1
|
Vandeput AS, Brijs K, De Kock L, Janssens E, Peeters H, Verhamme P, Politis C. Maxillofacial and oral surgery in patients with thrombophilia: safe territory for the oral surgeon? A single-center retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:514-522. [PMID: 34030997 DOI: 10.1016/j.oooo.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to analyze patients with thrombophilia who underwent oral and/or maxillofacial surgery at our center. STUDY DESIGN We performed a retrospective analysis of patients with hereditary or acquired thrombophilia who had undergone oral/maxillofacial surgery between January 1, 2000 and December 31, 2019. Data regarding demographic and patient characteristics, surgical treatment modalities, antithrombotic therapies, and complications were analyzed. RESULTS A total of 76 eligible patients (26 male, 50 female) were included in this study, with a mean follow-up period of 3.8 months (range, 0-51 months). The mean age at time of surgery was 44.7 ± 19.4 years. Seven different hereditary and acquired thrombophilia were identified: factor V Leiden (n = 31; 40.8%), prothrombin G20210A mutation (n = 5; 6.6%), protein C deficiency (n = 4; 5.3%), protein S deficiency (n = 11; 14.5%), antiphospholipid syndrome (n = 10; 13.2%), hyperhomocysteinemia (n = 8; 10.5%), and elevated factor VIII (n = 2; 2.6%). Complications occurred in 9 patients (11.8%) and included postoperative infections (n = 6; 7.9%) and postoperative bleeding (n = 3; 3.9%). CONCLUSION Our data suggest that oral and/or maxillofacial surgery in patients with a confirmed diagnosis of thrombophilia is not associated with a burden of thrombosis or high complication rates. Furthermore, we formulated a guideline for preoperative antithrombotic therapy for patients with thrombophilia undergoing oral and/or maxillofacial surgery.
Collapse
Affiliation(s)
- An-Sofie Vandeput
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Katrien Brijs
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lisa De Kock
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Elien Janssens
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Hilde Peeters
- Centre for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Vascular Medicine and Haemostasis, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
Collapse
Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
| |
Collapse
|
3
|
Friedersdorff F, Koch TM, Banuelos-Marco B, Gonzalez R, Fuller T, von Mechow S, Müller D, Lingnau A. Long-Term Follow-Up after Paediatric Kidney Transplantation and Influence Factors on Graft Survival: A Single-Centre Experience of 16 years. Urol Int 2018. [DOI: 10.1159/000487195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
4
|
Gülhan B, Tavil B, Gümrük F, Aki TF, Topaloglu R. Renal transplantation experience in a patient with factor V Leiden homozygous, MTHFR C677T heterozygous, and PAI heterozygous mutation. Pediatr Transplant 2015; 19:E126-9. [PMID: 25996881 DOI: 10.1111/petr.12526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/26/2022]
Abstract
Vascular complications are important causes of allograft loss in renal transplantation. A two and a half-month-old boy was diagnosed with posterior urethral valve and progressed to end-stage renal disease at eight yr of age. During the HD period, a central venous catheter was replaced three times for repeated thrombosis. The boy was found to be homozygous for FVL and heterozygous for both MTHFR (C677T) and PAI. At the age of 12, renal transplantation was performed from a deceased donor. Postoperative anticoagulation therapy was initiated with continuous intravenous administration of heparin at the dose of 10 IU/kg/h. HD was performed for the first three days. By the fourth day of transplantation, his urine output had increased gradually. Heparin infusion was continued for 18 days during hospitalization at the same dosage. Thereafter, he was discharged with LMWH. On the third month after transplantation, his serum creatinine level was 1.1 mg/dL and eGFR was 75.7 mL/min/1.73 m(2). He has still been using LMWH, and his eGFR was 78.7 mL/min/1.73 m(2) eight months after transplantation. Postoperative low-dose heparin treatment is a safe strategy for managing a patient with multiple thrombotic risk factors.
