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Response to Comment: Testosterone deficiency in men with end-stage renal disease and kidney transplantation: a narrative review

International Journal of Impotence Research (2025)Cite this article

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We would like to thank Dr. Selman Unal for his thoughtful commentary regarding testosterone replacement therapy (TRT) in men with a history of testosterone deficiency (TD) and end-stage renal disease (ESRD) or prior renal transplantation [1]. In our review article, we concluded that low testosterone in this vulnerable population may contribute to negative health and wellness outcomes; while limited high-quality data exists to construct clinical guidelines for management, TRT in this population is safe and contributes to improvements in endocrine profiles, sexual and erectile function, bone mineral density, anemia, and potential graft survival for transplant recipients [2]. Dr. Unal raises concerns with TRT in this population including an increased risk of prostate cancer (PC), altered PSA interpretation, and limited eligibility for multiparametric MRI (mpMRI).

We agree there is no existing data currently linking TRT to subsequent development of PC. While exogenous TRT in the setting of locally advanced or metastatic PC can aggravate disease progression, current evidence based on retrospective studies suggests TRT does not increase risk of progression or recurrence following definitive surgical or radiation treatment [3, 4]. Thus, unless there is an indication for androgen deprivation for management of PC, there seems to be no justification to deprive men of achieving eugonadal levels by TRT given its safety and significant beneficial impact on quality of life. Additionally, men without a pre- existing PC diagnosis did not demonstrate an increased risk for development the disease following initiation of TRT [5]. The TRAVERSE study was a placebo-controlled, double-blind randomized clinical trial that compared outcomes of men with hypogonadism based on receipt of topical TRT (1.62%) versus placebo; the study found that TRT was associated with low and similar incidence of high-grade or any PC compared to placebo [6]. Thus, while a routine discussion of risks and benefits of TRT should be part of shared decision- making, TRT appears to be a reasonable option in management of hypogonadism in appropriately selected men with ESRD.

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Authors and Affiliations

  1. Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

    Charles Rinehart, Kimberly Waggener, Nicholas A. Deebel & Ryan Terlecki

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  1. Charles Rinehart
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  2. Kimberly Waggener
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  3. Nicholas A. Deebel
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Contributions

CR was responsible for writing original draft as well as reviewing and editing. KW was responsible for writing original draft. ND was responsible for conceptualization, supervision, and writing (reviewing & editing). RT was responsible for conceptualization, supervision, and writing (reviewing & editing).

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Correspondence to Nicholas A. Deebel.

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Rinehart, C., Waggener, K., Deebel, N.A. et al. Response to Comment: Testosterone deficiency in men with end-stage renal disease and kidney transplantation: a narrative review. Int J Impot Res (2025). https://doi.org/10.1038/s41443-025-01097-4

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