Impact of pre-transplant antiaggregant and anticoagulant therapies on early hemorrhagic and cardiovascular events after kidney transplantation

Musetti, Claudio; Quaglia, Marco; Cena, Tiziana; Battista, Michèle; Fenoglio, Roberta; Lazzarich, Elisa; Stratta, Piero

doi:10.1007/s40620-015-0185-1

Cited by 10 publications

(10 citation statements)

References 30 publications

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“…Heparin infusion, starting within 24 h after surgery, has been associated with an increased risk for bleeding before , as in our analysis, whereas the prophylactic use of heparin (5000 IU s.c. twice daily) is reported to be safe . Others reported an increased risk of bleeding after continued VKA therapy as well, but concluded that the indication for VKA therapy was nonmodifiable in certain patients . We can concur this finding since all patients on continued VKA therapy in our analysis had a vital indication for anticoagulation therapy, i.e., due to paroxysmal atrial fibrillation with high CHA2DS2‐VASc scores.…”

Section: Discussionsupporting

confidence: 75%

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation – a retrospective study

et al. 2019

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SummaryPerioperative antithrombotic therapy could play a role in preventing thromboembolic complications (TEC) after kidney transplantation (KTx), but little is known on postoperative bleeding risks. This retrospective analysis comprises 2000 single‐organ KTx recipients transplanted between 2011 and 2016 in the two largest transplant centers of the Netherlands. TEC and bleeding events were scored ≤7 days post‐KTx. Primary analyses were for associations of antithrombotic therapy with incidence of TEC and bleeding. Secondary analyses were for associations of other potential risk factors. Mean age was 55 ± 14 years, 59% was male and 60% received a living donor kidney. Twenty‐one patients (1.1%) had a TEC. Multiple donor arteries [OR 2.79 (1.15–6.79)] and obesity [OR 2.85 (1.19–6.82)] were identified as potential risk factors for TEC. Bleeding occurred in 88 patients (4.4%) and incidence varied significantly between different antithrombotic therapies (P = 0.006). Cardiovascular disease [OR 2.01 (1.18–3.42)], pre‐emptive KTx [OR 2.23 (1.28–3.89)], postoperative heparin infusion [OR 1.69 (1.00–2.85)], and vitamin K antagonists [OR 6.60 (2.95–14.77)] were associated with an increased bleeding risk. Intraoperative heparin and antiplatelet therapy were not associated with increased bleeding risk. These regimens appear to be safe for the possible prevention of TEC without increasing the risk for bleeding after KTx.

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Section: Discussionsupporting

confidence: 75%

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation – a retrospective study

et al. 2019

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“…Our current data hint that an initiation of anticoagulation <6 h and an intake of antiplatelet therapy within 24 h after KT are significant predictors of the development of postoperative bleeding in univariable analysis and should possibly be avoided, whenever possible. In accordance with our results, other studies reported an increased risk for bleeding after a continuation of VKA in the perioperative period with urgent indications for continued VKA therapy in certain patients and risk constellations [5,39]. Likewise, in our current study, all patients on continued anticoagulative or antiplatelet therapy had vital indications for anticoagulation therapy, e.g., due to atrial fibrillation with high CHA2DS2-VASc scores, a history of deep venous thrombosis and/or pulmonary embolisms, a history of acute myocardial infarction with stenting of the coronary arteries or a history of stroke.…”

Section: Discussionsupporting

confidence: 93%

“…Initiation of heparin infusion in a therapeutical dose within 24 h after surgery has been associated with an increased risk of bleeding; accordingly, in our current analysis the bleeding risk was increased when heparin was started within the first 6 h postoperatively, whereas the prophylactic use of heparin is reported to be safe [5,6,8]. Interestingly, the use of intraoperative heparin as well as APT per se or in combination with prophylactic doses of heparin were not associated with an increased bleeding risk, which is also underlined by previous studies [5,39]. Hence, according to common clinical practice, heparin seems a good and safe choice for perioperative anticoagulation, whereas the timing and dose of postoperative heparin must be considered with caution.…”