Collapse
Affiliation(s)
- Bora Gülhan
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Betül Tavil
- Department of Pediatric Hematology, Faculty of Medicine, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Fatma Gümrük
- Department of Pediatric Hematology, Faculty of Medicine, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Tuncay F Aki
- Department Urology, Faculty of Medicine, Hacettepe University, Sıhhiye, Ankara, Turkey
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Faculty of Medicine, Hacettepe University, Sıhhiye, Ankara, Turkey
| |
Collapse
|
5
|
Bauer A, Limperger V, Nowak-Göttl U. End-stage renal disease and thrombophilia. Hamostaseologie 2015; 36:103-7. [PMID: 25639843 DOI: 10.5482/hamo-14-11-0063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/23/2015] [Indexed: 11/05/2022] Open
Abstract
Chronic kidney disease is an established risk factor for arterial and venous thromboembolism (TE). Whereas the overall risk of TE in moderately decreased kidney function is approximately 2.5-fold higher compared to patients with normal renal function, the risk increase is 5.5-fold in patients with severe renal dysfunction. In patients with renal dysfunction and arterial thrombosis (OR: 4.9), malignancy (OR: 5.8) surgery (OR: 14.0) or thrombophilia (OR: 4.3) the risk to suffer from venous TE is higher compared to the risk associated to the baseline renal dysfunction alone. The treatment options for end-stage renal diseases include hemodialysis, peritoneal dialysis and kidney transplantation. During all treatment modalities thrombotic complications have been described, namely catheter malfunction and shunt thrombosis in patients undergoing hemodialysis in up to 25% of patients, and TE, pulmonary embolism or graft vessel thrombosis in approximately 8% of patients. The reported incidence of reno-vascular thrombosis following renal transplantation leading to hemorrhagic infarction with organ rejection or organ loss varied between 2-12%. Keeping in mind the multifactorial etiology of TE in patients with kidney dysfunction a general screening for thrombophilia in this patient group is not indicated. Selected screening on an individual patient basis should be discussed if the family history for TE is positive or the patient itself had suffered one thrombosis before the onset of the renal disease or multiple TEs during hemodialysis or post kidney transplantation in patients waiting for living donor kidney transplantation.
Collapse
Affiliation(s)
| | | | - Ulrike Nowak-Göttl
- Prof. Dr. Ulrike Nowak-Göttl, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Univ. Hospital Schleswig Holstein, Campus Kiel & Lübeck, Arnold-Heller-Str. 5, 24105 Kiel, E-mail:
| |
Collapse
|
6
|
Shen E, Uemura T, Kadry Z, Sathishkumar S. Successful living donor kidney transplantation in a patient with prothrombin gene mutation: Case report and literature review. J Anaesthesiol Clin Pharmacol 2014; 30:106-8. [PMID: 24574607 PMCID: PMC3927270 DOI: 10.4103/0970-9185.125718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present a patient with known prothrombin gene mutation and a history of prior vascular events, who underwent living donor kidney transplantation. Given the presumed elevated risk of complication from known prothrombin mutation, clinical management was directed towards optimizing living donor allograft function.
Collapse
Affiliation(s)
- Edward Shen
- Department of Anesthesiology, Division of Transplantation, Penn State Hershey Medical Center, 500 University drive, Hershey PA 17033, USA
| | - Tadahiro Uemura
- Department of Surgery, Division of Transplantation, Penn State Hershey Medical Center, 500 University drive, Hershey PA 17033, USA
| | - Zakiyah Kadry
- Department of Surgery, Division of Transplantation, Penn State Hershey Medical Center, 500 University drive, Hershey PA 17033, USA
| | - Subramanian Sathishkumar
- Department of Anesthesiology, Division of Transplantation, Penn State Hershey Medical Center, 500 University drive, Hershey PA 17033, USA
| |
Collapse
|
7
|
The impact of inherited thrombophilia on surgery: A factor to consider before transplantation? Mol Biol Rep 2008; 36:1041-51. [DOI: 10.1007/s11033-008-9278-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 05/22/2008] [Indexed: 01/06/2023]
|
8
|
Bilginer Y, Ozaltin F, Duzova A, Erdogan I, Aki TF, Demircin M, Bakkaloglu M, Bakkaloglu A. Right atrial thrombosis complicating renal transplantation in a child. Pediatr Transplant 2008; 12:251-5. [PMID: 18179641 DOI: 10.1111/j.1399-3046.2007.00857.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nephrotic syndrome represents a form of acquired thrombophilia thereby causing increased risk of thrombosis. In patients with nephrotic syndrome both venous and arterial thrombosis can occur; however, intracardiac thrombus is among the rarest reported in the literature. In this case report, we present a 10.5-yr-old boy with right atrial thrombosis and an acute rejection episode after renal transplantation due to end stage renal disease caused by focal segmental glomerulosclerosis manifested by nephrotic syndrome. The clinical course was successfully managed with surgical removal of thrombus, institution of anticoagulant as well as antirejection therapy. This report draws attention to the risks that could be associated with thrombosis in renal recipients with congenital or acquired thrombophilias and emphasizes the importance of identifying risk factors for thrombosis in these patients.
