Erectile dysfunction in renal failure and transplant patients

Current treatment options for erectile dysfunction in kidney transplant recipients

INTRODUCTION

Erectile dysfunction (ED) and kidney dysfunction share common risk factors linked to conditions involving endothelial impairment, such as coronary artery disease, dyslipidemia, diabetes mellitus, hypertension, smoking, and obesity. Men with chronic kidney disease experience a high incidence and prevalence of ED. While a functional renal graft can alleviate the issue for some patients, a significant portion of recipients still experience ED (20%-50%).

OBJECTIVES

This narrative review describes the variety of current treatments modalities on ED in kidney transplant recipients (KTRs) and their clinical outcomes.

METHODS

MEDLINE, Web of Science, PubMed, and Google Scholar were used to find eligible articles pertaining to the treatment options of ED in KTRs. A total of 64 articles were evaluated.

RESULTS

In KTRs, ED stems from a multifaceted etiology: anxiety, drug side effects, interference with penile vascularity, or the response of cavernosal muscle to neurotransmitters, along with changes in the endocrine milieu. A diverse range of treatments to restore erectile function has proven to be safe and effective for KTRs. Options include drug therapy, surgical interventions, intracavernosal injection therapies, vacuum erection devices, and extracorporeal shockwave therapy.

CONCLUSION

The initial treatment approach may involve the use of a phosphodiesterase type 5 inhibitors at a low dosage, especially if testosterone-circulating levels align with the diagnosis of hypogonadism. The consideration of a combination therapy involving testosterone and phosphodiesterase type 5 inhibitors should be contemplated due to the associated beneficial effects. Extracorporeal shockwave therapy has shown positive short-term clinical and physiological effects on erectile function in patients who did not respond to first-line treatments, resulting in spontaneous erections sufficient for sexual penetration in 50% of cases. Penile implants should be considered as third-line options based on specific patient needs and compliance with clinical conditions.

Hypogonadism in hemodialysis patients: a first snapshot of prevalence and predictive factors in Tunisian patients

Introduction

patients with chronic kidney disease commonly exhibit testosterone deficiency. We aimed through the current study to assess the prevalence and the risk factors of hypogonadism in male patients on hemodialysis and to establish their relationship with erectile dysfunction.

Methods

we conducted a cross-sectional study based on data collected from hemodialysis male patients. Sociodemographic and clinical data as well as hormone levels were collected from January 2017 to December 2017. Sex hormones were measured in all subjects. The International Index of Erectile Function was used to evaluate erectile dysfunction. Data were expressed as mean ± standard deviation, and frequencies (number), and proportions (%).

Results

one hundred and ten: 55 male hemodialysis patients were recruited. The level of follicule-stimulating hormone, luteinizing hormone and prolactin were high and the level of testosterone was low in the hemodialysis group. Hypogonadism was significantly linked to advanced age, anemia, and absence of treatment by erythropoietin. The incidence of erectile dysfunction was high and the erectile function score was low. Testosterone significantly dropped in patients with erectile dysfunction.

Conclusion

hypogonadism was so prevalent in the hemodialysis men and it was associated with erectile dysfunction. Future studies are needed to determine the effect of testosterone therapy on erectile dysfunction.

Mechanisms Suggesting a Relationship between Vitamin D and Erectile Dysfunction: An Overview

Vitamin D deficiency (VDD) and erectile dysfunction (ED) heavily burden the male population. The higher prevalence of both conditions in the elderly suggests a possible relationship between the two conditions. In addition, in vitro, animal, and human studies have revealed several mechanisms that may relate VDD to ED. The main mechanism by which vitamin D might exert its action on sexual function appears to be through the regulation of endothelial function. Indeed, VDD correlates with several markers of endothelial function. The action of vitamin D on the endothelium would be exercised both indirectly through its intervention in inflammatory processes and through the production of oxygen free radicals, and directly through the regulation of vascular stiffness, the production of nitric oxide, and the regulation of vessel permeability. Furthermore, the ubiquitous distribution of the vitamin D receptor in the human body means that this hormone can also exert a beneficial effect on erectile function by interfering with those comorbidities significantly associated with ED, such as hypertension, diabetes mellitus, hypercholesterolemia, chronic kidney disease, and hypogonadism. In this review, we thoroughly and carefully presented the evidence and mechanisms that would appear to relate vitamin D levels to erectile function. Furthermore, we have summarized the meta-analytic evidence for and against this association to provide a true representation of this topic. Data published to date suggest that low levels of vitamin D could contribute to worsening erectile function through several mechanisms. Therefore, vitamin D levels should be measured in patients with ED and maintained at adequate levels by specific supplementation in case of deficiency. However, the low quality and heterogeneity of clinical trials evaluating the effects of vitamin D administration on erectile function and ED-associated comorbidities do not allow for a univocal conclusion, and indicate the need for further studies to analyze these aspects.

