies evaluated the concomitant presence of distress with SD. The levels of heterogeneity were substantially high for all outcomes and we could not adjust for further correlates, which might have affected our measures.

CONCLUSIONS

Sexual symptoms negatively affect the quality of life and warrants appropriate clinical attention, as they are an underdetermined and undertreated clinical entity in females with ESRD. Studies on treatment modalities of female SD in patients with ESRD are mandatory, as currently no relevant studies or clinical recommendations exist. Pyrgidis N, Mykoniatis I, Tishukov M, et al. Sexual Dysfunction in Women With End-Stage Renal Disease: A Systematic Review and Meta-Analysis. Sex Med Rev 2021;18:936-945.

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.

Amelioration of testicular damages in renal ischemia/reperfusion by berberine: An experimental study

Background

Ischemic acute kidney injury is associated with an inflammatory reaction.

Objective

In the current study, berberine was assessed for its effect on the functional disorders and histological damages of testis induced by renal ischemia/reperfusion (I/R).

Materials and Methods

Twenty-eight adult male Wistar rats (260-300 gr) were equally divided into four groups (n = 7/each): sham and I/R groups which received distilled water as well as berberine (BBR) and BBR + I/R groups which received berberine (15 mg/kg/day) orally seven days before the surgery. In both groups of sham and BBR, renal arteries were not clamped. Renal I/R was induced by occluding right and left renal artery for 45 min followed by a 24 hr reperfusion period. Blood samples were taken for determining the plasma levels of creatinine, urea nitrogen, FSH (follicle stimulating hormone), LH (luteinizing hormone), and testosterone. Then the rats were killed under deep anesthesia and the left testis was immediately isolated and preserved.

Results

The renal I/R injury led to testicular histological damages accompanied with increased plasma levels of creatinine, urea nitrogen, LH, and FSH, as well decrease of plasma testosterone concentration at the end of 24 hr reperfusion (All p < 0.001, except for FSH p < 0.01). Berberine diminished histological damage to the testis and attenuated the increase in plasma creatinine, urea nitrogen, LH, FSH, and decrease in plasma testosterone concentration in the BBR + I/R group (All p < 0.001).

Conclusion

These results suggest that ischemic acute renal failure induces functional disorders and tissue damages in testis of rat, which was improved through the administration of berberine.

[Sexual disorders in the renal patient]

Quality of Life Related to Health is currently considered one of the primary therapeutic objectives in renal failure patients who need substitution treatment as life prolonging therapy. Sexual health is a basic right that positively affects the quality of life. Although a significant percentage of chronic patients have some type of sexual dysfunction, this is not openly discussed, making it important for doctors to address these issues in the clinic. A review is presented on the pathophysiology of sexual dysfunctions in both male and female chronic renal patients. The effects of dialysis and transplantation on sexual function will be addressed, as well as presenting the main sexual dysfunctions and their treatment.

Belatacept during pregnancy in renal transplant recipients: Two case reports

Impaired fertility is common among patients with chronic organ failure, including end-stage renal disease (ESRD). Women of childbearing age undergoing transplantation may experience rapid return of fertility. Pregnancy posttransplant presents numerous risks for the patient, fetus, and allograft. Maternal risks include hypertension and preeclampsia. Allograft risks include acute rejection and failure of the organ, and fetal risks include miscarriage, birth defects from immunosuppressants, premature delivery, and low birth weight. Belatacept, a selective T cell costimulation blocker, was approved for use in kidney transplant recipients in the United States in 2011. Little is known about the safety of belatacept during pregnancy in humans. We describe 2 cases of successful pregnancy and delivery with the use of belatacept-based immunosuppression. The Transplant Pregnancy Registry International (TPR) is a voluntary registry for transplant recipients who have had pregnancies or fathered a pregnancy posttransplant. To date, these 2 cases are the only known exposures to belatacept that have been reported to the TPR.

