Sexual dysfunction in dialysis patients treated with antihypertensive or antidepressive medications: results from the DOPPS

Sexual Dysfunction Among Patients With Chronic Kidney Disease

Sexual dysfunction (SD) in patients with chronic kidney disease is common and negatively impacts quality of life. SD is often under-appreciated because of overall low awareness. Diagnosis of SD is subjective, and manifestations can be different among men and women. Causes of SD are multifactorial, including psychological disorders, hormonal imbalances, vascular disorders, neurological disorders, and medication side effects. Non-specific approaches to improving sexual function include addressing underlying psychological disorders, promoting lifestyle modifications, optimizing dialysis care, and facilitating successful kidney transplantation, whereas treatment with phosphodiesterase type 5 inhibitor, hormone replacement, and mechanical devices can be offered to patients with specific indications.

Sexual Dysfunction in Women With Kidney Disease

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

Dialysis modality and sexual dysfunction in male patients

Sexual dysfunction is an under-recognised problem in due to very limited number of studies in the literature. This study aims to evaluate the sexual dysfunction related effects of dialysis modality among male patients with chronic renal failure. All patients were asked to complete 2 questionnaires: Hospital Anxiety Depression Scale [HADS] and International Index of Erectile Function [IIEF-5]. A total of 51 patients who completed the questionnaires were included in the study. 31 of them were under haemodialysis (HD) treatment, and 20 were under peritoneal dialysis (PD) treatment. After adjustment for age and HADS score, there was no statistically significant difference between HD and PD groups in terms of the mean IIEF scores (55 vs. 40, p = .058), and the frequency of sexual dysfunction (12.9% vs. 30%, p = .163). Age (r = -0.553), blood pressure (r = -0.299/ -0.374), use of iron (r = -0.333), lipid levels (r = -0.281/ -0.276) and HADS-D score (r = -0.276) inversely associated with IIEF score (p < .05). To conclude, sexual dysfunction is more common in patients who receive PD therapy than those who receive HD therapy. Older age, higher blood pressure, iron treatment, higher lipid levels and the presence of depression were associated with higher prevalance of sexual dysfunction.

Pregnancy and Glomerular Disease: A Systematic Review of the Literature with Management Guidelines

During pregnancy, CKD increases both maternal and fetal risk. Adverse maternal outcomes include progression of underlying renal dysfunction, worsening of urine protein, and hypertension, whereas adverse fetal outcomes include fetal loss, intrauterine growth restriction, and preterm delivery. As such, pregnancy in young women with CKD is anxiety provoking for both the patient and the clinician providing care, and because the heterogeneous group of glomerular diseases often affects young women, this is an area of heightened concern. In this invited review, we discuss pregnancy outcomes in young women with glomerular diseases. We have performed a systematic review in attempt to better understand these outcomes among young women with primary GN, we review the studies of pregnancy outcomes in lupus nephritis, and finally, we provide a potential construct for management. Although it is safe to say that the vast majority of young women with glomerular disease will have a live birth, the counseling that we can provide with respect to individualized risk remains imprecise in primary GN because the existing literature is extremely dated, and all management principles are extrapolated primarily from studies in lupus nephritis and diabetes. As such, the study of pregnancy outcomes and management strategies in these rare diseases requires a renewed interest and a dedicated collaborative effort.

Gonadal dysfunction in chronic kidney disease

Sexual dysfunction is a common finding in both men and women with chronic kidney failure. Common disturbances include erectile dysfunction in men, menstrual abnormalities in women, and decreased libido and fertility in both sexes. These abnormalities are primarily organic in nature and are related to uremia as well as the other comorbid conditions that frequently occur in the chronic kidney failure patient. Fatigue and psycho social factors related to the presence of a chronic disease are also contributory factors. Disturbances in the hypothalamic-pituitary-gonadal axis can be detected prior to the need for dialysis but continue to worsen once dialytic therapy is initiated. Impaired gonadal function is prominent in uremic men while the disturbances in the hypothalamic-pituitary axis are more subtle. By contrast, central disturbances are more prominent in uremic women. Therapy is initially directed towards optimizing the delivery of dialysis, correcting anemia with recombinant erythropoietin, and controlling the degree of secondary hyperparathyroidism with vitamin D. For many practicing nephrologists sildenafil has become the first line therapy in the treatment of impotence. In the hypogonadal man whose only complaint is decreased libido, testosterone may be of benefit. Regular gynecologic follow up is required in uremic women to guard against potential complications of unopposed estrogen effect. Uremic women should be advised against pregnancy while on dialysis. Successful transplantation is the most effective means of restoring normal sexual function in both men and women with chronic kidney failure.

