Anna Bednarek-Skublewska

Prevalence and Correlates of Self-Reported Sexual Dysfunction in CKD: A Meta-analysis of Observational Studies

BACKGROUND Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively. STUDY DESIGN Systematic review and meta-analysis. SETTING & POPULATION Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD). SELECTION CRITERIA FOR STUDIES Observational studies conducted in patients with CKD only or including a control group without CKD. PREDICTOR Type of study population. OUTCOMES Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators. RESULTS 50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, -9.28; 95% CI, -12.92 to -5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods. LIMITATIONS Suboptimal and lack of uniform assessment of outcome measures. CONCLUSIONS Sexual dysfunction is highly prevalent in both men and women with CKD, especially among those on dialysis. Larger studies enrolling different ethnic groups, using validated study tools, and analyzing the influence of various factors on the development of sexual dysfunction are needed.

Prevalence and correlates of erectile dysfunction in men on chronic haemodialysis: a multinational cross-sectional study

BACKGROUND Factors associated with erectile dysfunction in men on haemodialysis are incompletely identified due to suboptimal existing studies. We determined the prevalence and correlates of erectile dysfunction and identified combinations of clinical characteristics associated with a higher risk of erectile dysfunction using recursive partitioning and amalgamation (REPCAM) analysis. METHODS We conducted a multinational cross-sectional study in men on haemodialysis within a collaborative network. Erectile dysfunction and depressive symptoms were evaluated using the erectile function domain of the International Index of Erectile Function questionnaire and the Center for Epidemiological Studies-Depression Scale, respectively. RESULTS Nine hundred and forty-six (59%) of 1611 eligible men provided complete data for erectile dysfunction. Eighty-three per cent reported erectile dysfunction and 47% reported severe erectile dysfunction. Four per cent of those with erectile dysfunction were receiving pharmacological treatment. Depressive symptoms were the strongest correlate of erectile dysfunction [adjusted odds ratio 2.41 (95% confidence interval (CI) 1.57-3.71)]. Erectile dysfunction was also associated with age (1.06, 1.05-1.08), being unemployed (1.80, 1.17-2.79) or receiving a pension (2.05, 1.14-3.69) and interdialytic weight gain (1.9-2.87 kg, 1.92 [CI 1.19-3.09]; >2.87 kg, 1.57 [CI 1.00-2.45]). Married men had a lower risk of erectile dysfunction (0.49, 0.31-0.76). The prevalence of erectile dysfunction was highest (94%) in unmarried and unemployed or retired men who have depressive symptoms. CONCLUSIONS Most men on haemodialysis experience erectile dysfunction and are untreated. Given the prevalence of this condition and the relative lack of efficacy data for pharmacological agents, we suggest that large trials of pharmacological and non-pharmacological interventions for erectile dysfunction and depression are needed.

Monocyte chemoattractant protein-1 (MCP-1) gene polymorphism as a potential risk factor for cardiovascular disease in hemodialyzed patients

AIM Polymorphism in the monocyte chemoattractant protein-1 (MCP-1) gene (A-2518G) has been associated with functional effects. The aim of the present study was to assess the effect of this polymorphism on end-stage renal disease (ESRD) and cardiovascular disease (CVD) in hemodialyzed patients. METHODS A total of 720 patients with ESRD treated with hemodialysis (450 patients with CVD) and 325 healthy control subjects were genotyped for the MCP-1 -2518 polymorphism by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) procedure. RESULTS There was a significant difference in genotype frequencies between entire group of hemodialyzed patients and controls (p<0.01). The odds ratio for the risk allele was 1.85, 95% CI 1.49-2.32 (p<0.01). Hemodialyzed patients were divided into subgroups with CVD (n=450) and without CVD (n=270). The G allele carriers occurred with significantly higher frequency in patients with CVD (62% vs. 38% in patients without CVD and 36% in controls). The odds ratio for the risk allele for patients with CVD vs. those without CVD was 2.17, 95% CI 1.71-2.79. There was no statistically significant difference in the distribution of MCP-1 genotypes between ESRD patients without CVD and healthy controls. CONCLUSION Our results demonstrate for the first time an association between the polymorphism in the regulatory region of the MCP-1 gene and susceptibility to CVD in hemodialyzed patients.