The relationship between hydration status, male sexual dysfunction and depression in hemodialysis patients

Background

Disturbances in sexual function are common among dialysis patients. Normal erections require a complex balance of physiological, psychological, emotional, hormonal, neurological and vascular factors. This study examined a possible association of overhydration (OH) with male sexual dysfunction and depression in hemodialysis (HD) patients.

Patients and methods

This cross-sectional study assessed hydration status by whole-body bioimpedance spectroscopy in patients on maintenance HD for more than 12 months. Patients were categorized according to OH to extracellular water (ECW) ratio: OH/ECW ratio >0.15 and OH/ECW ratio ≤0.15. Sexual function was assessed using the International Index of Erectile Function (IIEF) score. Psychological status was evaluated using the Beck Depression Inventory (BDI) score. Serum sex hormones were determined.

Results

Of 39 stable participants on HD, 53.8% were overhydrated (OH/ECW ratio >0.15) and 46.2% not overhydrated (OH/ECW ratio ≤0.15). Of participants with OH/ECW ratio >0.15, 85.7% had mild to severe ED, and 71.4% had abnormal BDI scores, ranging from mild mood disturbance to severe depression. Compared to patients with OH/ECW ratio ≤0.15, BDI scores, serum estradiol and plasma hsCRP were higher (18.48±8.34 vs 10.61±5.46, p<0.001; 140.10±44.51 vs 126.10±32.26, p=0.034; and, 17.70±12.14 vs 9.76±8.79, p=0.013; respectively) in those with OH/ECW ratio >0.15, while their IIEF score, serum total testosterone and dehydroepiandrosterone (DHEA) were lower (12.81±7.31 vs 41.44±23.79, p<0.001; 8.97±5.43 vs 14.10±8.30, p=0.013; and 85.31±55.14 vs 133.3±95.48, p=0.029; respectively). The OH/ECW ratio correlated inversely with the IIEF score (r=−0.69, p<0.001) and positively with BDI scores (r=0.64, p<0.001). IIEF scores were inversely correlated with BDI scores (r=−0.54, p<0.001).

Conclusion

OH in HD patients was found to be associated with a higher prevalence of sexual dysfunction and depression, lower serum levels of total testosterone and DHEA, and higher levels of serum estradiol.

Biochemical and Clinical Impact of Organic Uremic Retention Solutes: A Comprehensive Update

In this narrative review, the biological/biochemical impact (toxicity) of a large array of known individual uremic retention solutes and groups of solutes is summarized. We classified these compounds along their physico-chemical characteristics as small water-soluble compounds or groups, protein bound compounds and middle molecules. All but one solute (glomerulopressin) affected at least one mechanism with the potential to contribute to the uremic syndrome. In general, several mechanisms were influenced for each individual solute or group of solutes, with some impacting up to 7 different biological systems of the 11 considered. The inflammatory, cardio-vascular and fibrogenic systems were those most frequently affected and they are one by one major actors in the high morbidity and mortality of CKD but also the mechanisms that have most frequently been studied. A scoring system was built with the intention to classify the reviewed compounds according to the experimental evidence of their toxicity (number of systems affected) and overall experimental and clinical evidence. Among the highest globally scoring solutes were 3 small water-soluble compounds [asymmetric dimethylarginine (ADMA); trimethylamine-N-oxide (TMAO); uric acid], 6 protein bound compounds or groups of protein bound compounds [advanced glycation end products (AGEs); p-cresyl sulfate; indoxyl sulfate; indole acetic acid; the kynurenines; phenyl acetic acid;] and 3 middle molecules [β₂-microglobulin; ghrelin; parathyroid hormone). In general, more experimental data were provided for the protein bound molecules but for almost half of them clinical evidence was missing in spite of robust experimental data. The picture emanating is one of a complex disorder, where multiple factors contribute to a multisystem complication profile, so that it seems of not much use to pursue a decrease of concentration of a single compound.

