The D&T Report

Abstract

Dialysis & TransplantationVolume 37, Issue 8 p. 308-312 D&T ReportFree Access The D&T Report First published: 25 August 2008 https://doi.org/10.1002/dat.20255AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Dialysis and sex: It sounds like the setup to a bad joke, and maybe that is the problem. After all, end-stage renal disease (ESRD) is a serious illness, and dialysis is an extreme therapy, so sex and other quality-of-life issues are often considered secondary. But dialysis is such an all-consuming part of a person's life that his or her ability to live as normally as possible between sessions can be acutely important—especially because people can be on dialysis for years. Sexual difficulties in this patient population have been well documented in research settings. Depending on the study and the definition of sexual dysfunction used, the prevalence ranges from 17% to as high as 70%. Many patients say they have no sexual activity at all. Not surprisingly, lack of sexual function is also closely associated with emotional problems such as depression, and it can have a heavy impact on the patient's quality of life. For example, Francisco Martin-Diaz, MD, of the Perpetua Socorro Clinic in Alicante, Spain, and coauthors found that 47% of 103 men on hemodialysis no longer engaged in sex. Those patients tended to be older, have more comorbidities, and have been on dialysis longer than men who were still sexually active.1 Of 148 male hemodialysis patients with a mean age of 46 years studied by Süleyman Türk, MD, of Selcuk University Medical School in Istanbul, Turkey, and his coauthors, 104 (70%) had erectile dysfunction (ED). The presence of ED correlated with lower quality of life as measured in scores of physical and emotional functioning. Anemia also showed a negative correlation with quality of life.2 Similarly, Thomas E. Steele, MD, MPH, professor of psychiatry, and colleagues at the Medical University of South Carolina in Charleston, studied 68 male and female The emotional fallout of kidney disease and the stress and depression associated with undergoing dialysis probably exacerbate any physiological causes of sexual problems. patients on chronic peritoneal dialysis and found that 43 (63%) of those individuals reported “never having intercourse,” yet 50% claimed that they did want a sex life. Like the patients cited by Türk et al., the patients who never had intercourse had higher levels of depression and anxiety, more physical symptoms, and poorer overall self-reported quality of life than did patients who had sex at least twice a month.3 More Than a Headache Kidney disease and sexual dysfunction share an intimate relationship with several other factors—most notably, vascular disease, depression, and hormonal dysregulation, says Steven Weisbord, MD, assistant professor of medicine, Renal and Electrolyte Division, University of Pittsburgh School of Medicine. Sexual complaints may have “multiple potential mediators,” he says. Sexual dysfunction is common among people with kidney disease, in part because the two share several etiologies. Vascular disease, hypertension, and diabetes—three conditions closely associated with kidney disease—are also linked to loss of libido among women and are among the most common causes of ED in men. ED appears a reliable harbinger of future cardiovascular events and indicates a more thorough investigation for cardiovascular risk factors is needed.4 What's more, the endocrine and metabolic derangements associated with ESRD and uremia affect so many organ systems and bodily functions that it really is not surprising that they would impair a patient's ability to engage in sex as well. The disease stage at which these problems first develop is still unclear. What is known is that the cyclic release of gonadotropin-release hormone (GnRH) by the hypothalamus somehow becomes disordered, which in turn interrupts the systematic release of luteinizing hormone (LH) by the pituitary gland. Reduced clearance of GnRH and LH leads to disruption of normal feedback mechanisms, hyperprolactinemia, and elevated endorphin levels, all thought to contribute to this state of affairs, although the exact sequence of events is not known. The end result, however, is well known: men develop testicular atrophy and hypogonadism, and women can experience uterine bleeding and menstrual abnormalities. Both sexes develop fertility problems: men, from hypospermatogenesis, and women, from anovulation. Children with chronic kidney disease (CKD) often experience delayed puberty.5,6 These problems