Erectile dysfunction in chronic peritoneal dialysis patients: incidence and treatment with sildenafil.

OBJECTIVES: Sexual and erectile dysfunction (ED) have been reported to occur frequently in male patients with end-stage renal disease maintained on dialysis. Numerous etiologies for this ED have been suggested. Although a variety of therapies for the ED of the dialysis patient have been suggested, most clinicians indicate that patients report a poor response to therapy. Recently, sildenafil has been reported to be beneficial in treating patients with ED of both organic and psychogenic causes. The present study was designed to document the incidence of ED in male patients maintained on chronic peritoneal dialysis (CPD) and to determine the efficacy of prescribing sildenafil therapy to treat their ED. METHODS: All male patients in our CPD unit were notified by letter of the availability of sildenafil as a treatment modality for ED. A sexuality/erectile dysfunction assessment was conducted in all male patients by their primary nephrologist. Patients who reported ED and who had no medical contraindication to sildenafil were offered this therapy. Those patients who were interested in this treatment were interviewed by a social worker, and patients were asked to complete the International Index of Erectile Function questionnaire. Sildenafil was prescribed at a starting dose of 25 mg and increased to a maximum of 100 mg during a 12-week study trial. Patients were re-evaluated 6 and 12 weeks after the start of therapy. RESULTS: There were 68 male patients maintained on CPD at the time of the study. Mean age of all patients was 60.8 +/- 15.3 years and mean duration on PD was 32.6 +/- 25.6 months. Thirty-three patients had diabetes, 66 hypertension, 35 peripheral vascular disease, and 32 coronary artery disease. Thirty-two of 68 male patients in the CPD unit were assessed to have ED. Only 17 of the 32 patients expressed interest in pursuing sildenafil therapy. Two of these patients were excluded because they were receiving nitrate therapy. Of the 15 patients who agreed to take sildenafil, only 6 completed the 12-week study. Two of these patients responded to sildenafil. CONCLUSION: Erectile dysfunction is common in male patients maintained on CPD. Only about half of patients with ED in the present study were willing to consider sildenafil therapy to treat the ED and, of those who agreed to treatment, only a minority completed the 12-week trial; 2 of these 6 patients reported a satisfactory response.

Identification and treatment of depression in a cohort of patients maintained on chronic peritoneal dialysis.

Depression is the most commonly encountered psychological problem in patients with end-stage renal disease (ESRD). Depression has recently been shown to significantly impact on the morbidity and mortality of patients undergoing therapy for ESRD. The present study was designed as a pilot study to evaluate the feasibility of screening a large cohort of patients maintained on chronic peritoneal dialysis (CPD) for depression and then pharmacologically treating those patients assessed to have clinical depression. One hundred thirty-six patients maintained on CPD in our CPD unit were screened for depression using the Beck Depression Inventory (BDI), a self-administered questionnaire. Patients with scores of 11 or greater were referred to a trained psychiatric interviewer for further evaluation to confirm the diagnosis of clinical depression and determine whether the patient was a candidate for antidepressant medication. Sixty-seven patients had BDI scores of 11 or greater, and 60 of these patients were asked to participate in further evaluation and possible therapy. Only 27 patients agreed to further study and were evaluated by a trained psychiatric interviewer for clinical depression. Twenty-three of these patients were assessed to have clinical depression, and 22 patients were eligible for antidepressant medication based on their scores on the Hamilton Depression Scale and psychiatric interview. Eleven patients completed a 12-week course of therapy with antidepressant medication, and their BDI scores decreased from a mean of 17.1 +/- 6.9 (SD) to a mean of 8.6 +/- 3.2. Seven patients were treated with sertraline, 2 patients with bupropion, and 2 patients with nefazodone. It is concluded that (1) depression is commonly present in patients maintained on CPD, (2) the BDI is a useful tool to use to screen for clinical depression, and (3) clinical depression is treatable with medication in this patient population.

Patient assessment of quality of care in a chronic peritoneal dialysis facility.