Collapse
Affiliation(s)
- Yelda Bilginer
- Department of Pediatric Nephrology, Hacettepe Unviersity Faculty of Medicine, Ankara, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Kranz B, Vester U, Nadalin S, Paul A, Broelsch CE, Hoyer PF. Outcome after kidney transplantation in children with thrombotic risk factors. Pediatr Transplant 2006; 10:788-93. [PMID: 17032424 DOI: 10.1111/j.1399-3046.2005.00483.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND According to the data from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS), vascular thrombosis accounts for 11.6% of graft losses in pediatric renal transplantation. In adults, inherited and acquired thrombophilic risk factors, e.g. factor V Leiden mutation, have been associated with early graft loss and increased rejection episodes. Data on the impact of these factors on the outcome of children after renal transplantation are rare. METHODS/PATIENTS Sixty-six pediatric patients awaiting renal transplantation (mean age 10.1 yr) were screened for inherited and acquired risk factors for hypercoagulable disorders (protein C, S, and antithrombin III deficiency, antiphospholipid antibodies, factor V Leiden, prothrombin, and MTHFR mutation) in order to intensify anticoagulation in those with an increased risk for thrombophilia: intravenous heparin was administered with a partial prothrombin time (PTT) prolongation of 50 s for 14 days and switched to low-molecular-weight heparin for another 8 wk before aspirin was introduced for the first year. Patients without hypercoagulable risk factors were treated with heparin without PTT prolongation for 14 days and switched to aspirin immediately afterwards. The results on graft survival, incidence of acute rejection episodes, and long-term renal graft function were analyzed between recipients with and without hypercoagulable risk factors. RESULTS Thrombophilic risk factors were identified in 27.3% of our patients. No thrombosis occurred. One serious bleeding complication led to a second surgical intervention. The rate of acute rejection episodes was not increased in patients with and without thrombotic risk factors after 90 days (16.7 vs. 25%), 1 yr (22.2 vs. 33.3%), and 3 yr (38.9 vs. 41.7%) of follow-up, respectively (p = n.s.). After a mean follow-up of 3 yr the kidney function was comparable in both groups, with 63.1 in recipients with and 69.8 mL/min/1.73 m(2) in recipients without hypercoagulable risk (p = n.s.). At latest follow-up, three graft losses were found not to be attributed to thrombotic risk factors. INTERPRETATION Children with thrombophilic risk factors were identified and treated with an intensified anticoagulation regimen after renal transplantation. An increased risk for graft failure, acute rejection episodes, or impaired renal function for pediatric renal transplant recipients with hypercoagulable status was not found.