Section: Discussionsupporting

confidence: 79%

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Hau

Eckert

Laudi

et al. 2022

JCM

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Objective: Due to the high prevalence and incidence of cardio- and cerebrovascular diseases among dialysis-dependent patients with end-stage renal disease (ERSD) scheduled for kidney transplantation (KT), the use of antiplatelet therapy (APT) and/or anticoagulant drugs in this patient population is common. However, these patients share a high risk of complications, either due to thromboembolic or bleeding events, which makes adequate peri- and post-transplant anticoagulation management challenging. Predictive clinical models, such as the HAS-BLED score developed for predicting major bleeding events in patients under anticoagulation therapy, could be helpful tools for the optimization of antithrombotic management and could reduce peri- and postoperative morbidity and mortality. Methods: Data from 204 patients undergoing kidney transplantation (KT) between 2011 and 2018 at the University Hospital Leipzig were retrospectively analyzed. Patients were stratified and categorized postoperatively into the prophylaxis group (group A)—patients without pretransplant anticoagulation/antiplatelet therapy and receiving postoperative heparin in prophylactic doses—and into the (sub)therapeutic group (group B)—patients with postoperative continued use of pretransplant antithrombotic medication used (sub)therapeutically. The primary outcome was the incidence of postoperative bleeding events, which was evaluated for a possible association with the use of antithrombotic therapy. Secondary analyses were conducted for the associations of other potential risk factors, specifically the HAS-BLED score, with allograft outcome. Univariate and multivariate logistic regression as well as a Cox proportional hazard model were used to identify risk factors for long-term allograft function, outcome and survival. The calibration and prognostic accuracy of the risk models were evaluated using the Hosmer–Lemshow test (HLT) and the area under the receiver operating characteristic curve (AUC) model. Results: In total, 94 of 204 (47%) patients received (sub)therapeutic antithrombotic therapy after transplantation and 108 (53%) patients received prophylactic antithrombotic therapy. A total of 61 (29%) patients showed signs of postoperative bleeding. The incidence (p < 0.01) and timepoint of bleeding (p < 0.01) varied significantly between the different antithrombotic treatment groups. After applying multivariate analyses, pre-existing cardiovascular disease (CVD) (OR 2.89 (95% CI: 1.02–8.21); p = 0.04), procedure-specific complications (blood loss (OR 1.03 (95% CI: 1.0–1.05); p = 0.014), Clavien–Dindo classification > grade II (OR 1.03 (95% CI: 1.0–1.05); p = 0.018)), HAS-BLED score (OR 1.49 (95% CI: 1.08–2.07); p = 0.018), vit K antagonists (VKA) (OR 5.89 (95% CI: 1.10–31.28); p = 0.037), the combination of APT and therapeutic heparin (OR 5.44 (95% CI: 1.33–22.31); p = 0.018) as well as postoperative therapeutic heparin (OR 3.37 (95% CI: 1.37–8.26); p < 0.01) were independently associated with an increased risk for bleeding. The intraoperative use of heparin, prior antiplatelet therapy and APT in combination with prophylactic heparin was not associated with increased bleeding risk. Higher recipient body mass index (BMI) (OR 0.32 per 10 kg/m2 increase in BMI (95% CI: 0.12–0.91); p = 0.023) as well as living donor KT (OR 0.43 (95% CI: 0.18–0.94); p = 0.036) were associated with a decreased risk for bleeding. Regarding bleeding events and graft failure, the HAS-BLED risk model demonstrated good calibration (bleeding and graft failure: HLT: chi-square: 4.572, p = 0.802, versus chi-square: 6.52, p = 0.18, respectively) and moderate predictive performance (bleeding AUC: 0.72 (0.63–0.79); graft failure: AUC: 0.7 (0.6–0.78)). Conclusions: In our current study, we could demonstrate the HAS-BLED risk score as a helpful tool with acceptable predictive accuracy regarding bleeding events and graft failure following KT. The intensified monitoring and precise stratification/assessment of bleeding risk factors may be helpful in identifying patients at higher risks of bleeding, improved individualized anticoagulation decisions and choices of antithrombotic therapy in order to optimize outcome after kidney transplantation.

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“…Only a few prospective studies on interventions to prevent RGT are available, as confirmed by a recent systematic review [ 15 ], and these provide little evidence. Furthermore, the scarce number of retrospective studies also draws conflicting conclusions [ 3 , 9 , 11 , 16 ]. This survey further illustrates the high variation in antithrombotic management strategies in adult KTx, as a result of the paucity of high-quality studies.…”

Section: Discussion/conclusionmentioning

confidence: 99%

Antithrombotic Management in Adult Kidney Transplantation: A European Survey Study

et al. 2021

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In kidney transplantation (KTx), renal graft thrombosis (RGT) is one of the main reasons for early graft loss. Although evidence-based guidance on prevention of RGT is lacking, thromboprophylaxis is widely used. The aim of this survey was to obtain a European view of the different thromboprophylactic strategies applied in KTx. An online 22-question survey, addressed to KTx professionals, was distributed by e-mail and via platforms of the European Society for Organ Transplantation. Seventy-five responses (21 countries, 51 centers) were received: 75% had over 10 years’ clinical experience, 64% were surgeons, 29% nephrologists and 4% urologists. A written antithrombotic management protocol was available in 75% of centers. In 8 (16%) of centers respondents contradicted each other regarding the availability of a written protocol. Thromboprophylaxis is preferred by 78% of respondents, independent of existing antithrombotic management protocols. Ninety-two percent of respondents indicated that an anticipated bleeding risk is the main reason to discontinue chronic antithrombotic therapy preoperatively. Intraoperatively, 32% of respondents administer unfractionated heparin (400 – 10.000 international units with a median of 5000) in selected cases. Despite an overall preference for perioperative thromboprophylaxis in KTx, there is a high variation within Europe regarding type, timing and dosage, most likely due to the paucity of high-quality studies. Further research is warranted in order to develop better guidelines.

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Impact of pre-transplant antiaggregant and anticoagulant therapies on early hemorrhagic and cardiovascular events after kidney transplantation

Abstract: In conclusion, HE and CVE are relatively rare but can be severe, but there are no pre-KTx modifiable risk factors. If an anticoagulant therapy with low molecular weight heparins has to be started soon after surgery, monitoring of anti-Xa activity is highly recommended.

Cited by 10 publications

References 30 publications

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation – a retrospective study

Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation – a retrospective study

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Antithrombotic Management in Adult Kidney Transplantation: A European Survey Study

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