The percentage of patients with end-stage renal disease (ESRD) maintained on chronic peritoneal dialysis (CPD) in the United States remains well less than the percentage in several other countries. Furthermore, there has recently been a decline in the percentage of patients with ESRD in the United States undergoing CPD. The reasons for this decline are uncertain, and investigators have implicated problems with the kinetics of peritoneal dialysis, peritonitis and exit-site infections, and psychosocial stresses imposed by the therapy. Few studies, however, have considered the role of the dialysis facility itself and patient perceptions of the facility as contributing to problems with the long-term acceptance of CPD. This study is designed to examine patients' perceptions of the organization and structure of the peritoneal dialysis facility and their interactions with the facility, focusing attention on areas of patient satisfaction and dissatisfaction with the facility. The study was conducted in a large, freestanding peritoneal dialysis program in an urban area that currently treats 140 patients undergoing CPD. Thirty patients were randomly selected to participate in the present study. A structured interview that included open-ended questions was administered and tape-recorded by a trained interviewer not affiliated with the dialysis unit. Patient responses were then reviewed by two investigators, and a taxonomy of patient satisfaction and dissatisfaction was developed, using a modification of the classification proposed by Concato and Feinstein. Patient responses were then categorized according to the taxonomy. The most frequently cited areas of patient satisfaction included the amount of information and instruction provided by the staff (n = 30), personal atmosphere of the facility (n = 30), efficiency of delivery of the dialysis supplies (n = 23), and availability of the primary nurse (n = 18). The importance of the nurse-patient interaction was emphasized by all 30 patients, whereas the physician-patient interaction was cited by only 14 patients. The most frequently cited area of dissatisfaction noted by all 30 patients concerned the dialysis regimen itself. The present study focuses attention on patient perceptions of their CPD facility, identifying areas of satisfaction and dissatisfaction. The analysis is important not only in providing a framework for CPD facilities with which to review their own interactions with CPD patients, but also for identifying those areas that require attention to maintain the long-term viability of CPD therapy.

Psychosocial factors and clinical outcome on CAPD.

Patient dropout from chronic peritoneal dialysis (CPD) and transfer to hemodialysis remains a major problem with patients on CPD. Peritonitis, exit-site infections, and medical complications requiring hospitalization often adversely affect the outcome of CPD. The role of psychosocial factors in determining patient outcome and influencing the rates of these complications is not clear. Our group has employed a variety of instruments, including the Patient Related Anxiety Scale (PRAS), Beck's Depression Inventory (BDI), Kupfer-Detre System II somatic symptom scale (KDS-II), and a patient self-assessed quality of life (PAQOL) questionnaire to assess quality of life and to objectively evaluate the psychosocial status of the patient treated with CPD. The present study extends previous observations by relating the results of these psychosocial instruments to the incidence of various complications in 103 patients maintained on CPD. Patients were divided into low-scoring (lowest symptoms of depression, anxiety, somatic symptoms, and best quality of life evaluation), intermediate, and high-scoring (highest symptoms of depression, anxiety, somatic symptoms, and worst quality of life) categories. The peritonitis rates, exit-site infection rates, and days of hospitalization of the three categories were then compared. The results demonstrate significantly higher complication rates in the high-scoring when compared to the low-scoring patients. Thus screening patients maintained on CPD with objective measures of psychosocial functioning may enable caregivers to more accurately predict which patients are at greater risk for developing medical complications.

Quality of life assessment in chronic peritoneal dialysis patients.

Previous studies by our group have attempted to examine quality of life (QoL) issues in a cohort of end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) by assessing a variety of psychological tests and by asking patients to rate their own QoL. The present study was undertaken to extend previous observations by asking patients to spontaneously select those domains of life experience that they think are most important in determining their quality of life. Sixty-eight medically stable CPD patients were asked to spontaneously select those three to five domains felt to be most important to them in defining their QoL. The 307 responses were then grouped into 22 broad categories by three investigators. The most frequently selected domains focused on interpersonal relationships. Domains that enhance the quality of one's day and add meaning to one's life were selected with a midrange frequency. Some domains that might intuitively seem to be important for a patient's QoL were selected with a surprisingly low frequency. These findings suggest that to understand what CPD patients value in assessing their QoL can best be determined by asking them directly and not by using predetermined variables.

