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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 175-180

Impact of renal transplant on gonadal function


1 Department of Nephrology, Amrita Institute of Medical Sciences, Ernakulam, Kerala, India
2 Department of Statistics, Amrita Institute of Medical Sciences, Ernakulam, Kerala, India

Date of Web Publication28-Dec-2017

Correspondence Address:
Kartik Ganesh
Department of Nephrology, Amrita Institute of Medical Sciences, Ponekkara, Edappally, Ernakulam - 682 041, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_43_17

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  Abstract 

Objectives: We aimed at creating a clinical profile of end-stage renal disease patients' gonadal function and assessing the impact of renal transplant on gonadal dysfunction. We studied the influence of age, vascular anastomosis, dialysis vintage, and immunosuppression on sexual dysfunction. Materials and Methods: Twenty adults were included. Hormones (luteinizing hormone [LH], follicle-stimulating hormone [FSH], testosterone, prolactin (PRL), and estrogen), menstrual history and International Index of Erectile Function (IIEF)-5 questionnaires were assessed before and after renal transplantation. Hormone evaluation was done by chemiluminescent microparticle immunoassay technology. Results: Seventeen patients were male and three patients were female. Native kidney diseases were chronic glomerulonephritis (10%), IgA nephropathy (20%), autosomal dominant polycyctic kidney disease (5%), diabetic nephropathy (5%), focal segmental glomerulosclerosis (5%), renal calculus disease (5%), membranous nephropathy (5%), and pauci-immune vasculitis (5%). Fifteen males had erectile dysfunction (ED) before transplant. Eleven patients showed an increase and six patients showed a decrease in IIEF scores posttransplantation. Statistically significant changes were observed in the mean levels of testosterone, LH, PRL, and FSH. Age at transplant showed a negative correlation with IIEF score. In five patients with an end to side anastomosis to the external iliac artery, all had an increase in IIEF score posttransplant. In 12 patients with an end to end anastomosis to the internal iliac artery, 5 patients (42%) had a decrease in IIEF score posttransplant. Conclusions: Incidence of ED was 88% in our study. About 65% patients showed an increase in IIEF score posttransplantation. Increasing age at the time of transplant was a significant risk factor for the presence of ED. Renal transplantation corrected hormonal abnormalities in men. About 100% of patients with an end to side arterial anastomosis showed improvement in IIEF scores. There was no effect of dialysis vintage and immunosuppression regimes on sexual dysfunction.

Keywords: Erectile dysfunction, gonadal function, renal transplant


How to cite this article:
Ganesh K, Kurian G, Sreedharan S, Paul Z, Mathew A, Unnikrishnan U G, Nair RR. Impact of renal transplant on gonadal function. Indian J Transplant 2017;11:175-80

How to cite this URL:
Ganesh K, Kurian G, Sreedharan S, Paul Z, Mathew A, Unnikrishnan U G, Nair RR. Impact of renal transplant on gonadal function. Indian J Transplant [serial online] 2017 [cited 2018 Dec 10];11:175-80. Available from: http://www.ijtonline.in/text.asp?2017/11/4/175/221852


