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NDT Advance Access originally published online on February 1, 2007
Nephrology Dialysis Transplantation 2007 22(4):1163-1170; doi:10.1093/ndt/gfl755
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Sexual dysfunction in dialysis patients treated with antihypertensive or antidepressive medications: results from the DOPPS

George R Bailie1,2, Stacey J Elder3, Nancy A Mason4, Yasushi Asano5, Jose M Cruz6, Shunichi Fukuhara7, Antonio A Lopes8, Donna L Mapes3, David C Mendelssohn9, Juergen Bommer10 and Eric W Young11

1Albany College of Pharmacy, 2Albany Nephrology Pharmacy (ANephRx), Albany, NY, 3Arbor Research Collaborative for Health, 4College of Pharmacy, University of Michigan, Ann Arbor, MI, USA, 5Department of Internal Medicine, Koga Redcross Hospital, Ibaraki, Japan, 6Division of Nephrology, Hospital General University ‘La Fe’, Valencia, Spain, 7Health Care Research, Kyoto University, Kyoto, Japan, 8Internal Medicine, Federal University of Bahia, Bahia, Brazil, 9Internal Medicine, Humber River Hospital/University of Toronto, Weston, Ontario, Canada, 10University of Heidelberg, Heidelberg, Germany, 11Internal Medicine, Veterans Affairs Medical Center/University of Michigan, Ann Arbor, MI, USA

Correspondence and offprint requests to: George R. Bailie, Professor of Pharmacy, Albany Nephrology Pharmacy (ANephRx) Group, Albany College of Pharmacy, 106 New Scotland Avenue, Albany, NY 12208, USA. Email: bailieg{at}acp.edu



   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 
Background. The relationship between medication prescription and sexual dysfunction (SD) in dialysis patients is unclear.

Methods. We studied antihypertensive and antidepressive agents prescribed for 7346 patients in the Dialysis Outcomes and Practice Patterns Study phase 1 (DOPPS I) and 8891 patients in DOPPS II. At baseline, DOPPS I patients completed a quality of life survey, including four questions about sexual functioning, from which we created a composite SD scale. DOPPS II patients were asked only one question about SD. We examined predictors of SD with logistic regression, using numerous patient characteristics, comorbid conditions and additional variables.

Results. Reported SD ranged from 66.4% (France) to 84.5% (Spain). The mean composite SD score ranged from 6.4 (Spain) to 7.9 (Germany) (on a 3–15 scale). Peripheral {alpha}-blockers increased odds of DOPPS I patients having their sex life bothered by end-stage renal disease (ESRD) (OR = 1.18), and there were elevated odds of arousal problems with central antagonists, loop diuretics and peripheral {alpha}-blockers (OR = 1.19, 1.24 and 1.29, respectively). Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines increased odds of problems with enjoyment (OR = 1.59 and 1.26, respectively) and arousal (OR = 1.70 and 1.24, respectively), and having sex life bothered by ESRD (DOPPS I: OR = 1.36 and 1.24; DOPPS II: 1.30 and 1.31, respectively). Vasodilators reduced the odds of sexual enjoyment problems (OR = 0.75). Composite SD scores worsened with peripheral {alpha}-blockers (+0.41), tricyclics (+0.78), SSRIs (+0.80) and benzodiazepines (+0.50), but not with vasodilators (–0.57).

Conclusions. Awareness of associations between SD and prescribed medications may offer opportunities for intervention.

Keywords: antidepressives; antihypertensive agents; haemodialysis; medication-related; sexual dysfunction



   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Acknowledgements
 References
 
There is considerable information available about the degree of sexual dysfunction in the general population in the US. For example, a recent analysis of data from the National Health and Social Life Survey, conducted in 1992 from a probability sample of 1749 women and 1410 men aged between 18 and 59 years, indicated that there was a high rate of sexual problems in both genders [1]. Sexual dysfunction was determined to be more prevalent for women (43%) than for men (31%) and to be associated with a variety of demographic characteristics. Although the survey examined a variety of demographic and lifetime experiences in the participants of the study, it did not examine any impact of medications. Some information is available for individuals with end-stage renal disease (ESRD) treated with haemodialysis. Recent information from the Dialysis Outcomes and Practice Patterns Study (DOPPS) indicated that many men and women suffered from sexual dysfunction, with considerable variation between races [2], but the association of sexual dysfunction with prescribed medications was not examined. Other studies have examined specific aspects of sexual dysfunction, such as erectile dysfunction and associations with quality of life and comorbid conditions, in patients with kidney disease [3–7]. In addition, there is a high incidence of major depression in patients treated by dialysis, and depression itself is associated with reduced sexual activity.