Quality of life in peritoneal dialysis patients.

In 49 patients receiving continuous ambulatory peritoneal dialysis, we assessed the relative influences of adequacy of dialysis (assessed by kinetic transfer/volume urea) and psychological symptoms (depression and anxiety) upon the patients' evaluation of their overall quality of life (QoL). Subjects completed self-rating forms for anxiety, depressive, and somatic symptoms, for discrete areas relevant to QoL, and for overall QoL; clinicians also rated QoL. Depressive symptoms proved a much stronger correlate of overall QoL than did the biochemical measure of dialysis adequacy, and they remained influential even after adjustment for anxiety, kinetic transfer/volume, and somatic symptoms. In contrast, the effects of kinetic transfer/volume, anxiety symptoms, and somatic symptoms dropped sharply when adjusted for the other variables. Because psychological (especially depressive) symptoms may be stronger determinants of patients' overall QoL than is adequacy of dialysis, assessing QoL and psychological status should be part of the care of end-stage renal disease patients.

Psychosocial factors and incidence of peritonitis.

It has been suggested that psychosocial (PS) factors may influence morbidity and mortality in chronically ill patients. However, investigators have not examined how PS factors affect specific medical problems in chronic peritoneal dialysis (CPD) patients. Sixty-eight patients maintained on CPD therapy were studied. PS testing included a self-rating form of patient-assessed quality of life (PaQOL), depression [Beck's Depression Inventory (BDI)], anxiety [Patient Rated Anxiety Scale (PRAS)], and assessment of physical symptoms (KDS-II). Peritonitis rates six months prior to PS assessment and six months after assessment were tabulated. The data show that during the study period patients with more than one episode of peritonitis compared to those with no episodes of peritonitis had: (1) significantly higher anxiety and physical symptom scores; (2) significantly lower PaQOL; and (3) higher depression scores, which did not reach statistical significance (p < 0.06). Whether higher peritonitis rates result in worse PS symptoms, or whether poor PS symptoms cause higher peritonitis rates needs to be determined with further investigations.

Marital discord, sexual problems, and depression.

Systematic studies of relationships among depression, sexual function, and martial discord in hemodialysis patients and their spouses arelacking; existing studies focus upon only one of these three topics, or deal with patient or spouse as individuals rather than as a couple. We studied 17 chronic, medically stable hemodialysis patients and their husbands or wives. Although couples rated their degree of marital discord as low, the investigators rated it as high, based on the number and type of specific problems reported by the couple. The couples' evaluation may not represent denial, as has been commonly assumed. Instead their evaluation may imply that the disease and its treatment overshadow marital problems, even though couples recognize and react to these problems. Couples showed a high prevalence of sexual problems--in terms of overall satisfaction, frequency of intercourse, and specific dysfunctional symptoms (difficulty becoming excited, maintaining excitement, or having orgasm). We found a strong relationship between severity of depression and severity of sexual dysfunction in patients, but not in their mates. No strong relationship existed between a patient's depression score and marital discord, although spouses showed a trend toward correlation between severity of depression and martial discord. Younger couples, especially, seem not to want intercourse when severe martial discord exists. Patients' depression scores were comparable to thoseof psychiatric patients, while spouses' depression scores resembled those of normals. While psychosocial phenomena such as marital discord, sexual dysfunction, and depression are clear, causal chains are not. Despite disadvantages inherent in using questionnaires, short, self-administered, easily scored instruments may elicit problems with sex, marriage, and mood which might otherwise be overlooked by caretaking personnel.

Assessment of marital relationships of hemodialysis patients.

In addition to the somatic problems associated with uremia and dialysis it is apparent that successful hemodialysis is dependent upon psychological adjustment to this type of therapy. While previous studies have focused on the patient or spouse as individuals, patterns of marital interactions and conflicts have not been systematically evaluated. These factors ere examined in 17 medically stable patients maintained on hemodialysis for a mean duration of 22 +/- 4 SE months. Standardized pssychiatric evaluation forms ere used to examine mood and cognition disturbances in all patients and spouses, and a deailed marital questionnaire, which each patient and spouse filled out independently, was used to evaluate fundamental aspects of the marital relationship...