Muscle Atrophy in Chronic Kidney Disease

The renal damage and loss of kidney function that characterize chronic kidney disease (CKD) cause several complex systemic alterations that affect muscular homeostasis, leading to loss of muscle mass and, ultimately, to muscle atrophy. CKD-induced muscle atrophy is highly prevalent and, in association with common CKD comorbidities, is responsible for the reduction of physical capacity, functional independence, and an increase in the number of hospitalizations and mortality rates. Thus, this chapter summarizes current knowledge about the complex interactions between CKD factors and the pathophysiological mechanisms that induce muscle atrophy that, despite growing interest, are not yet fully understood. The current treatments of CKD-induced muscle atrophy are multidisciplinary, including correction of metabolic acidosis, nutritional supplementation, reducing insulin resistance, administration of androgenic steroids, resisted and aerobic exercise, neuromuscular electrical stimulation, and inspiratory muscle training. However, further studies are still needed to strengthen the comprehension of CKD-induced muscle atrophy and the better treatment strategies.

[Andrologic consequences of chronic renal failure: State of the art for the yearly scientific report of the French National Association of Urology]

OBJECTIVE

To describe the state of the art of current knowledge regarding gonadal consequences of end-stage chronic kidney disease (CKD) and renal transplantation.

MATERIAL AND METHOD

A systematic review of the literature search was performed from the databases Medline (NLM, Pubmed) and Embase, focused on the following keywords: "chronic kidney disease"; "chronic renal failure"; "hypogonadism"; "kidney transplantation"; "testicular dysfunction"; "testosterone". Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 383 articles. After reading titles and abstracts, 51 were included in the text, based on their relevance.

RESULTS

The prevalence of hypogonadism in CKD is reported between 24 % and 66 %, and decreases partially after renal transplantation. This is a hypogonadotropic hypogonadism whose pathophysiology is multifactorial, involving mainly a primitive testicular deficit, a hypothalamic-pituitary dysregulation, and an hyperprolactinemia. The consequences of this hypogonadism are not only sexual but also contribute to anemia, sarcopenia, atherosclerosis, and potentially in the progression of CKD. Hypogonadism is an independent risk factor for mortality in CKD patients.

CONCLUSIONS

CKD is frequently associated with an hypogonadism whose correction is validated only in the setting of erectile dysfunction treatment. The other benefits of the correction of hypogonadism in the CKD patients, including overall survival, needs to be evaluated.

Cognitive Changes in Chronic Kidney Disease and After Transplantation

Cognitive impairment is very common in chronic kidney disease (CKD) and is strongly associated with increased mortality. This review article will discuss the pathophysiology of cognitive impairment in CKD, as well as the effect of dialysis and transplantation on cognitive function. In CKD, uremic toxins, hyperparathyroidism and Klotho deficiency lead to chronic inflammation, endothelial dysfunction and vascular calcifications. This results in an increased burden of cerebrovascular disease in CKD patients, who consistently have more white matter hyperintensities, microbleeds, microinfarctions and cerebral atrophy on magnetic resonance imaging scans. Hemodialysis, although beneficial in terms of uremic toxin clearance, also contributes to cognitive decline by causing rapid fluid and osmotic shifts. Decreasing the dialysate temperature and increasing total dialysis time limits these shifts and helps maintain cognitive function in hemodialysis patients. For many patients, kidney transplantation is the preferred treatment modality, because it reverses the underlying mechanisms causing cognitive impairment in CKD. These positive effects have to be balanced against the possible neurotoxicity of infections and immunosuppressive medications, especially glucocorticosteroids and calcineurin inhibitors. A limited number of studies have addressed the overall effect of transplantation on cognitive function. These have mostly found an improvement after transplantation, but have a limited applicability to daily practice because they have only included relatively young patients.