  Introduction Top


Gonadal dysfunction is well documented in patients with end-stage renal disease. This occurs due to impaired spermatogenesis and testicular damage. The normal sexual function is an important component of quality of life. The symptoms of sexual dysfunction start early with declining Glomerular filtration rate and are rarely improve after starting dialysis. The etiology of these symptoms is complex and multifactorial. Clinically, sexual dysfunction may present as decreased libido, erectile dysfunction (ED), and anovulatory cycles in females. Multiple studies have attempted to record incidence of sexual dysfunction in this population of patients. Up to 50% of uremic, men have complaints of ED and both men and women complaint of decreased libido and a marked decline in the frequency of intercourse.[1],[2] The causes of sexual dysfunction are multifactorial. The uremic milieu, peripheral neuropathy, autonomic insufficiency, peripheral vascular disease, and drug therapy all contribute to sexual dysfunction. A functioning renal transplant may restore normal sexual activity, although some features of reproductive function may remain impaired.[3],[4] Various mechanisms operate in men and women with chronic renal failure. Chronic renal failure is associated with impaired spermatogenesis and testicular damage, often leading to infertility.[1],[3] These abnormalities are often apparent early in the course of illness, often before the need for dialysis and then deteriorate further once dialytic therapy is initiated. A defect in the hormonal regulation of the Leydig and Sertoli cells has been implicated. Total and free testosterone levels are typically reduced.[5],[6],[7] The total plasma estrogen concentration is often elevated in advanced renal failure.[5] Follicle-stimulating hormone (FSH) secretion is also increased in men with chronic renal failure, such that the lutenizing hormone [LH/FSH] ratio is typically increased. Clinically, all these endocrine abnormalities manifest in men as ED and/or infertility and in women with anovulatory cycles.[8] The prevalence of ED increases with age, with 25%, 55%, and 65% of men aged 65, 75, and 80 years old, respectively, reporting the disorder.[9] Diabetes mellitus and depression also contribute. Whether this improvement in sex hormones correlated with better sexual activity, given the multifactorial nature of sexual dysfunction in uremia is not fully established. The role of vascular anastomosis of the graft has also been a matter of concern in the context of posttransplant impotence. Unilateral ligation of the internal iliac artery has a negative role on hemodynamic parameters compared to unilateral end-to-side anastomosis to the external iliac artery. We attempted to study some of these factors in our study population.


  Materials and Methods Top


Twenty adults undergoing renal transplantation were included in the study. Hormone measurements (LH, FSH, Testosterone, prolactin [PRL], Estrogen), menstrual history, and International Index of Erectile Function (IIEF)-5 questionnaire were assessed before and after renal transplantation. Major drugs causing ED such as beta blockers, alpha blockers, spironolactone, and thiazide diuretics were withdrawn 6 months before starting the study. Hormone evaluation was done through chemiluminescent microparticle immunoassay technology. To test the statistical significance of mean hormone levels from pre- to post-renal transplantation, Wilcoxon signed rank test was applied. To test the statistical significance of mean percentage change in hormone levels from prerenal to postrenal transplantation with respect to IIEF-5 score (increase/decrease), Mann–Whitney U-test was applied. To obtain the correlation between age and IIEF-5 score pre-transplant Karl Pearson's correlation was used. The study was cleared by the Institution's Ethical Committee.


  Results Top


Demographics

Seventeen (85%) patients were male and three (15%) patients were female. Nine patients (45%) were aged <35 years, six patients (30%) were aged 35–50 years and five patients (25%) were more than 50 years of age. Ten patients (50%) had presumed chronic glomerulonephritis, four patients (20%) had IgA nephropathy, and there was one patient each (5% each) of autosomal dominant polycystic kidney disease, Diabetic nephropathy, focal segmental glomerulosclerosis, renal calculus disease, membranous nephropathy, and pauci-immune vasculitis. Out of 17 males, 15 (88%) had ED as defined by IIEF score of <22, and 2 patients (12%) had no ED before transplant [Figure 1]. Eleven patients (65%) showed an increase in IIEF score and six patients (35%) showed a decrease in IIEF score postrenal transplantation [Figure 2].
Figure 1: Incidence of erectile dysfunction prior to renal transplantation

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Figure 2: International Index of Erectile Function scores postrenal transplantation

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Hormone analysis in males (n = 17)

Mean serum testosterone increased from 25.07 (±14.23 standard deviation [SD]) nmol/L to 32.01 (±15.79 SD) nmol/L (P = 0.003). Mean serum estradiol increased from 25.47 (±11.69 SD) pg/ml to 26.18 (±10.63 SD) pg/ml (P = 0.925). Mean serum LH decreased from 7.48 (±3.68 SD) mIU/ml to 6.21 (±3.25 SD) mIU/ml (P = 0.039). Mean serum FSH decreased from 4.65 (±3.11 SD) mIU/ml to 3.79 (±2.35 SD) mIU/ml (P = 0.055). Mean serum PRL decreased from 36.04 (±43.58 SD) ng/ml to 18.19 (±12.12 SD) ng/ml (P = 0.018). No change except for hifen between post and transplant. In men who had an increase in IIEF score post-transplant (n = 11), mean testosterone increased by 48% compared to an 18% increase in patients who had a decrease in IIEF score post-transplant (n = 6), (P = 0.366). Mean estradiol increased by 20% compared to a 6% increase in patients who had a decrease in IIEF score posttransplant (P = 0.315). Mean LH decreased by 4.9% compared to a 25% decrease in patients who had a decrease in IIEF score posttransplant (P = 0.269). Mean FSH increased by 14% compared to a 1.3% decrease in patients who had a decrease in IIEF score posttransplant (P = 0.651). Mean PRL increased by 20.3% compared to a 23% increase in patients who had a decrease in IIEF score posttransplant (P = 1.0) [Table 1].
Table 1: Change in mean hormone levels pre- and post-renal transplantation in men and women

