Providing Care for Transgender Persons With Kidney Disease: A Narrative Review

Abstract

Purpose of review: Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients. Sources of information: Original research articles were identified from MEDLINE and Google Scholar using the search terms “transgender,” “gender,” “sex,” “chronic kidney disease,” “end stage kidney disease,” “dialysis,” “transplant,” and “nephrology.” Methods: A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons. Key findings: Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making. Limitations: There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants. Implications: This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

Transgender Person and Pre-Exposure Prophylaxis for HIV: A Renal Dilemma

“…There is no literature suggesting the ranges that should be used when faced with such a dilemma, such as this case, apart from one recent article that discusses the approach to estimated glomerular filtration rate in the transgender population [9]. It has been suggested that both male and female sexes should be considered in eGFR equations for transgender persons on gender-affirming hormone therapy that would provide a range of eGFR by sex that can be narrowed by deciding on which value likely reflects the muscle mass of the patient to which the calculations were applied.…”

“…It has been suggested that both male and female sexes should be considered in eGFR equations for transgender persons on gender-affirming hormone therapy that would provide a range of eGFR by sex that can be narrowed by deciding on which value likely reflects the muscle mass of the patient to which the calculations were applied. That value of muscle mass can then be used for dosing medications [9].…”

Assessment of Renal Function in Transgender Patients With Kidney Disease

“…Collister et al reviewed some of the literature surrounding serum creatinine changes after gender affirmation care and found that creatinine increases approximately 5 to 10 µmol/L in transgender men and decreases 5 to 10 µmol/L in transgender women. 3 In contrast, a recent review found that serum laboratory values were more similar to identified gender than birth-assigned gender in three-fourths studies. 4 The review recommended that creatinine clearance should be calculated with the patient’s identified gender if hormonal therapy had been taken for at least 6 months.…”

“… 1 , 2 As Collister et al mention in a recent review, “Providing Care for Transgender Persons With Kidney Disease: A Narrative Review,” an accurate estimated glomerular filtration rate (eGFR) is essential in the assessment and treatment of CKD and its associated comorbidities. 3 From our experience, the assessment of renal function should begin with a thorough understanding of the patient’s physical anatomy, medical/surgical history, medication history, and serum lab value history. Collister et al reviewed some of the literature surrounding serum creatinine changes after gender affirmation care and found that creatinine increases approximately 5 to 10 µmol/L in transgender men and decreases 5 to 10 µmol/L in transgender women.…”

A Retrospective Analysis of Creatinine-Based Kidney Function With and Without Sex Assigned at Birth Among Transgender Adults

“…In vivo and population-based cohort data describe conflicting effects of sex hormones on kidney function. 6 Although it is unclear whether hormone therapy influences kidney function directly, it typically causes marked physiologic and body composition changes within months after initiation among transgender adults. 7 Increased or decreased percent lean muscle mass, and corresponding increases or decreases in serum creatinine concentrations, may alter creatinine-based kidney function estimating equations.…”