Many medications may negatively affect sexual function in individuals in the general population. The regular use of ß-blockers by men is associated with erectile dysfunction [8]. Interestingly, the use of prescription anti-depressive agents has been associated with both an increase and a decrease in subsequent sexual function [9,10]. The increase in desire that occurs as depression becomes controlled may be mitigated by an inherent effect of some of the antidepressive medications themselves. For example, the use of selective serotonin reuptake inhibitors (SSRIs) has been demonstrated to decrease both sexual interest and function in both men and women.

ESRD patients treated by dialysis are generally prescribed a mean of 10–12 medications and may take an additional two to four over-the-counter medications [11]. Many ESRD patients are treated with anti-hypertensive and anti-depressive medications. However, the impact of these and other medications on sexual function in this patient population is largely unknown. This study used data from the DOPPS to describe the relationship between prescription of antihypertensive and antidepressive agents and markers of sexual dysfunction. The hypothesis was that there would be a statistical association between the use of selected groups of medications and decreased sexual activity and function.



   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Acknowledgements
 References
 
Data sources
This report used samples of prevalent haemodialysis patients from DOPPS I (1997–2002) and DOPPS II (2002–04). Both DOPPS I and DOPPS II are cross-sectional, prospective, observational studies involving samples of adult haemodialysis patients randomly selected from representative dialysis facilities in 12 countries. DOPPS I included patients from France, Germany, Italy, Japan, Spain, the UK and the US, and DOPPS II included patients from the DOPPS I countries and from Australia, Belgium, Canada, New Zealand and Sweden. The studies have been described previously [12,13]. Briefly, the major goal of DOPPS is to investigate the impact of haemodialysis practice patterns on patient outcomes. The primary study endpoints for DOPPS are mortality, hospitalization, vascular access outcomes and quality of life. A stratified random sample of chronic dialysis facilities was selected to document variation in practice patterns and outcomes. Within each facility, a random sample of 20–40 haemodialysis patients was selected for participation in the DOPPS. Patients who died or departed from the facility were replaced by newly enroled patients. Facilities in the US (n = 143) entered DOPPS I in 1997, facilities in Europe (n = 100) in 1998 and facilities in Japan (n = 65) in 1999. In addition, data were included from 320 facilities in DOPPS II. Institutional review boards approved the DOPPS in each country or facility, as required. Informed patient consent was obtained in accordance with the requirements of each country, review board and dialysis centre. Data collection is performed in a fashion that maintains patient anonymity at the coordinating centre.

Drug data were classified using a drug database system. This computerized system allowed drugs to be categorized down to the specific drug brand, dosage form and strength while allowing categorization into one or several drug classes. Anti-hypertensives were further subclassified as ß-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), centrally acting sympatholytics (e.g. methyldopa, clonidine, guanabenz and guanfacine), peripheral {alpha}-blockers (e.g. reserpine, guanethicine), vasodilators (e.g. hydralazine, minoxidil) and loop diuretics. Propranolol and nitroglycerin were analysed separately because of the wealth of primary literature on these two agents in the general population. All prescribed medications for the management of hypertension and depression were recorded for each patient, including name, dose and frequency, at one time only on entry into the study. Drugs used for erectile dysfunction were not included since they were not commercially available in DOPPS I and rarely used in DOPPS II. The actual consumption of prescribed medicines was not recorded.