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Hormone analysis in females (n = 3)

Mean serum testosterone decreased from 1.34 (±0.49 SD) nmol/L to 0.6 (±0.27 SD) nmol/L (P = 0.109). Mean serum estradiol increased from 38.33 (±13.32 SD) pg/ml to 75.67 (±29.02 SD) pg/ml (P = 0.109). Mean serum LH increased from 18.9 (±14.2 SD) mIU/ml to 23.4 (±11.29 SD) mIU/ml (P = 0.285). Mean serum FSH increased from 3.0(±0.7 SD) mIU/ml to 4.93(±0.9 SD) mIU/ml (P = 0.109). Mean serum PRL decreased from 29.63(±6.77 SD) ng/ml to 15.73(±3.56 SD) ng/ml (P = 0.109) [Table 1].

Risk factors

In patients with age <35 years, 2 patients (33.3%) had no ED, 3 (50%) had mild ED, and 1 (16.7%) had mild-moderate ED. In patients of age 35–50 years, 3 (50%) patients had mild ED and 3 (50%) had mild-moderate ED. In patients with age >50 years, 2 (40%) had mild ED, 2 (40%) had mild-to-moderate ED and 1 (20%) patient had severe ED. In patients with age <35 years, 3 patients (50%) had an increase in IIEF score postrenal transplant and 3 patients (50%) showed a decrease in IIEF score. In patients with age 35–50 years, 4 patients (66.6%) had an increase in IIEF score postrenal transplant and 2 patients (33.4%) showed a decrease in IIEF score. In patients with age >50 years, 4 patients (80%) had an increase in IIEF score postrenal transplant and 1 patient (20%) showed a decrease in IIEF score. Increasing age at time of transplant showed a negative correlation with IIEF score (r = −0.530, P = 0.02).

In patients who had an increase in IIEF score postrenal transplant (n = 11), 9 patients (82%) had a single donor artery, 1 patient (9%) had two donor renal arteries, and 1 patient (9%) had 3 donor arteries. Out of these, 7 patients' (63.6%) arterial anastomosis was to the internal iliac artery and 4 patients' (36.4%) arterial anastomosis was to the internal iliac artery. In patients who had a decrease in IIEF score postrenal transplant (n = 6), 4 patients (66.6%) had a single donor artery and 2 patients (33.4%) had two donor renal arteries. All 6 patients' (100%) arterial anastomosis was to the internal iliac artery. In 12 patients (70.5%), the graft artery was anastomosed end-to-end to the internal iliac artery. While 7 patients (58%) showed an increase in IIEF score posttransplant and 5 patients (42%) showed a decrease in IIEF score posttransplant. In 5 patients (29.5%), the graft artery was anastomosed end to side to the external iliac artery in 4 cases. All 5 patients (100%) showed an increase in IIEF score posttransplant.

In patients who had an increase in IIEF score postrenal transplant (n = 11), all were induced with basiliximab and were on maintenance immunosuppression with tacrolimus, mycophenolate mofetil (MMF), and steroid. In patients who had a decrease in IIEF score postrenal transplant (n = 6), 5 patients (83.3%) were induced with basiliximab and 1 patient (16.7%) was induced with anti-thymocyte globulin. All were on maintenance immunosuppression with tacrolimus, MMF and steroid.

The mean dialysis vintage in patients who had an increase in IIEF score postrenal transplant (n = 11) and in patients who had a decrease in IIEF score postrenal transplant (n = 6) was 4 months and 3.25 months, respectively.

