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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 500-506
Prevalence and associated risk factors of male erectile dysfunction among patients on hemodialysis and kidney transplant recipients: A cross-sectional survey from Sudan


1 Department of Nephrology, Khartoum Teaching Hospital, Federal Ministry of Health, Khartoum, Sudan
2 National Center for Dialysis and Kidney Transplantation, Khartoum, Sudan
3 Dr. Salma Center for Dialysis and Kidney Transplantation, Khartoum, Sudan
4 Faculty of Medicine, Department of Community Medicine, University of Khartoum, Khartoum, Sudan

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Date of Web Publication24-Apr-2013
 

   Abstract 

Male erectile dysfunction (ED) is an important issue worldwide occurring in 5-69% of men in community-based studies. It is more common in patients with chronic kidney disease (CKD) and those on peritoneal as well as hemodialysis (HD), occurring in more than 80% of patients. In Sudan, there is no pre­vious report on ED among patients with CKD. A cross-sectional study was done to determine the prevalence of ED and its associated risk factors among Sudanese CKD patients on HD and those who underwent renal transplant. This was conducted in Khartoum, Sudan from October 2005 to July 2006 including all married men who were on maintenance HD for more than three months and all married men who had received renal transplantation at least three months earlier. Single, divorced/separated men, those whose wives were living away, those who were bed-bound and those with cognitive impairment were also excluded. After obtaining consent for participation, demographic and clinical data were collected by using anonymous questionnaires and the Arabic version of International Index of Erectile Function (IIEF; the Egyptian version). Patients who did not participate in full and proper manner were considered as "non-responders." A total of 146 patients, 106 HD patients, and 40 renal transplant recipients completed the IIEF questionnaire. Non-responders constituted 43.7% and 54.5% of HD and transplant recipient patients, respectively. Blood samples were taken after completion of the IIEF questionnaire to determine the required investigations. ED prevalence was high among our study patients, 83% among the HD patients and 67.5% among the renal transplant recipients. Univariate analysis showed that there was a trend, although non-significant, of older age being associated with ED in both groups. Similar association was seen in those who were under-dialyzed in the HD group and DM in the transplant recipient group. Previous history of ED was significantly associated with current presence of ED in both groups. More studies with larger sample size are needed to clarify the results of this study.

How to cite this article:
Mekki M O, El Hassan K A, El Mahdi E, Haroun H H, Mohammed M A, Khamis K H, Ismail M O, Yousif M, El Sanousi H. Prevalence and associated risk factors of male erectile dysfunction among patients on hemodialysis and kidney transplant recipients: A cross-sectional survey from Sudan. Saudi J Kidney Dis Transpl 2013;24:500-6

How to cite this URL:
Mekki M O, El Hassan K A, El Mahdi E, Haroun H H, Mohammed M A, Khamis K H, Ismail M O, Yousif M, El Sanousi H. Prevalence and associated risk factors of male erectile dysfunction among patients on hemodialysis and kidney transplant recipients: A cross-sectional survey from Sudan. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Oct 20];24:500-6. Available from: http://www.sjkdt.org/text.asp?2013/24/3/500/111023

   Introduction Top


Male erectile dysfunction (ED) is an important issue worldwide, affecting the quality of life, as shown by several reports in communitybased studies. [1],[2],[3] It was reported to occur in 5%-69% of men in community-based studies. [4],[5],[6],[7],[8] Also, it was shown to be more common among patients with chronic kidney disease (CKD), occurring in 82.7% of CKD patients just ente­ring the dialysis treatment, [9] 51.9%-88% of peritoneal dialysis (PD) patients, [10],[11] and in up to 87.5% of hemodialysis (HD) patients. [12],[13] In Sudan, there has been no previous report on ED among patients with end-stage renal di­sease (ESRD), and in addition, there are no community-based data on this subject. The only available data were reported by Ahmed et al, when they studied 360 diabetic patients and reported ED prevalence of 45%. [14] The objec­tive of this study is to determine the preva­lence of ED and its associated risk factors among Sudanese HD and transplant recipient patients.


   Patients and Methods Top


Study design

This was a cross-sectional study conducted in Khartoum, Sudan from October 2005 to July 2006.

Study population

All married men who were on maintenance HD for more than three months in five major governmental dialysis centers in Khartoum (Dr. Salma, Khartoum, Military, Oumdurman, and Bahri centers) and all married men who had received renal transplantation more than three months ago and who were under regular follow-up at Dr. Salma center were included in the study.

Exclusion criteria

Single, divorced/separated men and those whose wives were living away were excluded. Also, we excluded patients who were bed-bound and those with cognitive impairment. Ethical clearance for this study was obtained from Ethical Committee, Sudan Minsitry of Health in September 2005.