Intensive dialysis and pregnancy

Pregnancy in women with end stage renal disease on renal replacement therapy is uncommon due to the physiologic changes associated with renal failure as well as the complexities and risk involved in managing these patients. As most of these women had long periods of illness with chronic kidney disease, the effects of their chronic illness together with the current societal trends to delay child bearing to a more advanced maternal age can hamper fertility. For those able to conceive, intensified hemodialysis (HD), through longer and/or more frequent dialysis sessions, offers improved maternal and neonatal outcomes. Intensified HD is most conveniently offered in the patient's home, where possible. This review expands the scope of the Implementing Hemodialysis in the Home website and associated supplement published previously in Hemodialysis International and includes information tailored to women of reproductive age. We describe the necessary counseling that women should receive before conception and before intensification of HD, and provide a detailed management strategy that includes nephrologic and obstetric care, should pregnancy occur.

Pregnancy in advanced chronic kidney disease and end-stage renal disease

PURPOSE OF REVIEW

This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy.

RECENT FINDINGS

Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.

SUMMARY

Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.

How Can We Improve the Quality of Life of Dialysis Patients?

As medical advances are made in the care of persons with chronic illnesses including those with end-stage renal disease (ESRD), patients are not only experiencing increasing life expectancy but also bearing the burden of illness and treatment for a longer duration of time. With this in mind, it is increasingly important for health care providers to pay close attention to their individual patient's perceptions of their health, fitness, life satisfaction, and well-being. This assessment of Health-Related Quality of Life (HRQOL) also includes an evaluation of the patient's level of satisfaction with treatment, outcome, and health status, also taking into account their perspective on future prospects. In addition to improving patient-provider communication by helping in the identification and prioritization of problems, it is important to note that high HRQOL has been shown to be associated with better medical outcomes, including reduction in hospitalizations and death. In this review, we outline several validated tools that are used to quantitatively measure HRQOL in the ESRD population and incorporate these instruments in a review of specific, evidence-based measures by which we can measurably improve health-related quality of life in dialysis patients.

Pregnancy in end stage renal disease

The ovulatory menstrual cycle is known to be affected on multiple levels in women with advanced renal disease. Menstrual irregularities, sexual dysfunction, and infertility worsen in parallel with the renal disease. Pregnancy in women with ESRD on dialysis is therefore uncommon. Furthermore, when pregnancy does occur, it can prove hazardous to both mother and baby owing to a multitude of potential complications including accelerated hypertension and preeclampsia, poor fetal growth, anemia, and polyhydramnios. Data are emerging, however, to suggest that pregnancy while on intensified renal replacement regimens may result in better pregnancy outcomes, and emerging trends include the decreased rate of therapeutic abortions probably reflecting a change in counseling practices over time. Nevertheless, a pregnant woman on intensive dialysis requires meticulous follow-up by a dedicated team including nephrology, obstetrics, and a full multidisciplinary staff. In this article, we will address fertility issues in young women with ESRD, review pregnancy outcomes in women on both hemodialysis and peritoneal dialysis, and provide suggestions for the management of the pregnant women on intensive hemodialysis.

Opioid and benzodiazepine use in end-stage renal disease: a systematic review

BACKGROUND AND OBJECTIVES

Chronic pain and psychiatric disorders are common in dialysis patients, but the extent to which opioids and benzodiazepines are used is unclear. We conducted a systematic review to determine the: (1) prevalence of opioid and benzodiazepine use among dialysis patients; (2) reasons for use; (3) effectiveness of symptom control; and (4) incidence of adverse events.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Two authors reviewed all relevant citations in MEDLINE/EMBASE/CINAHL/BIOSIS Previews/Cochrane and hand-searched bibliographies. Studies after 1990 reporting prevalence estimates for opioid and/or benzodiazepine use in ≥50 dialysis patients were included.

RESULTS

We identified 15 studies from 12 countries over 1995 to 2006. Sample size ranged from 75 to 12,782. Prevalence of opioid and benzodiazepine use was variable, ranging from 5 to 36% (95% CI, 4.1 to 45.5%; n=10) and 8 to 26% (95% CI, 7.1 to 27.3%; n=9), respectively. Prevalence was positively correlated with years on dialysis. Five studies reported on the same cohorts but gave different prevalence estimates. One study verified medication use through patient interviews. Reasons for use were reported in one study. Effectiveness of pain control varied from 17 to 38%, and 72 to 84% of patients with significant pain had no analgesia (n=2). No study rigorously examined for adverse events.