Lower serum uric acid level predicts mortality in dialysis patients

We evaluated the impact of serum uric acid (SUA) on mortality in patients with chronic dialysis. A total of 4132 adult patients on dialysis were enrolled prospectively between August 2008 and September 2014. Among them, we included 1738 patients who maintained dialysis for at least 3 months and had available SUA in the database. We categorized the time averaged-SUA (TA-SUA) into 5 groups: <5.5, 5.5-6.4, 6.5-7.4, 7.5-8.4, and ≥8.5 mg/dL. Cox regression analysis was used to calculate the hazard ratio (HR) of all-cause mortality according to SUA group. The mean TA-SUA level was slightly higher in men than in women. Patients with lower TA-SUA level tended to have lower body mass index (BMI), phosphorus, serum albumin level, higher proportion of diabetes mellitus (DM), and higher proportion of malnourishment on the subjective global assessment (SGA). During a median follow-up of 43.9 months, 206 patients died. Patients with the highest SUA had a similar risk to the middle 3 TA-SUA groups, but the lowest TA-SUA group had a significantly elevated HR for mortality. The lowest TA-SUA group was significantly associated with increased all-cause mortality (adjusted HR, 1.720; 95% confidence interval, 1.007-2.937; P = 0.047) even after adjusting for demographic, comorbid, nutritional covariables, and medication use that could affect SUA levels. This association was prominent in patients with well nourishment on the SGA, a preserved serum albumin level, a higher BMI, and concomitant DM although these parameters had no significant interaction in the TA-SUA-mortality relationship except DM. In conclusion, a lower TA-SUA level <5.5 mg/dL predicted all-cause mortality in patients with chronic dialysis.

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.

Anti-Müllerian hormone, a Sertoli cell-derived marker, is decreased in plasma of male patients in all stages of chronic kidney disease

Male patients with terminal renal failure are often infertile and exhibit an abnormal sex hormone pattern in plasma. We studied patients in all chronic kidney disease (CKD) stages to determine plasma levels of anti-Müllerian hormone (AMH), a Sertoli cell-derived marker, and other sex hormones. Seventy-eight male patients with CKD stages 1-5 and a median age of 40 years (22-50 years), as well as 20 healthy controls with a median age of 37 years (26-44 years), were enrolled. The CKD patients were evenly distributed; 18 with CKD stages 1-2, 19 with CKD stage 3, 19 with CKD stage 4, and 22 with CKD stage 5. Cystatin C, follicle-stimulating hormone, luteinizing hormone, prolactin, sex hormone-binding globulin, testosterone, and AMH levels in plasma were analysed. AMH was analysed using the Ansh Labs UltraSensitive AMH assay. Several changes occurred in plasma levels of sex hormones in male patients with CKD. Plasma AMH levels were lower in CKD stages 1-4 by 30% (p = 0.041) and by 70% (p < 0.001) in CKD stage 5 compared with controls. Plasma luteinizing hormone and prolactin levels were higher and testosterone levels were lower compared with controls. The pathophysiological role of this reduction in AMH is unclear, but can be linked to altered Sertoli cell function.

Menopausal symptoms in women with chronic kidney disease

OBJECTIVE

This study aims to determine whether menopausal symptoms differed between women with chronic kidney disease (CKD) and women without CKD, and whether CKD modified associations of late vasomotor symptoms (VMS) with mortality and/or cardiovascular events.

METHODS

CKD, defined as estimated glomerular filtration rate lower than 60 mL/minute/1.73 m (using the Chronic Kidney Disease Epidemiology Collaboration equation), was determined in 17,891 postmenopausal women, aged 50 to 79 years at baseline, in the multiethnic Women's Health Initiative cohort. Primary outcomes were presence, severity, and timing/duration of VMS (self-reported hot flashes and night sweats) at baseline. We used polytomous logistic regression to test for associations among CKD and four VMS categories (no VMS; early VMS-present before menopause but not at study baseline; late VMS-present only at study baseline; persistent VMS-present before menopause and study baseline) and Cox regression to determine whether CKD modified associations between late VMS and mortality or cardiovascular events.

