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

[Lower urinary tract symptoms and urinary incontinence in renal transplant recipients and candidates: The French guidelines from CTAFU]

OBJECTIVE

To propose surgical recommendations for the management of lower urinary tract symptoms (LUTS) and urinary incontinence in kidney transplant recipients and candidates.

METHOD

Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU focusing on medical and surgical treatment of LUTS and urinary incontinence in kidney transplant recipients and candidates. References were assessed according to a predefined process to propose recommendations with levels of evidence.

RESULTS

Functional bladder capacity and bladder compliance are impaired during dialysis. LUTS, related to pre-kidney transplantion alterations, frequently improve spontaneously after kidney transplantation. LUTS secondary to benign prostatic hyperplasia (BPH) may be underestimated before kidney transplantation due to oliguria, low bladder compliance and low bladder capacity. In LUTS associated with BPH, anticholinergics require dosage adjustment with creatinine clearance. If surgery is indicated after kidney transplantation, procedure can be safely performed in the early post-transplant course after removal of ureteral stent. Surgical management of urinary incontinence does not seem to be associated with an icreased risk for infectious complications in kidney transplant recipients. Particular attention should be paid to the management of postvoid residual and bladder pressures in case of neurological bladder disease. Optimal care of neurological bladder should be provided prior to transplantation: with a cautious management, and despite an increased occurrence of febrile urinary tract infections, transplant survival is not compromised.

CONCLUSION

These recommendations must contribute to improve the management of lower urinary tract symptoms and urinary incontinence in kidney transplant patients and kidney transplant candidates.

Multifaceted Sexual Dysfunction in Dialyzing Men and Women: Pathophysiology, Diagnostics, and Therapeutics

Patient survival continues to increase with the growing quality of dialysis and management of chronic kidney disease (CKD). As such, chronic therapy must include considerations of quality of life (QOL), and this includes the disproportionate prevalence of sexual dysfunction (SD) in this patient population. This review aims to describe the pathophysiological and the psychosocial causes of SD with regard to renal replacement therapy, particularly hemo- and peritoneal dialysis. The differences in its manifestation in men and women are compared, including hormonal imbalances—and therefore fertility, libido, and sexual satisfaction—the experience of depression and anxiety, and QOL. The impact of comorbidities and the iatrogenic causes of SD are described. This review also presents validated scales for screening and diagnosis of SD in CKD patients and outlines novel therapies and strategies for the effective management of SD. Increased prevalence of CKD invariably increases the number of patients with SD, and it is crucial for health care professional teams to become familiar with the clinical tools used to manage this sensitive and under-quantified field. As a known predictor of QOL, sexual function should become a point of focus in the pursuit of patient-centered care, particularly as we seek to achieve as “normal” a life as possible for individuals who receive dialysis.

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end-stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end-stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left-sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision-making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.

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.

Phosphodiesterase type 5 and cancers: progress and challenges

Cancers are an extraordinarily heterogeneous collection of diseases with distinct genetic profiles and biological features that directly influence response patterns to various treatment strategies as well as clinical outcomes. Nevertheless, our growing understanding of cancer cell biology and tumor progression is gradually leading towards rational, tailored medical treatments designed to destroy cancer cells by exploiting the unique cellular pathways that distinguish them from normal healthy counterparts. Recently, inhibition of the activity of phosphodiesterase type 5 (PDE5) is emerging as a promising approach to restore normal intracellular cyclic guanosine monophosphate (cGMP) signalling, and thereby resulting into the activation of various downstream molecules to inhibit proliferation, motility and invasion of certain cancer cells. In this review, we present an overview of the experimental and clinical evidences highlighting the role of PDE5 in the pathogenesis and prevention of various malignancies. Current data are still not sufficient to draw conclusive statements for cancer patient management, but could provide further rational for testing PDE5-targeting drugs as anticancer agents in clinical settings.

Drug-related problems in patients with erectile dysfunctions and multiple comorbidities

This study was conducted in a tertiary medical center in Kuala Lumpur, Malaysia. A total of 200 erectile dysfunction (ED) patients with 499 cases who had received pharmacological treatments for their ED participated in this study. Types, causes and factors associated with drug-related problems (DRPs) in ED patients with multiple comorbidities were assessed. A total of 244 DRPs with an average of 1.2±2.1 DRPs per patient were identified. Drug interaction contributed the most to DRPs occurrence. There was a significant higher risk of DRPs in patients with benign prostatic hyperplasia, lower urinary tract infection and elderly and end-stage renal disease. Early identification of types of DRPs and factors associated may enhance their prevention and management.

Penile transplantation: an emerging option for genitourinary reconstruction

Penile transplantation is an emerging option for patients with severe genital defects not amenable to traditional reconstructive options. In this article, we discuss the burgeoning problem of severe male genitourinary trauma in the military, the limitations of traditional reconstructive options in addressing these problems, and the potential for penile transplantation to provide improved outcomes. We also review the preclinical research and limited worldwide experience with penile transplantation to date, including lessons learned, and discuss the many important technical, logistical, and ethical considerations pertaining to penile transplantation that must be addressed to maximize the likelihood of successful implementation.