All patients in DOPPS I were administered a Kidney Disease Quality of Life (KDQoL) Short Form-36 (SF-36) survey at the time of entry into the study. Included in the survey were four questions about aspects of each patient's sexual function: (i) Have you had sex within the last four weeks? (ii) Have you had any problems with enjoyment of sex due to kidney disease? (iii) Have you had any problems with sexual arousal? and (iv) Is your sex life bothered by end-stage renal disease? One other question concerning patients’ sex lives was asked: Is your sex life worse with end-stage renal disease? For the question about whether patients had had any sexual activity in the previous 4 weeks, the possible responses were no or yes. For each of the other four questions, patients were able to respond on a 5-point Likert scale.

For the question about whether patients’ sex lives were bothered by ESRD, the possible responses ranged from 1 (not bothered at all) to 5 (extremely bothered). Those individuals who had had sexual activity in the 4 weeks before entering the study were asked to rate their enjoyment of it on a scale from 1 (not a problem) to 5 (severe problem). Possible responses to the question about difficulty with becoming sexually aroused ranged from 1 (not a problem) to 5 (severe problem). For the question about patients’ sex lives before and after ESRD, patients were able to respond on a 4-point scale, ranging from 1 (more satisfactory now than before kidney failure) to 4 (much less satisfactory now than before kidney failure).

We created a composite sexual dysfunction scale for the three questions relating to enjoyment, arousal and sex life among patients with ESRD, where the composite minimum score was 3 (little or no dysfunction) and the composite maximum score was 15 (the greatest amount of dysfunction). In order to be eligible for a sexual dysfunction score, a patient must have answered all three questions involved in the scale. Only one question about sexual dysfunction was asked of patients in DOPPS II. The question, Is your sex life bothered by ESRD?, had a range of possible responses from 1 to 5, as above. In DOPPS II the KDQoL SF-12 was used.

Statistical methods
The main outcome variables of interest were associations of sexual dysfunction with the use of anti-hypertensive agents and anti-depressives. Prevalence percentages from DOPPS I were calculated from a cross-section taken during 1999 (n = 5476) since all countries had entered the study by this time. To estimate the overall proportions of anti-hypertensive and anti-depressive medication use by country, we used sample weights to account for the differing proportion of patients sampled in each facility. This allowed our sample to represent all patients from a given facility.

Logistic regression models were employed to examine predictors of the four different types of sexual dysfunction. Patient characteristics included age, gender, race, time on ESRD, marital status, self-reported depression, ability to ambulate, geographic region, other medication use [non-steroidal anti-inflammatory drugs (NSAID), corticosteroids, oral iron, acetaminophen, narcotics for pain relief, SSRIs and tricyclic antidepressives], the year of the patient's enrolment in the study, country of residence, 14 comorbid conditions [coronary artery disease (CAD), congestive heart failure (CHF), cardiac disease other than CAD or CHF, hypertension, diabetes, cerebrovascular disease, peripheral vascular disease (PVD), cancer, HIV/AIDS, lung disease, neurologic disorders, psychiatric disease, gastrointestinal bleed and recurrent cellulitis/gangrene], hypotensive episodes during dialysis [defined as a drop in systolic blood pressure (SBP) of >30 mmHg, or a decrease of SBP to <100 mmHg] and responses to two questions concerning self-reported depressive symptoms (Have you ever felt downhearted and blue? and Have you felt so down in the dumps that nothing could cheer you up?). For the two questions about depressive symptoms, a good bit of the time, most of the time and all of the time were considered yes responses, and none of the time, a little of the time and some of the time were considered no responses.

Patients’ responses to the three questions about problems with enjoyment or arousal and being bothered by ESRD were dichotomized as yes (having a problem) or no (not having a problem). Patients who answered some problem, moderate problem or severe problem were considered to have a problem, and patients who responded no problem or small problem were considered to not have a problem. In response to the question about whether the patient's sex life was better or worse than before they had ESRD, answers of less satisfactory than before or much less satisfactory than before were considered yes (having a problem), whereas the same or more satisfactory than before were considered no (not having a problem). When using the sexual dysfunction score as an outcome, mixed linear regression was employed using the same adjustments as above.