Collapse
Affiliation(s)
- Birgitta Kranz
- Clinic of Pediatric Nephrology, University Clinic Essen, Essen, Germany.
| | | | | | | | | | | |
Collapse
|
11
|
John U, Kentouche K, Nowak G, Schubert J, Misselwitz J. Successful renal transplantation in a patient with heterozygous prothrombin gene, factor V Leiden mutation and heparin-induced thrombocytopenia using r-hirudin as anticoagulant. Pediatr Transplant 2006; 10:114-8. [PMID: 16499600 DOI: 10.1111/j.1399-3046.2005.00398.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Vascular complications remain the most common cause of early renal allograft loss in patients with end-stage renal failure. Underlying thrombophilic disorders increase the risk of early graft thrombosis. A male adolescent with high-risk thrombophilia because of combined heterozygous factor V Leiden (G1691A) and prothrombin gene (G20210A) mutation developed HIT II. Hemodialysis and subsequent renal transplantation were undertaken using recombinant hirudin, a direct and selective thrombin inhibitor, as an anticoagulant. Primary function in the transplanted kidney was excellent. No thrombotic or hemorrhagic events have occurred and follow-up showed excellent long-term graft survival. Patients on HD have an increased risk for the development of HIT, and therefore, they need repetitive screening for the development of acquired thrombotic risk factors (e.g. HIT II or lupus anticoagulant). R-hirudin is efficacious and safe on both HD and following renal transplantation.
Collapse
Affiliation(s)
- Ulrike John
- Department of Pediatric Nephrology, Friedrich-Schiller-University Jena, Jena, Germany.
| | | | | | | | | |
Collapse
|
12
|
Quintana LF, Cofan F, Reverté JC, Oppenheimer F, Campistol JM. Renal cortical necrosis after kidney transplantation associated with the prothrombin 20210A mutation. Nephrol Dial Transplant 2005; 21:1455-6. [PMID: 16357049 DOI: 10.1093/ndt/gfi341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
13
|
Meyer M, Czachurski D, Tran TH, Hien T, Opelz G, Mytilineos J. A new PCR-SSP typing method for six single-nucleotide polymorphisms impairing the blood-clotting cascade as well as T-cell stimulation. ACTA ACUST UNITED AC 2005; 66:650-5. [PMID: 16305681 DOI: 10.1111/j.1399-0039.2005.00493.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Single-nucleotide polymorphisms (SNPs) within the genes of factor V (FV) (G1691A; exon 10), prothrombin (FII) (G20210A; 3'untranslated - region) and methylenetetrahydrofolate reductase (MTHFR) (C677T; exon 4) are associated with hypercoagulability, and systematic screening of individuals being at higher risk of thrombosis has been suggested. SNPs in the 2q33 region within the genes of CD28 (+17T/C; intron 3) and CTLA4 (-318C/T; promoter and +49A/G; exon 1) are likely to affect T-cell proliferation and antigen presentation signaling, which may lead to altered sensitivity of allograft or self-tissue recognition and affect the incidence of autoimmune diseases. We developed primers that allow specific amplification of these six SNPs at test conditions identical with those used for HLA typing with the CTS PCR-SSP reagents. One hundred ninety-six healthy German Caucasian individuals were tested for the six SNPs. The genotype frequencies for all SNPs were in Hardy-Weinberg equilibrium. There was no significant difference in the distribution of genotypes when compared to other published studies in which these SNPs were tested. The described PCR-SSP method can be used to screen large numbers of patients for these SNPs.
Collapse
Affiliation(s)
- M Meyer
- Department of Transplantation Immunology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | | | | |
Collapse
|
14
|
Miriuka SG, Langman LJ, Evrovski J, Miner SES, Kozuszko S, D'Mello N, Delgado DH, Wong BYL, Ross HJ, Cole DEC. Thromboembolism in Heart Transplantation: Role of Prothrombin G20210A and Factor V Leiden. Transplantation 2005; 80:590-4. [PMID: 16177630 DOI: 10.1097/01.tp.0000170545.42790.6f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thromboembolism has been reported as a frequent complication after cardiac transplantation. Many risk factors for thrombosis may explain this, such as metabolic alterations and the use of cyclosporine. In the general population, two single nucleotide polymorphisms (SNPs), factor V Leiden and prothrombin G20210A (PT G20210A), have been associated with a significant increase in the risk of thrombosis. However, these mutations have not been analyzed in cardiac transplant patients. We describe the protracted history of recurrent thromboembolism in a rare case of homozygosity for the PT G20210A variant. This prompted us to analyze the entire cardiac transplant cohort for the incidence of thromboembolic events and their association with these genetic polymorphisms. METHODS We report the study of 84 cardiac transplant recipients. We retrospectively analyzed the frequency of thromboembolic episodes. The genotypes for FVL and PT G20210A were determined and correlated with those episodes. RESULTS Our results confirm a very high incidence of thromboembolism in this population. We also found a significant increase in the likelihood of thromboembolism in subjects with the PTB G20210A variant (odds ratio 3.08; 95% confidence interval: 1.7-5.5). CONCLUSIONS The incidence of thromboembolic complications after heart transplantation is increased and may be related in part to genetic predisposition.
