Testosterone therapy in chronic kidney disease patients: an underutilized resource

Testosterone deficiency is highly prevalent in men with chronic kidney disease (CKD), affecting 30-70% of patients depending on disease stage and diagnostic criteria. Despite its frequency and association with adverse outcomes including anemia, malnutrition, muscle wasting, cardiovascular disease, and impaired quality of life, testosterone replacement therapy (TRT) remains underutilized in this population. This review synthesizes evidence from randomized controlled trials, prospective registries, and observational studies demonstrating that TRT in CKD patients produces clinically meaningful improvements in hematologic parameters, nutritional markers, muscle strength, body composition, sexual function, and quality of life. Emerging observational data suggest potential renoprotective effects, with treated patients showing preserved or improved estimated glomerular filtration rate compared to untreated controls. Cardiovascular safety data from large trials indicate noninferiority to placebo for major adverse cardiac events, though vigilance for atrial fibrillation and acute kidney injury is warranted. Importantly, transdermal testosterone gel formulations offer superior pharmacokinetic profiles compared to intramuscular injections, providing stable physiological testosterone levels without supraphysiological peaks and consequently lower risk of excessive erythrocytosis. Given the substantial burden of hypogonadism in CKD and accumulating evidence of therapeutic benefit, systematic screening and individualized treatment of testosterone deficiency should be integrated into comprehensive CKD management.