For the logistic regression models, generalized estimating equations were used to account for clustering at the facility level, assuming a compound symmetry covariance structure (SAS/STAT User's Guide, Version 8; SAS Institute; Cary, NC; 1999 Volume 2; p. 1452). All analyses were performed using the SAS statistical package, version 9.1 (SAS Institute, Cary, NC).



   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Acknowledgements
 References
 
Data for 7346 patients from a January 1999 cross-section in 308 dialysis facilities in DOPPS I and 8891 patients from 320 facilities in DOPPS II were available for analysis. Patient demographics and comorbidities are shown in Table 1. On average, patients were older (mean age 59 years), were more likely to be male (58%), had been on dialysis for more than 5 years and had numerous comorbid conditions. There were more blacks in DOPPS I (17%) than in DOPPS II (8.6%). There were slight differences in comorbidities between groups, especially for those with CAD, cancer and PVD. There were marked differences in the prescription of medications, with more patients in DOPPS II prescribed ß-blockers, ARBs, loop diuretics, SSRIs and benzodiazepines.


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  		Table 1. Patient demographics and comorbidities (prevalent cross-section of DOPPS I and DOPPS II)

 
The proportion of patients who reported having had sex within 4 weeks of taking the survey ranged from 20.8% (Spain) to 27.4% (Italy) (DOPPS I data only). Figure 1 demonstrates the proportion by country of patients who had sexual dysfunction. Between 30% and 54% of patients complained that their sex life was bothered by ESRD, with very little variation between DOPPS I and DOPPS II databases. There was substantial inter-country variability, with the lowest reports from Japan and the highest from Italy and Germany. Slightly fewer patients reported having problems with sexual arousal, ranging from 35% (Italy) to 51% (Germany). The proportion of patients who reported problems with enjoyment of sexual activity ranged from 29% (France) to 48% (Germany). The proportion of patients who reported that their sex life was worse with ESRD ranged from 29% (Italy) to 47% (France) (data not shown). The proportion reporting that they had any form of sexual dysfunction varied from 66.4% (France) to 84.5% (Spain). The mean composite sexual dysfunction score (with a possible range from 4 to 12) ranged from 6.4 (Spain) to 7.9 (Germany) (data not shown).


Figure 1
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  		Fig. 1. Percent of patients who reported having sexual problems, by country for cross-section of prevalent HD patients, DOPPS I, 1997–2002, DOPPS II, 2002–04, weighted for facility size. DOPPS II is not included in enjoyment or arousal. Enjoyment = Have you had any problems with enjoyment of sex due to kidney disease? Arousal = Have you had any problems with sexual arousal? Bother DOPPS I = Is your sex life bothered by end-stage renal disease? (responses from DOPPS I data only) Bother DOPPS II = as above (responses from DOPPS II data only).

 
Patients in DOPPS I and DOPPS II had many non-medication-related variables associated with having sexual problems (Table 2). In DOPPS I, variables associated with the greatest odds of having problems of sexual enjoyment and arousal were increasing age, male gender, longer time on dialysis, being married, presence of diabetes and feelings of being down in the dumps or being blue. Decreased odds of these two problems in DOPPS I were associated with higher serum albumin and residence in France, Italy, Spain, or Japan (vs US) (Table 2). The question about whether patients’ sex lives were bothered by ESRD was asked both in DOPPS I and DOPPS II, and the responses were generally consistent. Increased odds of having one's sex life bothered by ESRD were associated with being male, increasing dialysis vintage, and the presence of gastrointestinal bleeds, diabetes and PVD. The odds were also increased by married status, feeling blue and residence in Germany or Italy (vs US). Overall, the proportion of patients in DOPPS II who reported that their sex lives were bothered moderately, bothered very much or extremely bothered by ESRD ranged from 30% (Japan) to 50% (Germany and Italy) (data not shown).