Collapse
Affiliation(s)
- Santiago G Miriuka
- Department of Medicine, Toronto General Hospital and University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Dick AA, Lerner SM, Boissy AR, Farrell CE, Alfrey EJ. Excellent outcome in infants and small children with thrombophilias undergoing kidney transplantation. Pediatr Transplant 2005; 9:39-42. [PMID: 15667609 DOI: 10.1111/j.1399-3046.2004.00232.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
One of the most common causes of early graft failure in children undergoing renal transplantation is vascular thrombosis. Numerous risk factors for graft thrombosis have been previously described. Children with various types of thrombophilias such as protein C, protein S and factor V Leiden deficiencies are at an increased risk for vascular thrombosis. Infants and small children with these disorders undergoing renal transplantation have not been well documented in the literature. We reviewed our experience in the diagnosis, peri-operative management and follow up of these patients at our institution. A retrospective analysis of all children undergoing renal transplantation at our institution, using data obtained from the Pediatric Transplant Registry at our institution since May 2000 was performed. The indications for renal transplant included focal segmental glomerulosclerosis, renal dysplasia and reflux nephropathy. One patient had factor V Leiden mutation and two patients had protein S deficiency. Patients were anticoagulated in the peri-operative and post-transplant period. All index transplants were performed with living donor kidneys. There were no adverse outcomes in children with thrombophilias despite having significantly lower weight at the time of transplant vs. children without thrombophilia. The incidence of graft thrombosis in the pediatric renal transplant recipients is high. We identify a potential cause of thrombosis in children not well documented in the literature. A high index of suspicion combined with preoperative screening and diagnosis of thrombophilias and an appropriate treatment plan may decrease the incidence of graft thrombosis in infants and small children undergoing renal transplantation.
Collapse
Affiliation(s)
- Andre A Dick
- Department of Surgery, Penn State University, Hershey, PA 17033, USA
| | | | | | | | | |
Collapse
|
16
|
Affiliation(s)
- Jody L Kujovich
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
| |
Collapse
|
17
|
Irish A. Hypercoagulability in renal transplant recipients. Identifying patients at risk of renal allograft thrombosis and evaluating strategies for prevention. Am J Cardiovasc Drugs 2004; 4:139-49. [PMID: 15134466 DOI: 10.2165/00129784-200404030-00001] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Renal transplantation improves survival and quality of life for patients with end-stage renal disease (ESRD). Improvements in immunosuppressive therapy have reduced early allograft loss due to acute rejection to very low levels. Early allograft loss, due to acute thrombotic complications, remains a constant and proportionally increasing complication of renal transplantation. Identifying risk factor(s) for thrombosis amenable to preventive strategies has been elusive. Epidemiological studies have attempted to define risk in terms of modifiable (drugs, dialysis modality, surgical procedure) and non-modifiable (age, diabetes mellitus, vascular anomalies) factors, or identify changes in coagulation or fibrinolysis promoting a more thrombotic state. Most recently the evolution of thrombophilia research has established the potential for inherited hypercoagulability to predispose to acute allograft thrombosis. Inheritance of the factor V Leiden (FVL), prothrombin G20210A mutation, or the presence of antiphospholipid antibodies (APA) may increase the risk of renal allograft thrombosis approximately 3-fold in selected patients. Patients with ESRD due to systemic lupus erythematosus (SLE) appear at particularly high