begin well before patients reach the point of needing dialysis. Of 214 men studied by investigators in the United Kingdom, 96 were in the low-clearance stage of the disease and 34 had functioning transplants. The remaining 84 were receiving either hemodialysis or peritoneal dialysis. Yet of the entire group, 121 patients (57%) had lownormal to very low levels of testosterone, demonstrating that hypogonadism extends across stages of kidney disease. The authors suggested that low testosterone levels may also contribute to the osteoporosis that is so common in kidney disease.7 Another recent study suggests that sexual difficulties and osteoporosis (or at least bone and joint pain) may overlap in dialysis populations. With Dr. Weisbord as senior author, Myra Carreon, MD, resident in internal medicine, and her colleagues at the University of Pittsburgh School of Medicine, measured the frequency of bone and joint pain as well as sexual arousal difficulties in 50 men and 25 women on chronic hemodialysis. Twenty-eight (37%) of the patients reported some type of bone or joint pain, with 20 rating the pain as moderate to severe. Among the men, 19 (38%) had some trouble with sexual arousal, with 15 of those patients describing it as moderate to severe. These findings don't unequivocally establish a relationship between hypogonadism and bone and joint problems, but the investigators made another important discovery: Only 48% of the patients who complained of pain received analgesics and only 21% of the men who reported ED received medical therapy such as sildenafil (Viagra). The researchers concluded that both sets of problems are prevalent yet undertreated.8 The emotional fallout from kidney disease and the stress and depression associated with undergoing dialysis probably exacerbate any physiological causes of sexual problems. In fact, some authors believe that the simple loss of interest on the part of male and female patients alike is the largest single manifestation of sexual dysfunction in this population.9,10 Treatment Treatment challenges are threefold: Patients first must acknowledge the condition and call it to their doctors' attention; clinicians must take the problem seriously and perform a thorough assessment; and effective remedies, if they exist, must be implemented. Patients are often reluctant to mention sexual difficulties in the first place, says Dr. Weisbord. Along with the usual bashfulness most people have about this subject, renal patients may believe that it's just part of growing old, an inevitable result of their disease, or simply not important compared with their other medical problems. The dialysis setting itself exacerbates the problem because it is hardly the environment most conducive to mentioning sexual concerns. Then there is the problem of getting clinicians to recognize the problem and appreciate its effects on their patients' quality of life. In one study Dr. Weisbord and colleagues administered the Dialysis Symptom Index, a 30-item survey of symptoms and their severity, to 75 patients during a dialysis session. Immediately after the patients completed the questionnaire, their renal providers were asked for their assessments of the patients' complaints. Sexual dysfunction was one of 25 symptoms, including pain, sleep disturbances, and psychological distress, that were significantly underestimated by the 18 clinicians participating in the study. The authors concluded that “renal providers are largely unaware of the presence and severity of symptoms in patients who are on maintenance hemodialysis.”11 Dr. Weisbord recommends that renal providers add an assessment of sexual function to their patient workups, investigate and correct any obvious causes, and (when indicated) refer the patient to a gynecologist, endocrinologist, or urologist. He also suggests that dialysis patients be offered a discreet way of conveying sexual concerns to their clinicians, perhaps by having them fill out a form that could then be given to the doctor, who could follow up in a more private setting. Limited data suggest that correction of physiologic abnormalities may help to restore sexual function, at least in men. There is evidence that hypogonadal men who take androgens experience improved libido and virility into the low-normal range.12 Male renal patients with ED also frequently respond to sildenafil or similar drugs. And in a small study, Taiwanese investigators found that erythropoietin improved androgen levels, libido, and sexual function in male hemodialysis patients with uremia and low testosterone levels