Methods

Initial interview with the target patients was held to explain the objectives and details of the study and to obtain consent for participation. Demographic and clinical data were collected by using anonymous questionnaires, besides the Arabic version of International Index of Erectile Function (IIEF; the Egyptian version), which was self-administered (filled by the pa­tient himself or helper). Patients who did not wish to participate, or did not complete the questionnaires, or even declined from parti­cipation at a later stage, were considered as "non-responders." Blood samples were taken after completion of the IIEF questionnaire to determine the required investigations [pre-dialysis hemoglobin (Hb), packed cell volume (PCV), creatinine, and pre- and post-dialysis urea for the HD patients and Hb, PCV, and crea­tinine levels for the renal transplant recipient patients]. The percent reduction of urea (PRU) was calculated as: [1 - post-dialysis blood urea nitrogen (BUN)/pre-dialysis BUN] multiplied by 100. Kt/v was calculated from the PRU using a single pool equation proposed by Daugridas et al: Kt/v = (0.026 × PRU) - 0.460. [15] Hormo­nal analysis was done initially by measuring parathormone, testosterone, prolactin, follicular stimulating and luteinizing hormones. Hor­monal tests were discontinued at an early stage of the study itself due to logistic reasons.

Statistical Analysis

Analysis was done using SPSS program, ver­sion 17, for Windows. χ 2 was used to determine the association of ED with the cause of renal failure, occupation, and diabetes mellitus (DM). Non-paired t -test was used to determine the association of ED with age, body mass index (BMI), income, duration of renal replacement therapy, creatinine, Kt/v, PRU, Hb, and other IIEF parameters. P value ≤0.05 was regarded as significant.


   Results Top


A total of 146 patients, 106 HD patients, and 40 renal transplant recipients completed the IIEF questionnaire. Non-responders constituted 43.7% and 54.5% of HD and transplant reci­pient patients, respectively. [Table 1] shows the characteristics of both the groups under study.
Table 1: Characteristics of Sudanese hemodialysis (HD) and renal transplant recipient (Tx) patients.

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The use of beta blockers (BB), angiotensin con­verting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), and calcium channel blockers (CCB) was reported by 16, 18, and 31 of HD patients and by 14, 15, and 20 of trans­plant recipient patients, respectively. Smoking, intermittent claudication, prostatic surgery, signs of hypogonadism, absent peripheral pulses, peripheral neuropathy, and postural hypo­tension were noted in 13, 5, 2, 1, 1, 15, and 4 patients in the HD group and in 0, 0, 0, 0, 1, 4, and 1 patient in the transplant recipient group, respectively. None of the patients in both groups admitted to taking alcohol. Only three HD patients had weekly Kt/v values of 3 and above (3.5%). All transplant recipient patients were on prednisolone, 39 patients on cyclosporine, 12 on mycophenolate mofetil (MMF), 26 on azathioprine, and none was receiving tacrolimus.

ED prevalence was 83% among the HD patients (88 patients) and 67.5% (27 patients) among the renal transplant recipient patients [Table 2]. Only 18 (20.5%) and 9 (33.3%) ED patients sought treatment in the HD and trans­plant recipient groups, respectively.
Table 2: Severity of erectile dysfunction among Sudanese hemodialysis and transplant recipient patients using international index of erectile function.

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Univariate analysis showed that there was a trend, although non-significant, of older age being associated with ED in both groups (P = 0.414 and 0.312 among HD and transplant recipient patients, respectively). However, there was significant impact of age on the erectile function (EF) value in both groups [Table 3] and [Table 4]. Similarly, there was significant impact of being under-dialyzed (as measured by weekly Kt/v and PRU) in the HD group and DM in the transplant recipients group on the EF values [Table 3] and [Table 4]. Previous history of ED was significantly associated with current presence of ED in both groups, while the creatinine le­vel showed a significant negative association with ED in the HD group [Table 5]. The use of ACEI/ARB had a significant positive asso­ciation with ED in the transplant recipient group [Table 5].
Table 3: Impact of age and underdialysis on erectile function score among Sudanese hemodialysis patients.

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Table 4: Impact of age and DM on the erectile function (EF) score among Sudanese transplant recipient patients.

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Table 5: Risk factors for ED among Sudanese HD and transplant recipient patients.

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In both groups, ED was not significantly asso­ciated with income, education, occupation, BMI, duration of renal replacement therapy, number of wives, Hb level, the cause of renal failure, absent peripheral pulses, peripheral neuropathy, postural hypotension, the use of CCB, and the use of BB, with P = 0.125, 0.493, 0.453, 0.130, 0.785, 0.075, 0.440, 0.671, 0.829, 0.189, 0.140, 0.381, and 0.517, respec­tively, in the HD group and 0.376, 0.575, 0.633, 0.225, 0.742, 0.497, 0.491, 0.786, 0.107, 0.677, 0.333, 0.286, and 0.458, respectively, in the transplant recipient group. Additionally, in the transplant recipients group, there was no sig­nificant association of ED with the level of creatinine or the use of cyclosporine, MMF, or azathioprine (P = 0.149, 0.675, 0.120, and 0.085, respectively). In the HD group, ED was not found to be significantly associated with, inter­mittent claudication, prostatic surgery, or smo­king (P = 0.656, 0.296, and 0.201, respectively).