risk of thrombosis, especially if they have either APA or detectable beta(2)-glycoprotein-1. Data for other hypercoagulable states such as hyperhomocystinemia or the C677T polymorphism of the methylenetetrahydrofolate reductase gene are deficient. Patients with APA, FVL, or prothrombin G20210A mutation also appear to have greater graft loss due to vascular rejection, possibly reflecting immunological injury upon the vascular wall exacerbated or induced by the prothrombotic state. While substantial in vitro data suggest cyclosporine is prothrombotic, an independent clinical association with allograft thrombosis is unproven. Interventions to reduce thrombotic risk including heparin, warfarin, and aspirin have been evaluated in both selected high-risk groups (heparin and warfarin) and unselected populations (heparin and aspirin). In unselected patients at low clinical risk, aspirin (75-150 mg/day) with or without a short period of unfractionated heparin (5000U twice a day for 5 days) appears to reduce the risk of renal allograft thrombosis significantly with a low risk of bleeding, especially when compared with low molecular weight heparins which risk accumulation in renal failure. In high-risk groups (identified thrombophilic risk factor, previous thrombosis, or SLE) longer period of heparin, with or without aspirin and maintenance with warfarin, should be considered. Re-transplantation following graft loss due to vascular thrombosis can be undertaken with a low risk of recurrence. Further prospective studies evaluating both putative risk factors and intervention strategies are required to determine whether routine clinical screening for thrombophilic factors is justified.
Collapse
Affiliation(s)
- Ashley Irish
- Department of Nephrology, Royal Perth Hospital, Western Australia.
| |
Collapse
|
18
|
Wullstein C, Woeste G, Zapletal C, Trobisch H, Bechstein WO. Prothrombotic disorders in uremic type-1 diabetics undergoing simultaneous pancreas and kidney transplantation. Transplantation 2003; 76:1691-5. [PMID: 14688517 DOI: 10.1097/01.tp.0000091119.03828.17] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although prothrombotic disorders (PTD) are known to increase the risk of graft failure in kidney transplantation only, there are no data on PTD in simultaneous pancreas and kidney transplantation (SPK). METHODS Forty-seven SPK performed between September 2000 and July 2002 underwent routine screening for PTD. Data were retrospectively analyzed in view of complications (relaparotomy, graft thrombosis, pancreatitis, rejection) and graft function (HbA1c, serum creatinine) 3 months posttransplantation. RESULTS Twenty-five of forty-seven (53.2%) patients had 30 PTDs. Homozygous mutations of the MTHFR gene (C677T) were found in six, factor-V Leiden mutation (homo- or heterozygous G1691A) in seven, and prothrombin mutation (20210A) in one patient (group 1). Group 2 consists of deficiencies of protein C (n=1), of protein S (n=12), of antithrombin (n=1), and antiphospholipid syndromes (n=2). Overall, PTD had no influence on graft thrombosis (P=0.36) or rejection (P=0.56). In patients with homozygous mutations, relaparotomies were more often necessary than in patients without mutations (42.9% vs. 11.8%, P=0.046). In group 1, there was a trend toward a higher incidence of graft pancreatitis than in patients without mutations (38.5% vs. 14.7%, P=0.075). Three months posttransplantation, HbA1c was 6.0% in patients with and 5.5% in patients without PTD (P=0.023). With regard to serum creatinine, no significant differences were observed. CONCLUSION PTD are frequent in type-1 diabetics receiving SPK and may have a role in relaparotomies, graft pancreatitis, and pancreas graft function.
Collapse
Affiliation(s)
- Christoph Wullstein
- Chirurgische Klinik der Ruhr-Universität Bochum, Knappschaftskrankenhaus Bochum-Langendreer, Bochum, Germany
| | | | | | | | | |
Collapse
|
19
|
Abstract
Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.