The Impact of Nutritional Status on Sexual Function in Male Kidney Transplant Recipients

Background and Objectives: Sexual function and nutritional status assessment are relevant topics in chronic kidney disease patients. This study was designed to investigate whether bioelectrical impedance analysis-derived nutritional parameters, nutritional biomarkers, and handgrip strength influence sexual function and to analyze the changes in sexual function after kidney transplantation in men. Materials and Methods: Fifty-four men with kidney failure who had undergone replacement therapy entered the study. In addition, sexual function and nutritional status were evaluated before kidney transplantation and 12 months after. We used the International Index of Erectile Function, bioelectrical impedance analysis, three different malnutrition screening tools, handgrip strength, and anthropometric measurements. The demographic profiles and biochemical nutritional markers were collected. Results: Sexual inactivity was associated with a lower phase angle (6 (1) vs. 7 (1), p < 0.05) and a higher fat mass index (7 (5) vs. 3 (4), p < 0.05). Normal erectile function before kidney transplantation was significantly related to higher fat-free mass (67 (11) vs. 74 (7), p < 0.05) and lean mass (64 (10) vs. 70 (7), p < 0.05). The improvement in erectile function after kidney transplantation was nonsignificant (44% vs. 33%, p = 0.57). Only a weak association between muscle mass and sexual desire 12 months after kidney transplantation was found (rS = 0.36, p = 0.02). Further, linear regression revealed that higher muscle mass could predict better sexual desire after kidney transplantation following adjustment for age, estimated glomerular filtration rate, and diabetes mellitus. Conclusions: Kidney transplantation did not significantly improve erectile dysfunction in our study population. Sexual desire and intercourse satisfaction are the most affected domains in patients with chronic kidney disease. Higher muscle mass predicts higher sexual desire after kidney transplantation. Higher levels of fat-free and lean mass are associated with normal erectile function before kidney transplantation.

Sexuality, Contraception, and Pregnancy in Kidney Transplantation

Sexual dysfunction is defined as any abnormality in sexual arousal, libido, intercourse, orgasm, or satisfaction. It is prevalent in patients with chronic and end-stage kidney disease, with 70% to 84% of men and 30% to 60% of women reporting some form of sexual dysfunction. Although kidney transplantation improves the overall quality of life for patients receiving dialysis, it can have unexpected effects on sexual function owing to the use of immunosuppressive medications and comorbid illnesses. It is important to recognize these adverse effects and pre-emptively discuss them with patients to help mitigate consequent psychosocial discontent. Women of reproductive age will often recover fertility after kidney transplantation and therefore need to be empowered to prevent unwanted pregnancies and plan for a safe pregnancy if desired. Complications such as preeclampsia, pregnancy-induced hypertension, gestational diabetes, ectopic pregnancy, still birth, low birth weight, and preterm birth are more common in pregnant women with a kidney transplant. Careful monitoring for infection, rejection, and immunosuppressive dose adjustment along with comanagement by a high-risk obstetrician is of utmost importance. Breast-feeding is safe with most immunosuppressive medications and should be encouraged.

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.

Prevalence of Erectile Dysfunction in Patients With End-Stage Renal Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Erectile dysfunction (ED) is an under-recognized clinical entity in men with end-stage renal disease (ESRD), and studies on renal transplant recipients, patients on dialysis, and patients starting dialysis report different prevalence rates and severity of ED among these groups.

AIM

To determine the prevalence and severity of ED in patients with ESRD, assessed with the International Index of Erectile Function-15 and International Index of Erectile Function-5.