Out of 3 female patients in the study, 1 patient had irregular menstrual cycles before renal transplant, which became normal after renal transplantation. None of them have conceived of this point.


  Discussion Top


In this study, we have defined ED according to the IIEF score [Figure 3]. Out of 17 males, 15 (88%) had ED as defined by IIEF score of <22, and 2 patients (12%) had no ED before transplant. This was at par with, indeed possibly slightly more than published literature evidence for ED in men with end-stage renal disease (ESRD), with some studies reporting an incidence of up to 50%[1],[2] and others reporting an incidence of about 50%–70% of sexual dysfunction in both male and female patients with ESRD on dialysis.[10] In our 3 female patients, one (33.33%) had irregular menstrual cycles before the transplant, which became regular 6 months after transplantation. Literature evidence regarding the effect of renal transplantation on patients with ED has been varied, with some demonstrating a regain of potency following renal transplantation,[11] some showing no benefit [12] and some showing an adverse effect on ED due to interference with penile arterial blood flow.[12] In our population, 11 patients (65%) showed an increase in IIEF score and 6 patients (35%) showed a decrease in IIEF score postrenal transplantation, demonstrating a benefit of renal transplantation on sexual function.
Figure 3: International Index of Erectile Function questionnaire

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We attempted to study few factors that may affect sexual potency. In our sample population, only one patient had diabetic nephropathy and none developed newonset diabetes after transplant in the follow-up period of 1 year. The lone patient with diabetic nephropathy had a pretransplant IIEF score of 16, which improved to 21 posttransplant. Diabetes is a proven cause of impotence in the ESRD population.[1],[2] The hypothalamic-pituitary axis was also studied in both men and women by assessing levels of 5 hormones-testosterone, estradiol, leutinizing hormone, FSH, and PRL before renal transplant and 6 months after renal transplant.

In 17 male patients in our study, statistically significant changes were observed in the Mean serum Testosterone, which increased from 25.07 (±14.23 SD) nmol/L to 32.01 (±15.79 SD) nmol/L (P = 0.003) and mean serum LH, and FSH, both of which decreased from 7.48 (±3.68 SD) mIU/ml to 6.21 (±3.25 SD) mIU/ml (P = 0.039) and 4.65 (±3.11 SD) mIU/ml to 3.79 (±2.35 SD) mIU/ml (P = 0.055), respectively. The Mean serum PRL also decreased from 36.04 (±43.58 SD) ng/ml to 18.19 (±12.12 SD) ng/ml and this change was statistically significant (P = 0.018). There was no significant change in estradiol levels in men (P = 0.925).

It is reasonably well established that in the uremic mileu, total and free testosterone levels are typically reduced,[5],[6],[7] total plasma estrogen is often elevated,[5] follicle-stimulating hormone (FSH) secretion is increased,[13],[14] and plasma PRL levels are elevated.[15] Studies have also demonstrated that serum testosterone level, sexual activities, and IIEF-5 score improve markedly after renal transplantation.[16],[17],[18] Whether this improvement in sex hormones correlates with better sexual activity, given the multifactorial nature of sexual dysfunction in uremia is not fully established. A study in China by Wang et al. assessed the effect of renal transplantation on a large cohort of patients with a follow-up period of 3 years and demonstrated improvement in hormonal profile, clinical sexual profile and fertility postrenal transplantation.[16] We also analyzed the difference in hormone profile between men who demonstrated an increase in the subjective qualitative IIEF score after renal transplant and those who did not [Table 2]. Patients who had an increase in IIEF score posttransplant showed an increase in mean testosterone levels increased by 48% compared to an 18% increase in patients who had a decrease in IIEF score posttransplant (P = 0.366). This theoretically corresponds with an increase in potency. LH levels also reduced in both groups, albeit not by more in the first group as expected. Estradiol and PRL showed marginal increases in both groups.
Table 2: Correlation between International Index of Erectile Function score change post renal transplant and mean percentage change in hormone levels

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These changes were not statistically significant, possibly with multiple confounding factors including low sample size age and time of collection.

