End stage renal disease affects approximately 500 people per million in the United States. Of these, about 100 qualify as candidates for transplantation. The indications for transplantation change yearly. New techniques and medications have greatly affected our philosophy regarding these patients. Dialysis is usually offered to the patient with end stage renal disease first; after a period of maintenance dialysis, transplantation is offered. There is a growing trend to transplant patients earlier, even without initially using maintenance dialysis. This is especially true in the subgroup of diabetics who characteristically do rather poorly on dialysis.
Distressing situation arises when consideration of termination of life-supporting therapy arises. This may occur in five circumstances: (1) patients undergoing acute dialysis in whom chronic dialysis is not considered appropriate; (2) chronic dialysis with extreme physical complications; (3) chronic dialysis with extreme psychosocial problems; (4) chronic dialysis with patient and/or family requests to terminate treatment; (5) chronic dialysis and successful transplant with loss of allograft function and refusal to return to dialysis. (Linda M. Whiteford, Marilyn L. Poland, 1989).
By the time dialysis is required to sustain life, many patients have already experienced diminished sexual functioning. The dysfunction may be physiological or psychosocial in nature and is intertwined with other problems such as depression, modified body image, and compliance. Anemia, uremia, middle molecules, secondary hyperparathyroidism, low zinc, and deficient hormone levels may, individually or collectively, physiologically result in impotence or diminished sexual responsiveness. Loss of job, social life, health, physical image, and even the ability to urinate may have significant negative effects on self-esteem and resultant sexual performance. Patients may require help in mourning the loss of normal sexual functioning; however, they should also receive assistance in identification of alternatives that can minimize the sense of loss. Recognition of the importance of sexuality in normal adult life reinforces the patient's perception of being an adult.