Collapse
Affiliation(s)
- Mark R Benfield
- Division of Pediatric Nephrology, University of Alabama at Birmingham, 1600 7th Avenue S-ACC 516, Birmingham, AL 35233, USA.
| |
Collapse
|
20
|
Abstract
Although renal failure has classically been associated with a bleeding tendency, thrombotic events are common among patients with end-stage renal disease (ESRD). A variety of thrombosis-favoring hematologic alterations have been demonstrated in these patients. In addition, "nontraditional" risk factors for thrombosis, such as hyperhomocysteinemia, endothelial dysfunction, inflammation, and malnutrition, are present in a significant proportion of chronic dialysis patients. Hemodialysis (HD) vascular access thrombosis, ischemic heart disease, and renal allograft thrombosis are well-recognized complications in these patients. Deep venous thrombosis and pulmonary embolism are viewed as rare in chronic dialysis patients, but recent studies suggest that this perception should be reconsidered. Several ESRD treatment factors such as recombinant erythropoietin (EPO) administration, dialyzer bioincompatibility, and calcineurin inhibitor administration may have prothrombotic effects. In this article we review the pathogenesis and clinical manifestations of thrombosis in ESRD and evaluate the evidence that chronic renal failure or its management predisposes to thrombotic events.
Collapse
Affiliation(s)
- Liam F Casserly
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts 02118, USA
| | | |
Collapse
|
21
|
Brenner BR, Nowak-Göttl U, Kosch A, Manco-Johnson M, Laposata M. Diagnostic studies for thrombophilia in women on hormonal therapy and during pregnancy, and in children. Arch Pathol Lab Med 2002; 126:1296-303. [PMID: 12421137 DOI: 10.5858/2002-126-1296-dsftiw] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To review the role of acquired and inherited prothrombotic risk factors that increase the risk of thrombosis in oral contraceptive users, during pregnancy, and in neonates, infants, and children; and to determine by the consensus opinion of recognized experts in the field which risk factors should be determined in which individuals at which time. DATA SOURCES Review of the medical literature and current clinical practice by a panel of experts in the field of thrombophilia. DATA EXTRACTION AND SYNTHESIS The experts made an extensive review of the published literature and prepared a draft manuscript, which included preliminary recommendations. The draft manuscript was circulated to participants in the College of American Pathologists Conference XXXVI: Diagnostic Issues in Thrombophilia prior to the conference. The manuscript and recommendations were then presented at the conference for discussion. Recommendations were accepted if a consensus of the 26 experts attending the conference was reached. The results of the discussion were used to revise the manuscript into its final form. CONCLUSIONS This report reviews the options for testing for thrombophilic states in women using oral contraceptives, during pregnancy, and in neonates and children. General guidelines for testing in these clinical situations are provided, along with citation of the appropriate supporting literature.
Collapse
|
22
|
Morrissey PE, Ramirez PJ, Gohh RY, Yango AY, Kestin A, Madras PN, Monaco AP. Management of thrombophilia in renal transplant patients. Am J Transplant 2002; 2:872-6. [PMID: 12392294 DOI: 10.1034/j.1600-6143.2002.20910.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Renal allograft recipients with thrombophilia (a hypercoagulable state) are at higher risk for early allograft loss. Following an episode of allograft renal vein thrombosis in a patient subsequently diagnosed with protein C deficiency, we adopted universal screening for hypercoagulable risk factors. Patients with a history of a thromboembolic event underwent laboratory screening for thrombophilia. Eight patients with a defined hypercoagulable disorder or a strong clinical history of thrombosis even in the absence of hematologic abnormalities were treated with anticoagulation following renal transplantation. We reviewed the outcomes of these eight patients and all renal transplant recipients at our center who developed thrombotic complications after renal transplantation. Since the introduction of universal screening for hypercoagulable risk factors, 235 consecutive transplants were performed without allograft thrombosis. Eight patients with evidence of thrombophilia, recognized before renal transplantation, received perioperative heparin and postoperative oral anticoagulation. Two of these eight patients developed perinephric hematomas requiring evacuation, blood transfusion, and temporary withholding of anticoagulation. Of interest, two of the remaining 227 patients, not identified with thrombophilia before surgery, developed thrombotic complications after renal transplantation. A hypercoagulable disorder was subsequently documented in each. Identifying patients with thrombophilia before transplantation and defining their management presents many challenges. The risk of allograft thrombosis must be weighed against the risk of perioperative bleeding and the need for long-term anticoagulation. Recommendations for managing thrombophilia in renal transplant recipients are suggested based on our experience and review of the literature.
