Is Continuing Anticoagulation or Antiplatelet Therapy Safe Prior to Kidney Transplantation?

Abstract

Background Patients undergoing kidney transplantation are often placed on anticoagulation or antiplatelet therapy, and their perioperative management is often challenging. This study aimed to determine the safety of continuing anticoagulation or antiplatelet therapy prior to kidney transplantation. The primary outcome was bleeding after transplantation. Material/Methods Patients who underwent kidney transplantation between January 2017 and July 2019 were included and divided into 3 groups: pretransplant anticoagulation with warfarin (WARF; n=23); pretransplant antiplatelet therapy with clopidogrel/aspirin (ASA/CLOP; n=32); and control (CTL; n=197). Patients received kidneys from live or deceased donors. Preoperative INRs and platelet counts were compared to ensure therapeutic anticoagulation in the warfarin group and no significant platelet count variation among groups. The primary outcome was graft exploration for bleeding at 3 and 6 months after transplantation. Secondary outcomes included perioperative transfusion requirements, prolonged length of stay (>7 days), and outcomes at 3 and 6 months after transplantation, including hemodialysis and rejection rates and creatinine levels. Results Pretransplant INR was significantly greater in the warfarin group (CTL 1.1, WARF 2.2, ASA/CLOP 1.2; P <0.01). There were no differences in pretransplant platelet count (CTL 202×10 3 , WARF 186×10 3 , ASA/CLOP 194×10 3 ; P =0.31), graft exploration for bleeding at 3 (CTL 3%, WARF 0%, ASA/CLOP 3%; P =0.69) and 6 months after transplantation (CTL 1%, WARF 4%, ASA/CLOP 0%; P =0.12), or perioperative blood transfusion requirements (CTL 4%, WARF 4%, ASA/CLOP 14%; P =0.13). Prolonged length of stay was similar (CTL 24%, WARF 26%, ASA/CLOP 44%; P =0.08). There were no significant differences among groups at 3 months in dialysis (CTL 2%, WARF 0%, ASA/CLOP 0%; P =0.71), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.7; P =0.13), or rejection (CTL 6%, WARF 0%, ASA/CLOP 0%) or at 6 months in dialysis (CTL 3%, WARF 0%, ASA/CLOP 0%; P =0.49), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.5; P =0.49), or rejection (CTL 1%, WARF 0%, ASA/CLOP 3%). Conclusions Continuing anticoagulation or antiplatelet was safe in not increasing bleeding complications or perioperative transfusion requirements. Outcomes were similar at 3 and 6 months among groups. This strategy avoids exposing patients to risk of thrombosis if treatment is held and simplifies proceeding to transplantation.

Cerebrovascular Disease Hospitalization Rates in End-Stage Kidney Disease Patients with Kidney Transplant and Peripheral Vascular Disease: Analysis Using the National Inpatient Sample (2005–2019)

“…Additionally, studies investigating the underlying mechanisms of stroke in these patients, such as the contribution of platelet dysfunction, vascular calcification, and inflammation, may provide valuable insights for targeted preventions. In addition to medical management, aggressive control of traditional cardiovascular risk factors is crucial in reducing the risk of cerebrovascular events in patients with ESKD or KTx and concurrent PVD [5,6,14,18].…”

“…For those patients with PVD undergoing renal transplantation, these anti-platelet medications are commonly paused during the perioperative phase [18], which may expose these patients to an increased risk of vascular events. For instance, there is a potential for cerebral infarction due to heightened coagulation during the early postoperative period, stemming from systemic inflammation [19].…”

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

“…However, these results should be interpreted with caution due to the small sample size and suboptimal methodology in bleeding definition and complication management. More recent data indicate that neither antithrombotic prophylaxis nor the continuation of antiplatelet therapy after KT lead to an increase in incidents of bleeding in the perioperative period, except for postoperative heparin infusion [ 40 , 41 ]. 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 ].…”

The Crosstalk between Nephropathy and Coagulation Disorder: Pathogenesis, Treatment, and Dilemmas

“…Guidelines for anticoagulant/antiplatelet treatment in kidney transplant recipients are still lacking, but continuous anticoagulation is necessary because the risk of thrombosis persists. 123 Heparin, low-molecular-weight heparin, and warfarin have been shown to be effective in kidney transplant recipients. Interestingly, unlike dialysis patients, kidney transplant recipients undergoing heparin treatment rarely experienced HIT even if they have a history of HIT.…”