when compared with CKD patients who were not on dialysis.13 Those authors concluded that aggressive dialysis also helped their patients' sex lives. Other experts, however, are not so sure about the impact of dialysis on sexual performance. “There is no clear evidence to my mind that dialysis has a meaningful impact on sexual dysfunction,” Dr. Weisbord says. “It's biologically plausible if the hormonal dysfunction and metabolic abnormalities are corrected with dialysis, but I'm not aware of any studies demonstrating that.” So far, women have been underrepresented in any study of sexuality and kidney disease, although it's clear that women find these problems as distressing as men do. Dr. Weisbord suggests that women have received less attention because there is no “magic bullet” for them like there is for men, in the form of sildenafil. Another possibility is that male physicians simply may be less comfortable discussing these issues with female patients, or vice-versa. Bottom Line Sexual dysfunction is a common complaint among patients with kidney disease-especially when they are on dialysis. The available treatments may not be perfect, but they can help when administered appropriately. Clinicians should encourage their patients to mention these problems when they occur and should provide a supportive and confidential setting in which they can be discussed. They should also include sexual dysfunction in their patient evaluations. Sexual problems among women with kidney disease need more attention from researchers as well as clinicians. D&T Briefs ASSOCIATIONS NKF Drops Fluoridation Support The National Kidney Foundation (NKF) has withdrawn its support of water fluoridation, citing a 2006 National Research Council (NRC) report that indicated kidney patients are more susceptible to fluoride's bone- and toothdamaging effects. The NRC reports that people with impaired kidneys retain more fluoride and risk skeletal fluorosis (an arthritic-type bone disease), fractures, and severe enamel fluorosis, which may increase the risk of dental decay. The NKF's former fluoridation position statement also carried cautions. The NKF advised monitoring children's fluoride intake along with that of patients with chronic kidney impairment, patients with excessive fluoride intake, and patients with prolonged disease. But in April, the NKF reported that “exposure from food and beverages is difficult to monitor, since FDA food labels do not quantify fluoride content.” Further, the association now says, “Individuals with CKD should be notified of the potential risk of fluoride exposure.” For more information, visit www.fluoridealert.org/health/kidney/index.html. PATIENTS Patient Essay Contest Open for Entries The 2008 Annual KidneyTimes.com essay contest, sponsored by the Renal Support Network (RSN), is calling for entries. This year's theme is “Funding a Dream: Giving Back.” In no more than 750 words, entrants are asked to imagine what they would choose to do to inspire or help fellow kidney patients. All essays will be judged by a panel of writers and kidney patients. The judges will evaluate appropriateness to the theme, originality of idea, creativity, and technical expertise. All people who have been diagnosed with chronic kidney disease and who love to write are encouraged to enter. Entries must be received by August 31 and can be submitted by mail, e-mail, or fax. Entrants must include their complete name, address, phone number, and e-mail address. Cash prizes of $500, $300, and $100 will be awarded to the top three entries. All winners will be featured on the front page of KidneyTimes.com and featured in RSN's publication Live & Give. For more information and contest rules, visit www.kidneytimes.com or www.rsnhope.org. BUSINESS DialysisPPO Files Provisional Patent Application DialysisPPO, a Pennsylvania Corporation providing cost-containment tools to the health plan market, has filed a provisional patent application covering its business method that enables health plans to significantly lower their exposure to the high cost of dialysis services while simultaneously improving the benefits to plan participants. The business method patent enables health plans to lower their annual costs by as much as 90% and increase the level of benefits for plan members with ESRD. Plan members diagnosed with ESRD must either receive a kidney transplant or undergo a regular course of life-sustaining dialysis treatments. ESRD is the only diagnosis in all of American healthcare that entitles a person to Medicare coverage regardless of his or her age. Unfortunately