METHODS

We performed a systematic review and meta-analysis of observational studies assessing the prevalence of ED in ESRD individuals. (PROSPERO ID: CRD42020182680). Records were identified by search in MEDLINE, Scopus, and CENTRAL databases and sources of gray literature until July 2020. We conducted a random-effects meta-analysis of proportions (double arcsine transformation).

OUTCOMES

We included 94 studies with 110 patient group entries and a total of 10,320 ESRD male individuals with a mean age of 48.8 ± 14.25 years.

RESULTS

Overall, 7,253 patients experienced ED. We estimated an overall pooled ED prevalence of 71% (95% CI: 67-74%, I² = 92%). In the subgroup analyses, the pooled prevalence was 59% (95% CI: 53-64%, I² = 92%) among renal transplant recipients, 79% (95% CI: 75-82%, I² = 86%) in patients on hemodialysis, 71% (95% CI: 58-83%, I² = 86%) in patients on peritoneal dialysis, and 82% (95% CI: 75-88%, I² = 0%) in patients with ESRD starting dialysis. The prevalence of the severity of ED was also estimated. Further assessment of heterogeneity was conducted via sensitivity analysis, cumulative meta-analysis, and meta-regression of significant risk factors.

CLINICAL TRANSLATION

Despite its high prevalence in patients with ESRD, ED constitutes an underestimated and taboo subject in this group. Therefore, arousing clinical concern among healthcare providers involved in ESRD management is more than necessary to screen and treat ED in patients receiving renal replacement therapy.

STRENGTHS & LIMITATIONS

We estimated ED solely for ESRD, included the largest number of patients compared with previous studies and estimated ED prevalence as per severity and renal replacement therapy subgroups. Contrary, because we restricted our eligibility criteria to the International Index of Erectile Function, some studies assessing ED prevalence with other validated tools were not included in this meta-analysis. Moreover, the levels of heterogeneity among studies remained high after sensitivity and meta-regression analyses, and for some moderators, the results of the meta-regression might have been underpowered.

CONCLUSIONS

ED is highly prevalent in patients with ESRD irrespective of the type of renal replacement therapy, thereby warranting clinical attention. Pyrgidis N, Mykoniatis I, Nigdelis MP, et al. Prevalence of Erectile Dysfunction in Patients With End-Stage Renal Disease: A Systematic Review and Meta-Analysis. J Sex Med 2021;18:113-120.

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.

Care Needs for Organ Transplant Recipients Scale: Development and psychometric testing

BACKGROUND

Needs assessment can determine how large the gap is between needs and available services; however, no tools are available to assess the unmet needs of renal transplant recipients.

OBJECTIVES

The aim of this study was to develop the Care Needs for Organ Transplant Recipients Scale (CNOTRS) and examine its psychometric properties.

DESIGN

A cross-sectional design for instrument development and psychometric testing.

PARTICIPANTS

In total, 217 renal transplant recipients were recruited through convenience sampling.

METHODS

An initial 36-item CNOTRS was developed after a comprehensive literature review. After the CNOTRS was tested through content validity and face validity, the factor structure was explored using exploratory factor analysis (EFA). Convergent validity was examined using Pearson's correlation between the CNOTRS and Hospital Anxiety and Depression Scale (HADS). Known-group validity was tested by comparing CNOTRS scores of patients grouped based on whether they had experienced complications or rejection.

RESULTS

Twenty-eight items with three factors (namely daily care and social interaction needs, psychological needs, and health system and service needs) were identified in EFA by parallel analysis and Velicer's MAP test. The psychological needs domain had a stronger positive correlation with the HADS than the other two domains. The known-group validity was supported as a significant association between complications or rejection occurrence and unmet needs. The Cronbach's α of the CNOTRS was 0.94.

CONCLUSIONS

The CNOTRS demonstrated satisfactory reliability and validity to assess the care needs for renal transplant recipients and can assist health care professionals to tailor more personalised care for their individual needs.

Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study

BACKGROUND

The effects of kidney transplantation on male sexual function are controversial.

AIM

To evaluate the impact of kidney transplantation on erectile and ejaculatory function and to assess a possible correlation between some selected characteristics of patients and their erectile and ejaculatory function after renal transplantation.

