LAUSR

It is important that healthcare professionals are aware of the unique considerations and challenges of kidney transplantation in transgender patients, as both kidney transplantation and gender affirmation treatments are becoming more prevalent. We understand that there is no consensus on many of the topics discussed in our review and encourage discussion regarding the data and recommendations from our review. Despite advances in transgender healthcare since the early 2000s, this patient population still has a high prevalence of psychiatric and medical comorbidities. A recent systematic review from 2016 highlights the prevalence of depression as high as 64.2% in a study of 573 patients [1] and 63.0% in a study of 230 patients [2]. These studies utilized the Center for Epidemiologic Studies Depression Scale (CESD) as their assessment instrument [1, 2]. Despite a uniform assessment for depression, transgender studies are limited by heterogenous transgender populations and timeframes [3]. While the reply authors note that lower estimates of transgender depression exist, they are wrong to assert that high estimates have not been found in large contemporary cohorts. Medical compliance and adherence are essential to prevent acute rejection, chronic rejection, and allograft loss [4]. Identifying and addressing risks to noncompliance preoperatively are of paramount importance. While the reply authors may focus on the details of the National Center for Transgender Equality survey, Hoch wrote that “17% refused medical care due to gender expression” [5]. These statistics from the medical literature are important to note, since noncompliance can jeopardize the health of the allograft and patient. Our review also acknowledges the special considerations of hormone status in transgender renal transplant recipients. The interactions between the patient’s reproductive organs and hormone therapy with the renal transplantation drugs are difficult to predict and may affect renal function, serum hormone levels, and physical appearance [6, 7]. The specific source and composition of the hormone therapy should be noted, since a study of 433 individuals found that 26.8% of patients currently using hormones had a history of nonprescribed hormone use [8]. Our recommendation to perform a more detailed medication history is intended to increase patient safety. The reply authors incorrectly compare the prevalence of nonprescribed gender affirming hormone use with nonprescription opioid use. In summary, the patient and transplant team should discuss the potential consequences of these interactions and how they may affect the patient’s gender affirmation treatment goals. Our discussion points and recommendations can be evaluated in relation to a recent series of transgender renal transplant recipients. This series found that 1/4 patients had significant complications from medication nonadherence [9]. The patient from this series suffered from pyelonephritis, urosepsis, and transplant kidney abscess within the first postoperative year. These complications could have resulted in allograft loss or even death if not detected and treated early. Although this is a small patient series, it underscores the prevalence and potential consequences of medical noncompliance in this patient population. While large-scale, controlled studies are needed to further understand transgender needs, our published recommendations are intended to identify individuals who need additional resources to care for their renal allograft. The reply authors misconstrue special preoperative assessment and counseling This article is part of the Topical Collection on Kidney Diseases