RESULTS

Women with CKD (1,017 of 17,891; mean estimated glomerular filtration rate, 50.7 mL/min/1.73 m) were more likely to have had menopause before age 45 years (26% vs 23%, P = 0.02) but were less likely to experience VMS (38% vs 46%, P < 0.001) than women without CKD. Women with CKD were not more likely than women without CKD to experience late VMS. Late VMS (hazard ratio, 1.16; 95% CI, 1.04-1.29) and CKD (hazard ratio, 1.74; 95% CI, 1.54-1.97) were each independently associated with increased risk for mortality, but CKD did not modify the association of late VMS with mortality (Pinteraction = 0.53), coronary heart disease (Pinteraction = 0.12), or stroke (Pinteraction = 0.68).

CONCLUSIONS

Women with mild CKD experience earlier menopause and fewer VMS than women without CKD.

[Pregnancies in hemodialysis and in patients with end-stage chronic kidney disease : epidemiology, management and prognosis]

Pregnancy in patients presenting end-stage renal disease is rare and there are currently no recommendations for the management of these patients. In hemodialysis patients, reduced fertility and medical reluctance limit the frequency of pregnancies. Although the prognosis has significantly improved, a significant risk for unfavorable maternal (pre-eclampsia, eclampsia) and fetal (pre-term birth, intrauterine growth restriction, still death) outcome still remains. Increasing dialysis dose with the initiation of daily dialysis sessions, early adaptation of medications to limit teratogenicity and management of chronic kidney disease complications (anemia, hypertension) are required. A tight coordination between nephrologists and obstetricians remains the central pillar of the care. In peritoneal dialysis, pregnancy is also possible with modification of the exchange protocol and reducing volumes.

Erectile dysfunction in chronic hemodialysis patients in dakar: a cross-sectional study in 2012

BACKGROUND

Patients with chronic kidney disease (CKD) experience multiple complications including erectile dysfunction (ED). It involves more than 50% of patients on dialysis or transplant. In Africa, the true extent of ED in CKD is unknown although some studies have been done in this regard.

OBJECTIVES

This study aimed to determine the prevalence and identify risk factors of ED in patients on hemodialysis.

PATIENTS AND METHODS

This cross-sectional multicenter study was conducted from January 2, 2012 through April 30, 2012 in four hemodialysis centers in Dakar. We included all patients on chronic hemodialysis who aged ≥ 18 years old and freely consented to participate in the study. Sociodemographic, clinical, and hemodialysis data were collected through a questionnaire. Erectile function was assessed by a short version of International Index of Erectile Function (IIEF-5).

RESULTS

Among a target of 80 patients, 73 met the inclusion criteria and were included in this study. Mean dialysis vintage was 27.3 months (range, 1-156). Their mean age was 53.81 ± 12.52 years, with a higher proportion of age group of 50 to 69 years old. Fifty-six patients were married (37 monogamous and 19 polygamous) and six were singles. Overall prevalence of ED was 84.9% and it was severe in 14 patients (19.2%). Hypertension and diabetes were the most frequent etiologies and antihypertensive treatment was used in 95.5%. The main factors associated with ED were age > 50 years old and polygamy.

CONCLUSIONS

ED is a common problem among patients on hemodialysis in Dakar with a high prevalence. Aging and diabetes represent most common causes. More efforts are needed for its early detection, prevention, and multidisciplinary management.