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  		Table 2. Predictors of having sexual problem (DOPPS I, unless specified) and of sex life bothered by ESRD*

 
Logistic regression was used to analyse the associations between the presence of various types of sexual dysfunction and the use of medication classes (Table 3). Analysis of data from DOPPS I showed statistically significant increases in the odds of patients having problems with arousal (OR = 1.29) and having their sex life bothered by kidney disease (OR = 1.18) with use of peripheral {alpha}-blockers and having elevated risks of arousal problems with use of central antagonists (OR = 1.19) and loop diuretics (OR = 1.24). However, the classes associated with the largest extent of sexual problems were SSRIs and benzodiazepines, which increased the odds of patients having problems with enjoyment (OR = 1.59 and 1.26, respectively) or arousal (OR = 1.70 and 1.24, respectively), or having their sex life bothered by ESRD (OR = 1.36 and 1.24 in DOPPS I and 1.30 and 1.31 in DOPPS II, respectively). Of all classes examined, only vasodilators demonstrated a reduction in odds of problems with sexual enjoyment (OR = 0.75).


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  		Table 3. OR of various types of sexual dysfunction associated with the use of different medications (DOPPS I data unless otherwise specified)

 
Mixed linear regression analysis showed that there were significant associations between composite sexual dysfunction score and the use of certain medications (Table 4). There were statistically significant elevations on the score (i.e. worsening sexual problems) with use of peripheral {alpha}-blockers (change in score of +0.41), tricyclics (+0.78), SSRIs (+0.80) and benzodiazepines (+0.50). Only vasodilators were associated with a reduction in score (i.e. improved function) (–0.57).


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  		Table 4. Difference in the composite sexual dysfunction score associated with the use of medications

 


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Acknowledgements
 References
 
This is the first study to examine aspects of medication use in haemodialysis patients that influence sexual activity and functioning, and to compare the findings between countries. It has resulted in a number of interesting findings.

Depending on which index is used, approximately one-quarter to one-half of all patients self-report some form of sexual dysfunction. Data from the general, non-kidney-disease population help to place this alarming proportion into context: an early report from the Massachusetts Male Aging Study, conducted from 1987 to 1989 in the area surrounding Boston, examined the prevalence of impotence in a community-based, random sample of non-institutionalized men aged between 40 and 70 years [14]. The report notes that the combined prevalence of all severities of impotence was 52% and that the prevalence of complete impotence tripled from 5% at 40 years to 15% at 70 years. Another study examined the prevalence and predictors of sexual dysfunction in men and women, using data from the National Health and Social Life Survey [1]. In a cohort of more than 1700 women and 1400 men aged 18–59 years, the authors reported sexual dysfunction among 43% of women and 31% of men. These data confirm other community-based studies, suggesting that sexual dysfunction occurs in 10–52% of men and 25–63% of women [15,16].

Other data exist that measure the extent of sexual dysfunction in dialysis populations. For example, Toorians et al. [17] showed a high prevalence of sexual dysfunction among both male and female haemodialysis, peritoneal dialysis and kidney transplant patients. Recent reviews by Palmer have examined the multifaceted pathophysiology of sexual dysfunction in uraemia, including uraemia per se, peripheral neuropathy, autonomic insufficiency, PVD and drug therapy [10]. In addition, a recent study of female Taiwanese haemodialysis patients showed that sexual dysfunction was associated with increased age, dyslipidemias depression, and quality of life [7].

Our study showed many interesting results pertaining to medications and sexual dysfunction. Both tricyclic anti-depressives and SSRIs increased the odds of suffering from a sexual dysfunction, which is consistent with findings from the general population [18]. Unfortunately, patients with a diagnosis of depression also have a worsened risk of sexual dysfunction, and so the overall effect on sexual function probably reflects improvements in clinical depression being offset by drug-induced difficulties. The potential for confounding by indication is further exacerbated by the fact that patients with severe depression may be more likely to be treated with anti-depressive agents and that the use of anti-depressives, in improving depression, may make adjustment for depression invalid. Between 3% and 6% of our patients were prescribed tricyclics or SSRIs, compared with about 16–17% who had a diagnosis of a psychiatric disorder. While the proportion of patients with a psychiatric disorder who suffer from depression is unknown, previous studies have suggested that patients with ESRD have a high rate of undiagnosed depression and a low rate of treatment for depression. Taken together, our findings that [1] SSRIs are associated with a 30–70% increase in the odds of sexual dysfunction and that [2] tricyclics are associated with a 32% increase in the odds of patients’ having their sex life worsened by ESRD suggest that any increase in the prescription of these agents for the management of depression must be given careful consideration.