for health plans, Medicare does not become the primary payer for approximately 3 years, leaving health plans responsible for treatments that can cost in excess of $600,000 per person annually. New Microsoft HealthVault Applications and Devices Unveiled At the second Microsoft HealthVault Solutions Conference, a range of health technology companies introduced more than 40 new online health applications and devices designed to improve information sharing between patients and physicians; promote fitness, wellness, and workplace productivity; and give people online tools to manage their health and that of their families as effectively as possible. These applications and devices take advantage of new features in HealthVault, Microsoft's consumer health platform. Several participating companies are introducing new health technology solutions that transfer information between a patient's electronic medical record or clinical record and the patient's HealthVault account. This connection opens new channels of online communication between patients and physicians and provides greater opportunity to share a patient's complete health information for more informed care decisions. For more information on HealthVault and third-party applications and devices, visit http://www.microsoft.com/presspass/events/healthvault/default.mspx. WellCentive Launches Secure Messaging Platform WellCentive announced the launch of the WellCentive Secure Messaging System, which is now a part of its online patient registry system for healthcare providers. Atlanta-based WellCentive is one of 12 organizations selected from across the United States to help the Centers for Medicare and Medicaid Services (CMS) test direct clinical outcomes reporting from healthcare registries for the CMS Physician Quality Reporting Initiative program. The WellCentive Secure Messaging System allows patient information and related documents to be securely and quickly shared among physicians and other healthcare providers. Additionally, the WellCentive Patient Portal allows patients to access their own healthcare information from home and use the secure messaging system to discuss health matters with their physicians at their convenience. The WellCentive Secure Messaging System is included with each organization's WellCentive registry system at no additional charge. For more information, visit www.wellcentive.com. References 1 Martin-Diaz F, Reig-Ferrer A, Ferrer-Cascales R. Sexual functioning and quality of life in hemodialysis male patients [in Spanish]. Nefrologia. 2006; 26: 452– 460. 2 Türk S, Guney I, Altintepe L, Tonbul Z, Yildiz A, Yeksan M. Quality of life in male hemodialysis patients. Role of erectile dysfunction. Nephron Clin Pract. 2004; 96: c21- c27. 3 Steele TE, Wuerth D, Finkelstein S, et al. Sexual experience of the chronic peritoneal dialysis patient. J Am Soc Nephrol. 1996; 7: 1165– 1168. 4 Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, Coltman CA. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005; 294(23): 2996– 3002. 5 Holley JL. The hypothalamic-pituitary axis in men and women with chronic kidney disease. Adv Chronic Kidney Dis. 2004; 11(4): 337– 341. 6 Handelsman DJ, Dong Q. Hypothalamo-pituitary gonadal axis in chronic renal failure. Endocrinol Metab Clin North Am. 1993; 22: 145– 161. 7 Albaaj F, Sivalingham M, Haynes P, et al. Prevalence of hypogonadism in male patients with renal failure. Postgrad Med J. 2006; 82: 693– 696. 8 Carreon M, Fried LF, Palevsky PM, Kimmel PL, Arnold RM, Weisbord SD. Clinical correlates and treatment of bone/joint pain and difficulty with sexual arousal in patients on maintenance hemodialysis. Hemodial Int. 2008; 12: 268– 274. 9 Toorians AW, Janssen E, Laan E, et al. Chronic renal failure and sexual functioning: clinical status versus objectively assessed sexual response. Nephrol Dial Transplant. 1997; 12: 2654– 2663. 10 Messina LE, Claro JA, Nardozza A, Andrade E, Ortiz V, Srougi M. Erectile dysfunction in patients with chronic renal failure. Int Braz J Urol. 2007; 33: 673– 678. 11 Weisbord SD, Fried LF, Mor MK, et al. Renal provider recognition of symptoms in patients on maintenance hemodialysis. Clin J Am Soc Nephrol. 2007; 2: 960– 967. 12 Johansen KL. Treatment of hypogonadism in men with chronic kidney disease. Adv Chronic Kidney Dis. 2004; 11: 348– 356. 13 Wu SC, Lin SL, Jeng FR. Influence of erythropoietin treatment on gonadotropic hormone levels and sexual function in male uremic patients. Scand J Urol Nephrol. 2001; 35: 136– 140. Volume37, Issue8August 2008Pages 308-312 ReferencesRelatedInformation