Women, on the other hand, have a different hormonal physiology. In 3 female patients in the study, the Mean serum Testosterone and mean PRL showed a reduction, however, these were not statistically significant. The direction of the hormones is however theoretically expected. The change in LH and FSH is slightly more complicated to analyze as already described in the review of literature. All our patients were premenopausal, and two of them had no mentrual complaints, to begin with. In the patient who did have irregular menses, the serum testosterone and PRL levels reduced, and the LH and FSH levels showed an increase, in line with the overall trend. Estradiol however reduced in this patient postrenal transplant, whereas overall, the Mean serum Estradiol increased from 38.33 (±13.32 SD) pg/ml to 75.67 (±29.02 SD) pg/ml (P = 0.109).

The effect of age on sexual activity was also assessed, with increasing age a clear risk factor for worse baseline sexual function, this fact being supported by multiple studies.[9],[19] In fact, ED has been shown to be considerably more common in patients with ESRD than the control population, despite the transplant recipients being younger than those in the control group.[19] In our study, the severity of ED was also more with increasing age [Table 3]. In patients with age <35 years, 2 patients (33.3%) had no ED, 3 (50%) had mild ED, and 1 (16.7%) had mild-to-moderate ED. In patients of age 35–50 years, 3 (50%) patients had mild ED and 3 (50%) had mild-to-moderate ED. In patients with age >50 years, 2 (40%) had mild ED, 2 (40%) had mild-to-moderate ED, and 1 (20%) patient had severe ED. Thus, the grade of ED was higher above the age of 35.
Table 3: Age-wise distribution of severity of erectile dysfunction

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Response to renal transplant also varied with age. In patients with age <35 years, 3 patients (50%) had an increase in IIEF score compared to 66.6%–80% in the age groups of 35–50 years and >50 years, respectively [Table 4]. This may lead to two observations: (1) ED is evident at an early age and (2) The response in younger patients may depend on multiple factors (psychogenic, depression) rather than purely an improvement in the hormonal mileu or vascular anastomotic issues. 50%, 33.4%, and 20% patients had a decrease in IIEF score in the respective groups after renal transplant, also probably reflecting the multifactorial nature of the condition.
Table 4: Change in erectile dysfunction postrenal transplantation: Age distribution

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We also studied the role of vascular anastomosis of the graft in the context of ED in our 17 male patients. All renal veins were anastomosed to the external iliac vein in the end to side fashion. In 12 patients (70.5%), the graft artery was anastomosed end-to-end to the internal iliac artery. Out of these, 7 patients (58%) showed an increase in IIEF score posttransplant and 5 patients (42%) showed a decrease in IIEF score posttransplant. In 5 patients (29.5%), the graft artery was anastomosed end to side to the external iliac artery in 4 cases and the internal iliac artery in 1 case. All 5 (100%) showed an increase in IIEF score posttransplant. These results are consistent with the hypothesis that unilateral ligation of the internal iliac artery has a negative role on normal sexual function compared to unilateral end-to-side anastomosis to the external iliac artery. Studies have reported an up to 10% risk of vasculogenic impotence following anastomosis of renal graft end-to-end to internal iliac artery,[20] which has been seen to increase to 25%–65% in cases with a second transplant and a similar vascular anastomosis.[21],[22] Thus, the thought is that anastomosis of the graft to external iliac artery could preserve the potency to some degree.

There were no significant differences in the immunosuppressive regimens or mean dialysis vintage between men who demonstrated an increase in the subjective qualitative IIEF score after renal transplant and those who did not. Some studies have depicted the impact of sirolimus on male gonadal function.[23] Studies showed consistent evidence of sirolimus-related gonadal function suppression and increases in FSH and LH concentrations.[24] None of our patients were on mTor inhibitors.

The mean dialysis vintage in patients who had an increase in IIEF score postrenal transplant and in patients who had a decrease in IIEF score postrenal transplant was 4 months and 3.25 months, respectively. Some studies have identified time on dialysis as a risk factor for ED in the renal transplant population.[25]

This was not confirmed in our study. Other studies have also not documented the relation between duration of dialysis and ED.[26]

However, it should be noted that the patients in our current study only required dialysis for a short duration (mean 4 months), compared with studies that identified a relation between dialysis status and erectile function (28.5 months to 7.9 years).

