Symptomatic Venous Thromboembolism and Major Bleeding After Renal Transplantation: Should We Use Pharmacologic Thromboprophylaxis?

Incidence and risk factors of venous thromboembolism in kidney transplantation patients: a prospective cohort study

To investigate the incidence and explore the risk factors of venous thromboembolism (VTE) within 6 months after kidney transplantation. Total of 331 kidney transplant recipients were assessed by venous ultrasonography for VTE at 14 days, 1 month, 3 months, and 6 months post-transplantation. Cox forward regression were used to identify the independent risk factors of VTE. This study registration number is ChiCTR1900020567 and the date of registration was 2019/01/08. The cumulative incidence of VTE was 2.72% (9/331) within 6 months after transplant. 77.8% (7/9) of VTEs occurred in the first 3 months post-transplantation. 88.9% (1/9) of VTEs were asymptomatic, 66.7% (6/9) of VTEs were mural thromboses and in the right lower extremity. Central vena catheterization (HR = 6.94) and severe pulmonary disease (including pneumonia) (HR = 57.35) were the risk factors for VTE in kidney transplantation recipients. KT patients are the high risk population of VTE. Future interventions should be strengthen for KT patients to receive a minimum of 3-month of precautionary measures for VTE, including infection prevention, and strengthening thromboprophylaxis on the CVC or transplanted side of lower extremity.

Renal transplant and hemostasis: early postoperative changes in recipients and donors

Background

The benefit of administering pharmacologic thromboprophylaxis following renal transplantation remains uncertain.

Objectives

To compare hemostatic parameters before and after renal transplant surgery in both recipients and their donors at predetermined time points.

Methods

Blood samples were collected at baseline (T1), immediately after surgery (T2), and at 24 hours after surgery (T3) in both recipients and donors and at 72 (T4) and 120 hours (T5) from recipients only. Assays included in vitro thrombin generation, factor VIII (FVIIIc) activity, von Willebrand factor (VWF) antigen, D-dimer, antithrombin activity, prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes, and plasminogen activator inhibitor-1 (PAI-1) antigen.

Results

Fifty-two patients (28 recipients and 24 donors) were enrolled. Both donors and recipients had increased FVIIIc, VWF, F1 + 2, D-dimer, and PAI immediately after surgery but reduced antithrombin. Mixed-model analysis showed that the magnitude of change over time (between T1 and T3) for FVIIIc (mean estimated difference [MED], 72; 95% CI, 41-102; P < .0001), VWF (MED, 89; 95% CI, 35-142; P = .001), F1 + 2 (MED, 283; 95% CI, 144-422; P < .0001), thrombin-antithrombin complexes (MED, 3.5; 95% CI, 1.9-5.1; P < .0001), D-dimer (MED, 2.2; 95% CI, 1.0-3.3; P < .0001), PAI-1 (MED, 9.2; 95% CI, 3.4-14.9; P = .002), and time to peak thrombin generation (MED, 1.5; 95% CI, 0.35-2.7; P = .01) was more significant in recipients than in donors.

Conclusion

Persistence of a hypercoagulable state was more prominent in recipients after 24 hours despite recovery in renal function and initiation of thromboprophylaxis.

Venous thromboembolism, factor VIII and chronic kidney disease

Chronic kidney disease (CKD) affects 30 million Americans and is associated with approximately a two-fold increased risk of venous thromboembolism (VTE). There is a graded increased risk of VTE across declining kidney function, as measured by estimated glomerular filtration rate (eGFR) and albuminuria. When patients with end-stage kidney disease (ESKD) experience VTE they are more likely than the general population to be hospitalized and they have a higher mortality. The incidence and consequences of VTE may also differ depending on the cause of kidney disease. In addition, kidney transplant patients with VTE are at a greater risk for death and graft loss than transplant patients without VTE. The reasons that patients with CKD are at increased risk of VTE are not well understood, but recent data suggest that factor VIII is a mediator. Factor VIII is an essential cofactor in the coagulation cascade and a strong risk factor for VTE in general. It is inversely correlated with eGFR and prospective studies demonstrate that factor VIII activity predicts incident CKD and rapid eGFR decline. The etiology of CKD may also influence factor VIII levels. This review summarizes the epidemiology VTE in CKD and reviews the biochemistry of factor VIII and determinants of its levels, including von Willebrand factor and ABO blood group. We explore mechanisms by which the complications of CKD might give rise to higher factor VIII and suggests future research directions to understand how factor VIII and CKD are linked.