Nutrition and dietary intake and their association with mortality and hospitalisation in adults with chronic kidney disease treated with haemodialysis: protocol for DIET-HD, a prospective multinational cohort study

Introduction Adults with end-stage kidney disease (ESKD) treated with haemodialysis experience mortality of between 15% and 20% each year. Effective interventions that improve health outcomes for long-term dialysis patients remain unproven. Novel and testable determinants of health in dialysis are needed. Nutrition and dietary patterns are potential factors influencing health in other health settings that warrant exploration in multinational studies in men and women treated with dialysis. We report the protocol of the “DIETary intake, death and hospitalisation in adults with end-stage kidney disease treated with HaemoDialysis (DIET-HD) study,” a multinational prospective cohort study. DIET-HD will describe associations of nutrition and dietary patterns with major health outcomes for adults treated with dialysis in several countries. Methods and analysis DIET-HD will recruit approximately 10 000 adults who have ESKD treated by clinics administered by a single dialysis provider in Argentina, France, Germany, Hungary, Italy, Poland, Portugal, Romania, Spain, Sweden and Turkey. Recruitment will take place between March 2014 and June 2015. The study has currently recruited 8000 participants who have completed baseline data. Nutritional intake and dietary patterns will be measured using the Global Allergy and Asthma European Network (GA2LEN) food frequency questionnaire. The primary dietary exposures will be n-3 and n-6 polyunsaturated fatty acid consumption. The primary outcome will be cardiovascular mortality and secondary outcomes will be all-cause mortality, infection-related mortality and hospitalisation. Ethics and dissemination The study is approved by the relevant Ethics Committees in participating countries. All participants will provide written informed consent and be free to withdraw their data at any time. The findings of the study will be disseminated through peer-reviewed journals, conference presentations and to participants via regular newsletters. We expect that the DIET-HD study will inform large pragmatic trials of nutrition or dietary interventions in the setting of advanced kidney disease.

Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study

BackgroundPeople with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated.Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required.Methods/designThe ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022.DiscussionThis large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

Patient satisfaction with in-centre haemodialysis care: an international survey

Objectives To evaluate patient experiences of specific aspects of haemodialysis care across several countries. Design Cross-sectional survey using the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) questionnaire. Setting Haemodialysis clinics within a single provider in Europe and South America. Participants 2748 adults treated in haemodialysis. Primary and secondary outcomes The primary outcome was patient satisfaction with overall care. Secondary outcomes included patient experiences of individual aspects of dialysis care. Results 2145 (78.1%) adults responded to the questionnaire. Fewer than half (46.5% (95% CI 44.5% to 48.6%)) rated their overall care as excellent. Global perceptions of care were uninfluenced by most respondent characteristics except age and depressive symptoms; older respondents were less critical of their care (adjusted OR for excellent rating 1.44 (1.01 to 2.04)) and those with depressive symptoms were less satisfied (0.56 (0.44 to 0.71)). Aspects of care that respondents most frequently ranked as excellent were staff attention to dialysis vascular access (54% (52% to 56%)); caring of nurses (53% (51% to 55%)); staff responsiveness to pain or discomfort (51% (49% to 53%)); caring, helpfulness and sensitivity of dialysis staff (50% (48% to 52%)); and ease of reaching dialysis staff by telephone (48% (46% to 50%)). The aspects of care least frequently ranked as excellent were information provided when choosing a dialysis modality (23% (21% to 25%)), ease of seeing a social worker (28% (24% to 32%)), information provided about dialysis (34% (32% to 36%)), accuracy of information from nephrologist (eg, about prognosis or likelihood of a kidney transplant; 37% (35% to 39%)) and accuracy of nephrologists’ instructions (39% (36% to 41%)). Conclusions Haemodialysis patients are least satisfied with the complex aspects of care. Patients’ expectations for accurate information, prognosis, the likelihood of kidney transplantation and their options when choosing dialysis treatment need to be considered when planning healthcare research and practices.

The effect of a single dialysis session on spatial QRS-T angle in haemodialysis patients

BACKGROUND Abnormal values of the spatial angle between the directions of ventricular depolarization and repolarization (QRS-T) reflect the action potential inhomogeneities and predict cardiac events and mortality in various patient groups. The study was designed to (i) compare QRS-T in haemodialysis (HD) patients and healthy subjects, (ii) assess the influence of HD on QRS-T and (iii) evaluate the possible associations between QRS-T and echocardiography, haemodynamic as well as biochemical parameters. METHODS The angular differences between the maximum spatial QRS and T vectors were measured in 73 HD patients and in 57 controls. QRS-T in patients was estimated pre- and post-dialysis together with the evaluation of blood chemistry and haemodynamic parameters. RESULTS Pre-dialysis QRS-T was higher compared with controls (30.18 ± 9.84 and 13.65 ± 7.23, respectively; P < 0.001). HD induced an increase of QRS-T (41.09 ± 11.74; P < 0.001). Pre-dialysis QRS-T adjusted for left ventricular mass index correlated with troponin T (r = 0.398, P = 0.001) and HDL (r = -0.270, P = 0.043). The differences between pre- and post-dialysis (Δ) QRS-T correlated with Δ potassium (r = 0.453, P < 0.001), Δ calcium (r = -0.309, P = 0.011) and Δ stroke index (SI; r = 0.311, P = 0.017). On multivariate analysis, troponin T was found to be an independent predictor of pre-dialysis QRS-T, whereas independent predictors of the HD-induced increase in QRS-T were potassium and cardiac index changes. CONCLUSIONS QRS-T is high in HD patients. HD enhances the inhomogeneities of action potential. Pre-dialysis QRS-T is mainly associated with troponin T elevation. HD-induced increase in QRS-T is mainly associated with potassium and SI changes. The possible clinical importance of the higher QRS-T in HD patients remains to be confirmed in further studies.