The limitations of the study were:

  • A larger sample size would have been desirable, which was not possible due to financial constraints
  • Additional semen analysis would have been useful to correlate hormonal deficiencies with infertility quantitatively. This was not possible in our setup
  • There was no objective assessment of anovulatory cycles in women. A larger number of patients would be desirable
  • We have not assessed the role of clinical depression in ED which plays a major role in its causation
  • Long-term follow-up is required to truly assess fertility.



  Conclusions Top


ED is a common problem in patients with ESRD regardless of age. Incidence in our study was 88%. Sexual dysfunction is multifactorial - age, disturbed hypothalamo-pituitary axis, diabetes, depression, and sometimes transplantation itself (due to anatomy of vascular anastomosis) may be causative. Renal transplantation can alleviate many of the causes for sexual dysfunction. In our study, 65% patients showed an increase in IIEF score postrenal transplantation. Renal transplantation in men corrects hormonal abnormalities that occur in ESRD. In our study, we demonstrated a significant increase in serum testosterone and decrease in luteinizing hormone, follicle stimulating hormone and PRL in males postrenal transplant. Increasing age at the time of transplant was a significant risk factor for the presence of ED. Younger patients may respond better to corrective measures such as transplantation. About 100% of patients with an end to side arterial anastomosis showed improvement in IIEF scores as opposed to 58% of patients with an end-to-end anastomosis. End-to-side anastomosis may be an option in this regard. We found no significant effect of dialysis vintage and immunosuppression regimes on sexual dysfunction in our patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Procci WR, Goldstein DA, Adelstein J, Massry SG. Sexual dysfunction in the male patient with uremia: A reappraisal. Kidney Int 1981;19:317-23.  Back to cited text no. 1
[PUBMED]    
2.
Toorians AW, Janssen E, Laan E, Gooren LJ, Giltay EJ, Oe PL, et al. Chronic renal failure and sexual functioning: Clinical status versus objectively assessed sexual response. Nephrol Dial Transplant 1997;12:2654-63.  Back to cited text no. 2
[PUBMED]    
3.
Anantharaman P, Schmidt RJ. Sexual function in chronic kidney disease. Adv Chronic Kidney Dis 2007;14:119-25.  Back to cited text no. 3
[PUBMED]    
4.
Akbari F, Alavi M, Esteghamati A, Mehrsai A, Djaladat H, Zohrevand R, et al. Effect of renal transplantation on sperm quality and sex hormone levels. BJU Int 2003;92:281-3.  Back to cited text no. 4
[PUBMED]    
5.
Lim VS, Fang VS. Restoration of plasma testosterone levels in uremic men with clomiphene citrate. J Clin Endocrinol Metab 1976;43:1370-7.  Back to cited text no. 5
[PUBMED]    
6.
de Vries CP, Gooren LJ, Oe PL. Haemodialysis and testicular function. Int J Androl 1984;7:97-103.  Back to cited text no. 6
[PUBMED]    
7.
Levitan D, Moser SA, Goldstein DA, Kletzky OA, Lobo RA, Massry SG, et al. Disturbances in the hypothalamic-pituitary-gonadal axis in male patients with acute renal failure. Am J Nephrol 1984;4:99-106.  Back to cited text no. 7
    
8.
Lim VS, Henriquez C, Sievertsen G, Frohman LA. Ovarian function in chronic renal failure: Evidence suggesting hypothalamic anovulation. Ann Intern Med 1980;93:21-7.  Back to cited text no. 8
[PUBMED]    
9.
Morgentaler A. Male impotence. Lancet 1999;354:1713-8.  Back to cited text no. 9
[PUBMED]    
10.
Bailie GR, Elder SJ, Mason NA, Asano Y, Cruz JM, Fukuhara S, et al. Sexual dysfunction in dialysis patients treated with antihypertensive or antidepressive medications: Results from the DOPPS. Nephrol Dial Transplant 2007;22:1163-70.  Back to cited text no. 10
[PUBMED]    
11.
Burgos FJ, Pascual J, Gomez V, Orofino L, Liaño F, Ortuño J, et al. Effect of kidney transplantation and cyclosporine treatment on male sexual performance and hormonal profile: A prospective study. Transplant Proc 1997;29:227-8.  Back to cited text no. 11
    