METHODS

An observational retrospective analysis was conducted on male patients who had undergone kidney transplantation from January 2009 to April 2019. A prospectively maintained database was used to collect all data. Patients were evaluated before kidney transplant and 6 and 12 months after kidney transplant. Male patients undergoing renal transplantation for any cause who were sexually active with a stable partner were included in the study.

OUTCOMES

The main outcome measures included the International Index of Erectile Function (IIEF-15) and the 4-item version of Male Sexual Health Quality-Ejaculation Disorders (MSHQ-EjD Short Form) questionnaires. The first 3 questions of the MSHQ-EjD Short Form were used to assess the ejaculatory function, whereas the fourth question was used to evaluate the ejaculation bother.

RESULTS

A total of 95 patients were eligible in the study. The evaluation of sexual function was available in 56 patients (58.9%). Mean IIEF-15 significantly decreased at 6 months (P < .001) remaining unchanged at 12 months (P = .228). Mean MSHQ-EjD Short Form (1-3) significantly decreased at 6-month follow-up (P < .001) and at 12-month follow-up (P = .024). Mean MSHQ-EjD Short Form (4) was significantly increased compared with the baseline at both 6 and 12 months (P < .05). IIEF-15 was significantly related to the MSHQ-EjD Short Form at 6-month and 12-month follow-up (P < .001). Age, diabetes, hypertension, smoking, pretransplantation testosterone, time for transplantation, baseline IIEF-15, and baseline MSHQ-EjD Short Form (1-3) were significantly associated (P < .05) with both IIEF-15 and the MSHQ-EjD Short Form (1-3) at 6-month and 12-month follow-up after kidney transplantation.

CLINICAL IMPLICATIONS

Improvement of knowledge regarding the effects of kidney transplantation on sexual function and about the patient characteristics related to sexual health after transplantation.

STRENGTH & LIMITATIONS

This is the first article that analyzes in depth the ejaculatory function in patients who had undergone kidney transplantation assessing ejaculation with a validated questionnaire. The main limitation is the retrospective design of the study.

CONCLUSION

Kidney transplantation appears to have a negative impact on sexual health, significantly worsening both erectile and ejaculatory functions. Age, diabetes, hypertension, smoking, pretransplantation testosterone levels, time for transplantation, as well as erectile and ejaculatory function before transplant were significantly related to erectile and ejaculatory functions after renal transplantation. Spirito L, Manfredi C, Carrano R, et al. Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study. J Sex Med 2020;17:2191-2197.

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.

Is There an Association Between Vitamin D Deficiency and Erectile Dysfunction? A Systematic Review and Meta-Analysis

Erectile dysfunction (ED) is found very frequently in the male population, in particular in its arteriogenic form, which also represents an important predictor of cardiovascular diseases (CVDs). Some evidence suggests that vitamin D could play a role in cardiovascular risk prevention thanks to its ability to reduce endothelial damage, oxidative stress, the production of inflammatory cytokines, and dyslipidemia. Since ED and CVDs have pathogenic mechanisms in common, numerous studies have evaluated a possible association between vitamin D deficiency (blood concentrations of 25-hydroxyvitamin D < 20 ng/mL) and ED, but with conflicting results. This meta-analysis was therefore performed to clarify the discrepancy of the data so far published. To achieve this, articles have been searched extensively in the Pubmed, MEDLINE, Cochrane, Academic One Files, Google Scholar, and Scopus databases from the first day they were created until January 2020. The search strategy included pertinent Medical Subjects Headings (MeSH) terms. Of the 431 items retrieved, only eight observational studies were included, resulting in a total sample size of 4055 patients. It was found that 25-hydroxyvitaminD (25(OH)D) levels did not show any significant difference between patients with and without ED. However, when patients with vitamin D deficiency only were taken into account, the international index of erectile function (IIEF) score for erectile dysfunction was significantly worse than in controls. This association remained significant even when eugonadal-only patients were considered. Finally, we found that eugonadal patients with severe ED have lower 25(OH)D₃ levels than patients with mild ED. In conclusion, this meta-analysis suggests an association between vitamin D deficiency and the presence of severe forms of ED, independent of testicular function.