   Discussion Top


The overall response was low among both the groups under study compared to other reports, [16],[17],[18],[19],[20],[21],[22],[23],[24],[25] although in the HD group, it was com­parable to that reported in a community-based study in Switzerland. [26] This lower response in our study population could be attributed to the fact that this type of survey was relatively new to our Sudanese people who tend to be con­servative regarding sexual issues.

The prevalence of ED was high among HD patients, compared to reports from Morocco, Turkey, and Brazil, [27],[28],[29],[30] although it was com­parable to other reports from Iran, Egypt, the USA, Brazil, and Turkey. [12],[16],[18],[19],[31] Older age was shown to be associated with ED in com­munity-based studies [4],[22],[32],[33],[34],[35],[36] and also among HD patients, [16],[17],[20],[29],[30] in both regional and international reports. We could not demonstrate such an association among our HD group pa­tients, probably due to the small size of our study population. However, we were able to demonstrate a significant negative impact of older age on the EF value, an observation sim­ilar to that reported in Iran, Japan, Canada, and Turkey. [9],[12],[18],[19] Also, we could not demonstrate the association of ED, among our HD patients, with DM. Nassir reported similar observation among the patients just entering dialysis treatment. [9] However, we demonstrated a signifi­cant negative impact of DM on the EF value, an observation which was not reported by any of the mentioned reports. DM was shown to be associated significantly with ED in HD pa­tients in the USA, Brazil, and Japan. [16],[19],[30],[37] Again, similar to reports from Brazil and Egypt, ED prevalence among our HD patients was significantly negatively correlated with the level of creatinine. [30],[31] We could not de­monstrate an association of ED with Kt/v, and a similar observation was reported in Brazil. [37] However, we demonstrated a significant nega­tive impact of Kt/v value on the EF value. Messina et al reported that ED patients undergoing HD had significantly lower values of Kt/v. [30] In the HD patients of our study, below-target Kt/v was almost universal. This could be attributed to the policy of having twice-weekly dialysis for the majority of our patients due to financial constraints. Adding to this, the PRU values were also low for many patients and this might be a result of poor selection of dialyzer sizes observed in many HD centers. ED prevalence, among our HD patients, was not found to be related to the level of education, income, occupation, smo­king, cause of renal failure, Hb level, and dia­lysis duration, an observation similar to that re­ported from the USA, Brazil, and Japan. [16],[19],[29],[37]

In the transplant recipient patients of our study, ED prevalence was comparable to the reports from China and Mexico, [23],[38] although it was higher than that reported in Spain, Italy, France, and Egypt. [22],[24],[25],[39] Arslan et al, Robello et al, and Tian Ye et al reported that older age was significantly negatively associated with ED among the renal transplant recipients. [18],[22],[23] We could not demonstrate such an association among the transplant recipients of our study, probably due to the small size of the popu­lation studied. However, we demonstrated that older age had a significant negative impact on the EF value, an observation similar to that reported by Tian Ye, Arslan et al, Al-Bahnasawi et al, and Malavaud et al [18],[23],[25],[39] Also, similar to what was reported by Al-Bahnasawi et al, we could demonstrate a significant nega­tive impact of DM on the EF values. [39] Although ACEI were found to be probably protective in HD patients in the USA, [16] we demonstrated significant association of ED with the use of ACEI/ARB among our trans­plant recipient patients, which might be a reflection of our tendency to the use of these drugs among diabetic patients.

Despite the high prevalence of ED among both groups, smaller proportion sought medi­cal advice and treatment. Similar observation was reported among HD patients from the USA, Brazil, and Turkey. [16],[18],[30],[37]


   Conclusions and Recommendations Top


ED prevalence was high among our study patients. In HD patients, ED was significantly negatively associated with creatinine and posi­tively associated with previous ED episodes. Lower EF value was associated with older age (≥45 years) and under-dialysis. In transplant recipient patients, only previous ED episode was associated with ED. Again, lower EF value was associated with older age (≥50 years) and DM. ED prevalence was on the upper scale of the international and regional reports among our HD patients, although it was comparable to international reports among our transplant recipient patients. Despite the high prevalence of ED reported in our studied patients, only a low proportion of them sought treatment.

A significant limitation to this study is the large proportion of non-responders, who could well have different characteristics. More efforts are needed to increase the awareness of our pa­tients and encourage their participation in the different studies addressing sexual issues, which would be of help in treating them. More studies with larger sample size are needed to clarify the results of this study. In addition, studies to analyze hormonal analysis pattern and psychosocial aspects are also needed.


   Acknowledgments Top


Thanks to MAPI Institute for providing the IIEF questionnaire and its Arabic translation (Egyptian version) for free.

Support for the study:

Logistics: Dr. Salma Center for Dialysis and Kidney Transplantation, University of Khartoum, Khartoum, Sudan

Lab investigations: Diagnostic Research Labo­ratory, Khartoum Teaching Hospital, and National Center for Kidney Diseases, Federal Ministry of Health, Sudan

 
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Correspondence Address:
M O Mekki
Department of Nephrology, Khartoum Teaching Hospital, Federal Ministry of Health, Khartoum
Sudan
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DOI: 10.4103/1319-2442.111023

PMID: 23640621

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