12.
El-Bahnasawy MS, El-Assmy A, Dawood A, Abobieh E, Dein BA, El-Din AB, et al. Effect of the use of internal iliac artery for renal transplantation on penile vascularity and erectile function: A prospective study. J Urol 2004;172:2335-9.  Back to cited text no. 12
[PUBMED]    
13.
Prem AR, Punekar SV, Kalpana M, Kelkar AR, Acharya VN. Male reproductive function in uraemia: Efficacy of haemodialysis and renal transplantation. Br J Urol 1996;78:635-8.  Back to cited text no. 13
[PUBMED]    
14.
Phocas I, Sarandakou A, Rizos D, Kapetanaki A. Serum alpha-immunoreactive inhibin in males with renal failure, under haemodialysis and after successful renal transplantation. Andrologia 1995;27:253-8.  Back to cited text no. 14
[PUBMED]    
15.
Gómez F, de la Cueva R, Wauters JP, Lemarchand-Béraud T. Endocrine abnormalities in patients undergoing long-term hemodialysis. The role of prolactin. Am J Med 1980;68:522-30.  Back to cited text no. 15
    
16.
Guang-Chun W, Jun-Hua Z, Long-Gen X, Zhi-Lian M, You-Hua Z, Jun Q, et al. Measurements of serum pituitary-gonadal hormones and investigation of sexual and reproductive functions in kidney transplant recipients. Int J Nephrol 2010;2010:6.  Back to cited text no. 16
    
17.
Lessan-Pezeshki M, Ghazizadeh S. Sexual and reproductive function in end-stage renal disease and effect of kidney transplantation. Asian J Androl 2008;10:441-6.  Back to cited text no. 17
[PUBMED]    
18.
Shamsa A, Motavalli SM, Aghdam B. Erectile function in end-stage renal disease before and after renal transplantation. Transplant Proc 2005;37:3087-9.  Back to cited text no. 18
[PUBMED]    
19.
Malavaud B, Rostaing L, Rischmann P, Sarramon JP, Durand D. High prevalence of erectile dysfunction after renal transplantation. Transplantation 2000;69:2121-4.  Back to cited text no. 19
[PUBMED]    
20.
Hefty TB. Complications of renal transplantation: The practising urologist's role. AUA Update Ser 1991;10:58-63.  Back to cited text no. 20
    
21.
Taylor RM. Impotence and the use of the internal iliac artery in renal transplantation: A survey of surgeons' attitudes in the United Kingdom and Ireland. Transplantation 1998;65:745-6.  Back to cited text no. 21
[PUBMED]    
22.
Gittes RF, Waters WB. Sexual impotence: The overlooked complication of a second renal transplant. J Urol 1979;121:719-20.  Back to cited text no. 22
[PUBMED]    
23.
Fritsche L, Budde K, Dragun D, Einecke G, Diekmann F, Neumayer HH, et al. Testosterone concentrations and sirolimus in male renal transplant patients. Am J Transplant 2004;4:130-1.  Back to cited text no. 23
    
24.
Huyghe E, Zairi A, Nohra J, Kamar N, Plante P, Rostaing L, et al. Gonadal impact of target of rapamycin inhibitors (Sirolimus and Everolimus) in male patients: An overview. Transpl Int 2007;20:305-11.  Back to cited text no. 24
    
25.
Rebollo P, Ortega F, Valdés C, Fernández-Vega F, Ortega T, García-Mendoza M, et al. Factors associated with erectile dysfunction in male kidney transplant recipients. Int J Impot Res 2003;15:433-8.  Back to cited text no. 25
    
26.
El-Bahnasawy MS, El-Assmy A, El-Sawy E, Ali-El Dein B, Shehab El-Dein AB, Refaie A, et al. Critical evaluation of the factors influencing erectile function after renal transplantation. Int J Impot Res 2004;16:521-6.  Back to cited text no. 26
[PUBMED]    


    Figures

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