Hypertension and antihypertensive agents have historically been associated with sexual problems, especially erectile dysfunction. Recently, Dusing [19] provided an extensive review of the literature related to hypertension and male sexual dysfunction, which provides a useful point of comparison for our study. Hypertension likely causes erectile dysfunction as one of the manifestations of atheroschlerotic vascular disease. Also, many anti-hypertensive medications tend to worsen sexual function due to their direct effects on the vascular system. With regard to ß-blockers, both ß-1-selective (e.g. atenolol) and -non-selective agents (e.g. carvedilol, propranolol) tend to be associated with a higher frequency of sexual problems than placebo in patients without kidney failure. Other anti-hypertensive drug classes, such as ACE inhibitors and calcium channel blockers (CCBs), have not been well studied with regard to sexual side effects, but they appear to have no major negative influence. Neither ß-blockers (except propranolol in one indicator), nor ACE inhibitors, nor CCBs had significant negative sexual effects in our study. Use of losartan and valsartan has been shown in preliminary studies to improve sexual function in hypertensive patients. In our study, ARBs were associated with an inconsistent effect on sexual function between the DOPPS I and DOPPS II data sets. Centrally acting sympatholytic agents and peripherally acting {alpha}-blocking agents are typically considered to have a high risk of association with sexual dysfunction. Of this group, the peripheral {alpha}-blockers demonstrated the most negative effects in our study. Our finding that vasodilators improve sexual enjoyment is consistent with earlier findings, and is probably related to increased genital blood flow associated with these agents. In summary, for patients with sexual dysfunction related to anti-hypertensive therapy, a reduction of the medication dose or a change to ARBs, ACE inhibitors or CCBs may help to alleviate the problem.

Benzodiazepines were associated with a high incidence of sexual dysfunction in our study of haemodialysis patients. This association was also shown in the study of nearly 2400 men enroled in the Massachusetts Male Aging Study [20]. In that study, adjustment for comorbidities and health behaviours resulted in just two classes of drugs (non-thiazide diuretics and benzodiazepines) having a statistically significant association with erectile dysfunction.

Only one question was used to determine sexual dysfunction from the DOPPS II data. Table 3 indicates that some 45.5% of the patients asked this question were from DOPPS II, which may raise a concern about the ability to detect true sexual dysfunction when using only one question. The purpose behind including the question as to whether patients’ sex lives were bothered by ESRD for DOPPS II was to confirm the results from DOPPS I concerning this question. All significant non-medication related predictors of patients having their sex life bothered by ESRD trend in the same manner between DOPPS I and DOPPS II (Table 2), and a similar consistency is demonstrated for medication-related predictors (Table 3). Very similar trends between countries in DOPPS I and DOPPS II are shown in Figure 1. Therefore, the results from DOPPS II validate those for this question in DOPPS I.

In conclusion, large proportions of our study patients reported that they had at least one sexual dysfunction. Sexual dysfunction was associated with the use of several anti-hypertensive and anti-depressive agents. With the large variation in prescription patterns between facilities and countries, perhaps clinicians should actively increase surveillance of sexual problems because of their association with decreased quality of life. Further study is required to see if the associations reported are true or causal.



   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
References
 
The DOPPS is supported by research grants from Amgen, Inc. and Kirin Brewery, Ltd. without restrictions on publications. This study was also partially supported by a grant from Renal Research Institute, LLC.

Conflict of interest statement.

We have had no involvements that might raise the question of bias in the work reported or in the conclusions, implications, or opinions stated. An earlier draft of this article was presented in part at the meeting of the American Society of Nephrology, St. Louis, MO, October 27-November 1, 2004 (Bailie GR, Elder SJ, Asano Y, Cruz JM, Fukuhara S, Lopes AA, Mapes DL, Mason NA, Mendelssohn DC, Young EW. Sexual dysfunction in haemodialysis (HD) patients: The Dialysis Outcomes and Practice Patterns Study (DOPPS) (abstract). J Am Soc Nephrol 2004; 15:619A).