Depression and all-cause and cardiovascular mortality in patients on haemodialysis: a multinational cohort study.

Background: Depression and early death are both common in adults with Stage 5 chronic kidney disease. Studies have shown an association between depression and total mortality, but the association between depression and cardiovascular death is less certain. Methods: We conducted a prospective multinational cohort study involving adults who were treated with long‐term haemodialysis within a single dialysis network between April and November 2010. Depression was considered present when patients reported a Beck Depression Inventory (BDI) II score ≥14 at baseline. Sensitivity analyses considered a BDI II score ≥20 to identify moderate depression. Multivariable Cox proportional hazards regression was used to assess adjusted hazards for all‐cause and cardiovascular mortality at 12 months. Results: Three thousand and eighty‐six participants in the network received the BDI II questionnaire, and 2278 (73%) provided complete responses to the survey questions. Among these, 1047 (46%) reported depression. During a mean follow‐up of 11 (standard deviation: 2.5) months (2096 person‐years), we recorded 175 deaths, of which 66 were attributable to cardiovascular causes. Depression (BDI score ≥14) was not associated with all‐cause mortality [adjusted hazard ratio: 1.26 (95% confidence interval: 0.93‐1.71)] or cardiovascular mortality [0.82 (0.50‐1.34)]. When a higher BDI score (BDI score ≥20) was used to identify moderate depression, depression was associated with total mortality [1.40 (1.02‐1.93)] but not cardiovascular mortality [1.05 (0.63‐1.77)]. Conclusions: The association between depression and cardiovascular mortality in adults with kidney failure treated with haemodialysis is uncertain. Depression is a heterogeneous disorder and may only be a risk factor for premature death when at least of moderate severity.

Iodine-123 metaiodobenzylguanidine myocardial imaging in haemodialysed patients asymptomatic for coronary artery disease: a preliminary report.

AimThe aim of this study was to evaluate the usefulness of iodine-123 metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy in the detection of cardiac sympathetic neuropathy in haemodialysed patients without relevant cardiovascular symptoms. Materials and methodsA group of 20 haemodialysed patients were examined. The stress/rest myocardial perfusion scintigraphy by gated single-photon emission computed tomography was performed. Cardiac sympathetic functions were evaluated by single-photon emission computed tomography and planar 123I-mIBG myocardial scintigraphy and also by 24-h Holter study, with heart rate variability (HRV) and signal-averaged electrocardiogram analysis of ventricular late potentials. Semiquantitative analysis of 123I-mIBG myocardial uptake was expressed as routine heart/mediastinum ratio (HMR) 15 [early (eHMR)] and 240 min [delayed (dHMR)] after administration and washout rate (WOR). ResultsMyocardial perfusion scintigraphy showed normal values of all parameters, but semiquantitative 123I-mIBG cardiac imaging assessment indicated low values of HMR (eHMR 1.87±0.27; dHMR 1.74±0.25) and high values of WOR (31.38±9.49) compared with normal values. In 10 patients (50%) ventricular late potential was determined, and in these patients mean values of dHMR came up to 1.59±0.20. The mean value of HRV came up to 88.40±16.05 and significant correlations were found between HRV and eHMR (P=0.01) and dHMR (P=0.007). Conclusion 123I-mIBG scintigraphy can detect very early stages of cardiac sympathetic dysfunction. Low values of HMR and high values of WOR suggest an impaired cardiac adrenergic system in patients without any relevant symptoms of heart failure. Low values of HRV may confirm cardiac autonomic neuropathy.

Complement receptor 1 gene polymorphism and cardiovascular disease in dialyzed end-stage renal disease patients.

Inflammation plays an important role in cardiovascular disease (CVD). The complement system is a critical component of innate and acquired immunity. We investigated whether the polymorphisms in the complement receptor 1 (CR1) gene are associated with CVD in end-stage renal disease (ESRD) patients. The study groups of 1200 patients with ESRD, 360 patients with type 2 diabetes and 924 healthy individuals were genotyped. The GG genotype of the C5507G polymorphism was significantly more frequent in ESRD patients with CVD than in patients without CVD and controls (odds ratio [OR] = 3.44, 95% confidence interval [CI] = 2.23-5.3, and OR = 5.46, 95% CI = 3.72-8.0, respectively). The GG genotype was observed in 62% of patients with a history of myocardial infarction. The frequency of the G allele was also higher in patients with CVD (OR = 2.24, 95% CI = 1.93-2.61 vs controls, and OR = 1.97, 95% CI = 1.63-2.36 vs patients without CVD). In the multivariate logistic regression analysis the carrier status of G allele of C5507G polymorphism was an independent risk factor of CVD in ESRD patients (p < 0.001). In conclusion, our results suggest strong association between the CR1 gene polymorphism and CVD in ESRD patients.