RE: Kidney transplantation and donation in the transgender population: A single-institution case series.

Abstract

To the Editor: Kidney transplant in the transgender population is a multidisciplinary subject that is increasing in prevalence due to advances in kidney transplant and greater access/acceptance to gender affirmation care. Although case reports have been published on these patients, Ramadan et al published one of the first case series on kidney transplant and donation within the transgender population.1Ramadan OI, Naji A, Levine MH, et al. Kidney transplantation and donation in the transgender population: a single-institution case series [published online ahead of print 2020]. Am J Transplant. https://doi.org/10.1111/ajt.15963Google Scholar In a series of 4 renal transplant recipients, all patients have functioning grafts at a median follow-up of 786 days. The study includes the mean serum creatinine at 1 month and 2 years postoperatively as a marker of renal function. Although serum creatinine is used as a surrogate for estimated glomerular filtration rate (eGFR) in most renal transplant recipients, perhaps renal function should be assessed differently in transgender patients. An accurate assessment of renal function is essential for the management of kidney transplant recipients. A recent review of gender-affirming hormone therapy and serum creatinine concentration found that serum laboratory values were more similar to identified gender than birth-assigned gender in 3 of 4 studies.2Webb AJ McManus D Rouse GE Vonderheyde R Topal JE. Implications for medication dosing for transgender patients: a review of the literature and recommendations for pharmacists.Am J Heal Pharm. 2020; 77: 427-433Crossref PubMed Scopus (16) Google Scholar The authors ultimately recommended that creatinine clearance and ideal body weight calculations should be calculated with identified gender if hormonal therapy has been taken for at least 6 months.2Webb AJ McManus D Rouse GE Vonderheyde R Topal JE. Implications for medication dosing for transgender patients: a review of the literature and recommendations for pharmacists.Am J Heal Pharm. 2020; 77: 427-433Crossref PubMed Scopus (16) Google Scholar While this recommendation is helpful for the medication dosing of most transgender patients, serum creatinine clearance may not be the best marker of renal function in transgender patients when accurate assessments are necessary. Urinary inulin clearance and serum cystatin C are not affected by muscle mass and are less affected by sex compared with serum creatinine.3Jue JS Alameddine M Ciancio G. Kidney transplantation in transgender patients.Curr Urol Rep. 2020; 21: 1Crossref PubMed Scopus (8) Google Scholar Although inulin clearance has been primarily restricted to the research setting due to financial and labor costs, it is considered the gold standard measurement of eGFR and should be used in settings where serum creatinine is unreliable.3Jue JS Alameddine M Ciancio G. Kidney transplantation in transgender patients.Curr Urol Rep. 2020; 21: 1Crossref PubMed Scopus (8) Google Scholar An accurate understanding of renal function is necessary to appropriately assess the status of the renal allograft and manage immunosuppression/hormone regimens. The case series by Ramadan et al1Ramadan OI, Naji A, Levine MH, et al. Kidney transplantation and donation in the transgender population: a single-institution case series [published online ahead of print 2020]. Am J Transplant. https://doi.org/10.1111/ajt.15963Google Scholar highlights the importance of a multidisciplinary team with close psychiatric screening. Within the discussion, there is mention of a transplant social worker who annually assesses patient appropriateness for transplant and decides if transplant psychiatry is necessary. In addition to psychosocial screening, it is also essential to regularly screen for noncompliant behavior before transplant.3Jue JS Alameddine M Ciancio G. Kidney transplantation in transgender patients.Curr Urol Rep. 2020; 21: 1Crossref PubMed Scopus (8) Google Scholar Recipient 1 had pyelonephritis, urosepsis, and transplant kidney abscess within the first postoperative year due to medication nonadherence.1Ramadan OI, Naji A, Levine MH, et al. Kidney transplantation and donation in the transgender population: a single-institution case series [published online ahead of print 2020]. Am J Transplant. https://doi.org/10.1111/ajt.15963Google Scholar These complications could have resulted in allograft loss and even death if not treated early and appropriately. Multiple tools have been used to evaluate patients before transplant, including the Psychosocial Assessment of Candidates for Transplantation, Stanford Integrated Psychosocial Assessment for Transplant, Transplant Evaluation Rating Scale, INTERMED, Psychosocial Assessment Tool, and Psychosocial Transplant Evaluation Scale.3Jue JS Alameddine M Ciancio G. Kidney transplantation in transgender patients.Curr Urol Rep. 2020; 21: 1Crossref PubMed Scopus (8) Google Scholar While helpful, there is marked heterogeneity in the use of these instruments among transplant programs. Nevertheless, the presence of 1 of 4 renal transplant recipients having significant complications from medication nonadherence underscores the importance of appropriately screening this high-risk population before transplantation. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.