Testosterone and mortality

Epidemiological studies have found that men with low or low normal endogenous testosterone are at an increased risk of mortality than those with higher levels. Cardiovascular disease accounts for the greater proportion of deaths in those with low testosterone. Cancer and respiratory deaths in some of the studies are also significantly more prevalent. Disease-specific studies have identified that there are higher mortality rates in men with cardiovascular, respiratory and renal diseases, type 2 diabetes and cancer with low testosterone. Obesity, metabolic syndrome, type 2 diabetes, cardiovascular disease and inflammatory disorders are all associated with an increased prevalence of testosterone deficiency. Two major questions that arise from these findings are (1) is testosterone deficiency directly involved in the pathogenesis of these conditions and/or a contributory factor impairing the body's natural defences or is it merely a biomarker of ill health and the severity of underlying disease process? (2) Does testosterone replacement therapy retard disease progression and ultimately enhance the clinical prognosis and survival? This review will discuss the current state of knowledge and discuss whether or not there are any answers to either of these questions. There is convincing evidence that low testosterone is a biomarker for disease severity and mortality. Testosterone deficiency is associated with adverse effects on certain cardiovascular risk factors that when combined could potentially promote atherosclerosis. The issue of whether or not testosterone replacement therapy improves outcomes is controversial. Two retrospective studies in men with diagnosed hypogonadism with or without type 2 diabetes have reported significantly improved survival.

Patient Outcome in Pregnancy Requiring Dialysis: A Case Series

The optimal management of pregnant dialysis patients remains a great challenge for nephrologists, end-stage renal disease being a predictor of adverse outcomes in this condition. We report a single-center experience of four patients requiring dialysis during pregnancy, all of which resulted in successful delivery of viable infants. Our success rate may reflect an overall improvement in management of this population, with special attention paid to multiple risk factors. These include blood pressure and volume control, anemia management with erythropoietin analogues, nutritional intake and total dose of dialysis.

Women and ESRD: modalities, survival, unique considerations

Women currently constitute 44.3% of prevalent patients on hemodialysis and 47% of those on peritoneal dialysis. Women on dialysis do not experience the survival benefit seen in those not on dialysis. This loss of a survival advantage is partially related to a lower cardiovascular survival benefit along with a higher noncardiovascular mortality rate compared with their male counterparts. Of particular concern is the markedly higher mortality rates seen in women less than 45 years of age on dialysis. There are several female hormonal abnormalities in the female dialysis patient that can result in menstrual irregularities, anovulation, infertility, sexual dysfunction, early menopause, accelerated bone loss, and potentially increased risk of cardiovascular complications. Although fertility is impaired in dialysis, conception occurs in 1% to 7% of women of childbearing years on dialysis. Hence, all women with a potential for pregnancy should be counseled regarding the risks of pregnancy and contraceptive options. There are specific gynecologic considerations unique to peritoneal dialysis, including hemoperitoneum, decreased fertility, and uterine prolapse. Sexual dysfunction is commonly seen in the female dialysis population and is associated with depression and a lower quality of life; however, despite the high prevalence, it is generally not assessed nor is it treated. Depression is also common in the female dialysis population. Like sexual dysfunction, depression is underdiagnosed and undertreated in this population.

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.

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.

Timing and route of exposure affects crystal formation in melamine and cyanuric exposed male and female rats: gavage vs. feeding

Effects of the dosing matrix and timing on the onset of renal crystal formation were evaluated in male and non-pregnant female rats (Fisher 344) exposed to both melamine (MEL) and cyanuric acid (CYA) for 28 days. Rats were fed ground feed containing 60 ppm MEL and 60 ppm CYA, (5 mg/kg bw/day equivalent), or exposed via oral gavage to carboxymethylcellulose containing 5 mg/kg bw MEL followed by 5 mg/kg bw CYA either consecutively (<1 min apart) or delayed 45 min after MEL. Staggered gavage exposure to MEL/CYA caused extensive renal crystal formation as compared to when the two compounds were administered consecutively or in feed. Treatment related effects included reduced weight gain, feed consumption, and testicular weight and increased kidney weight, water consumption and urine output. Animals from the staggered MEL/CYA gavage exposure group became ill and were removed after 9 days of exposure. Approximately 1 week after the initiation of exposure microscopic urinalysis revealed MEL/CYA crystals in both groups of gavaged animals but not in the MEL/CYA feed treatment groups. Urinary crystals were smaller (10 μm) in animals consecutively gavaged. In contrast the urinary crystals were larger (20-40 μm) and frequently clumped in the animals in the staggered gavage group.