[Sexuality, fertility and pregnancy after kidney transplantation]

AIMS

To describe sexuality and fertility alterations secondary to chronic kidney disease and their outcomes after renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: erectile dysfunction; impotence; sexuality; pregnancy; fertility; renal transplantation. 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 706 articles. After reading titles and abstracts, 76 were included in the text, based on their relevance.

RESULTS

The observed prevalence of erectile dysfunction is high in men with chronic kidney disease. The causes of erectile dysfunction are numbers and its origin is often multifactorial. Most of the time, kidney transplantation improves sexuality and the management of erectile dysfunction in transplanted men is similar to the general population. Improvement in sexuality in men and women after kidney transplantation may conduct to pregnancy. The outcomes of pregnancy after transplantation are quite good in absence of risk factors such as time to pregnancy less than 1 year after transplantation, uncontrolled high blood pressure, and decreased renal function of the graft. Adaptation of immunosuppression may be required to avoid any teratogenicity for the fetus.

CONCLUSION

Kidney transplantation improves sexuality and fertility in men and women with chronic kidney disease.

The role of cGMP and its signaling pathways in kidney disease

Cyclic nucleotide signal transduction pathways are an emerging research field in kidney disease. Activated cell surface receptors transduce their signals via intracellular second messengers such as cAMP and cGMP. There is increasing evidence that regulation of the cGMP-cGMP-dependent protein kinase 1-phosphodiesterase (cGMP-cGK1-PDE) signaling pathway may be renoprotective. Selective PDE5 inhibitors have shown potential in treating kidney fibrosis in patients with chronic kidney disease (CKD), via their downstream signaling, and these inhibitors also have known activity as antithrombotic and anticancer agents. This review gives an outline of the cGMP-cGK1-PDE signaling pathways and details the downstream signaling and regulatory functions that are modulated by cGK1 and PDE inhibitors with regard to antifibrotic, antithrombotic, and antitumor activity. Current evidence that supports the renoprotective effects of regulating cGMP-cGK1-PDE signaling is also summarized. Finally, the effects of icariin, a natural plant extract with PDE5 inhibitory function, are discussed. We conclude that regulation of cGMP-cGK1-PDE signaling might provide novel, therapeutic strategies for the worsening global public health problem of CKD.

Neurological complications in chronic kidney disease

Patients with chronic kidney disease (CKD) are frequently afflicted with neurological complications. These complications can potentially affect both the central and peripheral nervous systems. Common neurological complications in CKD include stroke, cognitive dysfunction, encephalopathy, peripheral and autonomic neuropathies. These conditions have significant impact not only on patient morbidity but also on mortality risk through a variety of mechanisms. Understanding the pathophysiological mechanisms of these conditions can provide insights into effective management strategies for neurological complications. This review describes clinical management of neurological complications in CKD with reference to the contributing physiological and pathological derangements. Stroke, cognitive dysfunction and dementia share several pathological mechanisms that may contribute to vascular impairment and neurodegeneration. Cognitive dysfunction and dementia may be differentiated from encephalopathy which has similar contributing factors but presents in an acute and rapidly progressive manner and may be accompanied by tremor and asterixis. Recent evidence suggests that dietary potassium restriction may be a useful preventative measure for peripheral neuropathy. Management of painful neuropathic symptoms can be achieved by pharmacological means with careful dosing and side effect considerations for reduced renal function. Patients with autonomic neuropathy may respond to sildenafil for impotence. Neurological complications often become clinically apparent at end-stage disease, however early detection and management of these conditions in mild CKD may reduce their impact at later stages.

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 dysfunction in patients with peripheral nervous system lesions

Peripheral nervous system (PNS) disorders may cause sexual dysfunction (SD) in patients of both genders. These disorders include mainly polyneuropathies (particularly those affecting the autonomic nervous system (ANS)) and localized lesions affecting the innervation of genital organs. Impaired neural control may produce a malfunction of the genital response consisting of loss of genital sensitivity, erectile dysfunction, loss of vaginal lubrication, ejaculation disorder, and orgasmic disorder. In addition, there is often a loss of desire which actually has a complex pathogenesis, which goes beyond the mere loss of relevant nerve function. In patients who have no manifest health problems - particularly men with erectile dysfunction - one should always consider the possibility of an underlying polyneuropathy; in patients with SD after suspected denervation lesions of the innervation of genital organs within the lumbosacral spinal canal and in the pelvis, clinical neurophysiologic testing may clarify the PNS involvement. SD can alter self-esteem and lower patients' quality of life; opening up a discussion on sexual issues should be a part of the management of patients with PNS disorders. They may greatly benefit from counseling, education on coping strategies, and specific treatments.