   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

  1. Laumann EO, Paik A, Rosen RC. (1999) Sexual dysfunction in the United States: problems and predictors. JAMA 281:537–544.[Abstract/Free Full Text]
  2. Lopes AA and Bragg-Gresham JL, et al. (2003) Worldwide Dialysis Outcomes and Practice Patterns Study Committee. Health-related quality of life and associated outcomes among haemodialysis patients of different ethnicities in the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 41:605–615.[CrossRef][Web of Science][Medline]
  3. Turk S, Guney I, Altinepe L, et al. (2004) Quality of life in male haemodialysis patients: role of erectile dysfunction. Nephron Clin Pract 96:c21–c27.[CrossRef][Web of Science][Medline]
  4. Rosas SE, Joffe M, Franklin E, et al. (2003) Association of decreased quality of life and erectile dysfunction in haemodialysis patients. Kidney Int 64:232–238.[CrossRef][Web of Science][Medline]
  5. Krishnan R, Izatt S, Bargman JM, Oreopoulos D. (2003) Prevalence and determinants of erectile dysfunction in patients on peritoneal dialysis. Int Urol Nephrol 35:553–556.[CrossRef][Medline]
  6. Palmer BF. (2003) Sexual dysfunction in men and women with chronic kidney disease and end-stage kidney disease. Adv Ren Replace Ther 10:48–60.[CrossRef][Web of Science][Medline]
  7. Peng YS, Chiang CK, Kao TW, et al. (2005) Sexual dysfunction in female haemodialysis patients: a multicenter study. Kidney Int 68:760–765.[CrossRef][Web of Science][Medline]
  8. Palmer BF. (1999) Sexual dysfunction in uremia. J Am Soc Nephrol 10:1381–1389.[Free Full Text]
  9. Taylor MJ, Rudkin L, Hawton K. (2005) Strategies for managing sexual dysfunction induced by antidepressant medication: systematic review of randomized controlled trials. J Affect Disord 88:241–254.[CrossRef][Web of Science][Medline]
  10. Baldwin DS. (2004) Sexual dysfunction associated with antidepressant drugs. Expert Opin Drug Saf 3:457–470.[CrossRef][Medline]
  11. Manley HJ, Garvin CG, Drayer DK, et al. (2004) Medication prescribing patterns in ambulatory haemodialysis patients: comparisons of USRDS to a large not-for-profit dialysis provider. Nephrol Dial Transplant 19:1842–1848.[Abstract/Free Full Text]
  12. Young EW, Goodkin DA, Mapes DL, et al. (2000) The Dialysis Outcomes and Practice Patterns Study (DOPPS): an international haemodialysis study. Kidney Int 57:[Suppl 74], S74–S81.
  13. Goodkin DA, Mapes DL, Held PJ. (2001) The Dialysis Outcomes and Practice Patterns Study (DOPPS): how can we improve the care of haemodialysis patients? Semin Dial 14:157–159.[CrossRef][Web of Science][Medline]
  14. Feldman HA, Goldstein I, Hatzichristou DG, et al. (1994) Impotence and its medical and psychosocial correla. J Urol 151:54–61.[Web of Science][Medline]
  15. Rosen RC, Taylor JF, Leiblum SR, et al. (1993) Prevalence of sexual dysfunction in women: results of a survey of 329 women in an outpatient gynecologic clinic. J Sex Marital Ther 19:171–188.[Web of Science][Medline]
  16. Spector IP and Carey MP. (1990) Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature. Arch Sex Behav 19:389–408.[CrossRef][Web of Science][Medline]
  17. Toorians AWFT, Janssen E, Laan E, et al. (1997) Chronic renal failure and sexual functioning: clinical status versus objectively assessed sexual response. Nephrol Dial Transplant 12:2654–2663.[Abstract/Free Full Text]
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  20. Derby CA, Barbour MM, Hume AL, et al. (2001) Drug therapy and prevalence of erectile dysfunction in the Massachusetts Male Aging Study cohort. Pharmacother 6:676–683.
Received for publication: 2. 8.06
Accepted in revised form: 17.11.06


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