CONCLUSIONS

The prevalence of opioid and benzodiazepine use in dialysis patients is highly variable between centers. Further information is needed regarding the appropriateness of these prescriptions, adequacy of symptom control, and incidence of adverse effects in this population.

Measurements of serum pituitary-gonadal hormones and investigation of sexual and reproductive functions in kidney transplant recipients

Objective. To investigate changes in serum pituitary-gonadal hormones and restoration of sexual and reproductive functions after successful kidney transplantation. Patients and Methods. Serum pituitary-gonadal hormones before and after kidney transplantation were measured in 78 patients with end-stage renal disease (ESRD) and in 30 healthy adults. Pre- and postoperative semen specimens of 46 male recipients and 15 male controls were collected and compared. Additional 100 married kidney transplant recipients without children were followed up for 3 years to observe their sexual function and fertility. Results. Serum PRL, LH, and T or E₂ levels gradually restored to the normal ranges in all kidney transplant recipients, and sperm density, motility, viability, and morphology significantly improved in the male recipients 4 months after successful kidney transplantation (P < .05). Thirty-three male recipients (55.93%) reobtained normal erectile function, and 49 kidney transplant recipients (61.25%) had children within the 3-year follow-up period. Conclusion. Successful kidney transplantation could effectively improve pituitary-gonadal hormone disturbance and sexual and reproductive dysfunctions of ESRD patients.

Planning a social activity to improve psychological well-being and quality of life of hemodialysis patients: a pilot study

We aimed to investigate the impact of social activity on anxiety-depression, self-esteem and quality of life in hemodialysis patients. Ninety-one patients were recruited to the current study. Of these, 31 patients wanted to take part in a theater play, while 60 patients (group C) did not. Thirty-one patients were randomly assigned to two groups: Group A (N = 15) started activities immediately and group B (N = 16) was assigned to a waiting list to be included in the activity of theater acting four months later. Beck Depression Inventory, Beck Anxiety Inventory, Rosenberg Self-esteem Scale and World Health Organization Quality of Life Scale short form (WHOQOL-BREF) were used to compare psychological parameters and quality of life of the groups before and after the social activity. The patients who were younger, more literate, and wealthier, had longer disease duration, and who were feeling physically and psychologically well, were willing to participate in social activity. The impact of social activity was evaluated between group A and C. After the social activity, there were significant differences in terms of depression (P = 0.008), self-esteem (P = 0.003), and physical (P = 0.04) and psychological (P = 0.05) sub-dimensions of quality of life between the groups. The depression score of the patients in group A decreased while their self-esteem increased, but the increase in the physical and psychological sub-dimension scores of quality of life scale did not reach statistical significance. This pilot study showed that social activity primarily improved depression and self-esteem in hemodialysis patients.

Sexual dysfunction in peritoneal dialysis patients

BACKGROUND/AIMS

Sexual dysfunction in patients undergoing peritoneal dialysis (PD) is highly prevalent, but studies addressing this issue are scarce. This cross-sectional study aims to evaluate sexual dysfunction and the determinants among PD patients.

METHODS

All chronic PD patients in 8 PD centers were asked to complete a self-reported questionnaire - the International Index of Erectile Function (IIEF) for men and the Index of Female Sexual Function (IFSF) for women - so that sexual function could be assessed. They also answered the Beck Depression Inventory (BDI) to measure depressive symptoms.

RESULTS

Among 294 patients invited for study, 54 men (mean age 48.8 +/- 10.8 years) and 45 women (mean age 43.6 +/- 7.4 years) were willing to and completed the sexual function questionnaires. The median IIEF score in the men was 56.25. The prevalence of erectile dysfunction, identified by the score in erectile domain of IIEF <or=25, was 51.9%. Older age and higher fasting glucose levels were independently associated with a decreased IIEF score. In women, IFSF score (with a median 27) was significant lower than in healthy peri- or postmenopausal control women. Factors of higher BDI score, receiving automated PD, and older age independently associated with a decreased IFSF score.

CONCLUSIONS

Sexual dysfunction is clinically relevant and multi-dimensional among PD patients. Gender differences exist in the attributing factors of sexual functioning. These warrant more awareness and investigation in the global health care of dialysis patients.