Collapse
Affiliation(s)
- Paul E Morrissey
- Department of Surgery, Rhode Island Hospital and Brown University, Providence, RI, USA.
| | | | | | | | | | | | | |
Collapse
|
23
|
Matas AJ, Humar A, Gillingham KJ, Payne WD, Gruessner RWG, Kandaswamy R, Dunn DL, Najarian JS, Sutherland DER. Five preventable causes of kidney graft loss in the 1990s: a single-center analysis. Kidney Int 2002; 62:704-14. [PMID: 12110036 DOI: 10.1046/j.1523-1755.2002.00491.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite improvements in immunosuppressive protocols and patient care, kidney allografts continue to fail. We studied causes of graft loss for primary kidney transplants in the 1990s to determine major causes and potential interventions. METHODS Causes of graft loss were reviewed for 1467 primary kidney transplants done at our institution between January 1, 1990, and December 31, 1999. Graft loss for that entire population was studied and then the causes of loss selectively examined at <1 year, 1 to 5 years, and>5 years post-transplant. Finally, causes of loss in the 1990s versus the 1980s were compared. RESULTS Five major causes of graft loss were noted in the 1990s: thrombosis, acute rejection (either alone or combined with delayed graft function or infection), chronic rejection, death with function, and noncompliance. In the first year post-transplant, thrombosis (25%) and death with function (41%) were the major causes of graft loss. After the first year, chronic rejection and death with function predominated. For recipients dying with graft function, cardiovascular disease was the major cause of death. CONCLUSIONS This study identified the five major causes of kidney graft loss in the 1990s. Different interventions are required to decrease loss from each of these causes. Future research needs to be directed at such interventions.
Collapse
Affiliation(s)
- Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
|
25
|
Fischereder M, Schneeberger H, Lohse P, Krämer BK, Schlöndorff D, Land W. Increased rate of renal transplant failure in patients with the G20210A mutation of the prothrombin gene. Am J Kidney Dis 2001; 38:1061-4. [PMID: 11684560 DOI: 10.1053/ajkd.2001.28602] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In patients with thrombophilia caused by reduced physiological anticoagulation, renal transplant failure occurs more frequently. Previous studies showed the importance of the protein C system, a physiological anticoagulatory pathway that inhibits thrombus formation. However, excess activation of the hemostatic system also may result in thrombosis. The G20210A mutation in the prothrombin gene is such a prothrombotic risk factor that results in increased thrombus formation because of elevated factor II levels in plasma. We analyzed graft function in 270 consecutive patients who received 311 renal transplants. The presence of a normal or mutated prothrombin allele was determined by polymerase chain reaction amplification and restriction fragment length polymorphism analysis of genomic DNA. Demographic data were extracted from hospital records. Graft survival was calculated for patients with and without the G20210A mutation. We identified 9 patients heterozygous for the G20210A mutation in the prothrombin gene who had received a total of 12 renal transplants. Of these 12 transplants, 2 grafts were lost within the first year. Median graft survival for patients heterozygous for the 20210A allele was 65.9 months (range, 0 to 101 months) compared with 149 months (range, 0 to 237 months) for patients homozygous for the normal 20210 G allele (P = 0.02). The G20210A mutation represented a 2.95-fold (95% confidence interval, 1.03 to 8.46) increase in risk for graft loss. Only 1 patient with this mutation achieved graft function exceeding 101 months. The G20210A mutation of the prothrombin gene is an independent risk factor for graft failure.
Collapse
Affiliation(s)
- M Fischereder
- Abteilung für Transplantationschirurgie and Institut für Klinische Chemie, Klinikum Grosshadern, Germany.
| | | | | | | | | | | |
Collapse
|
26
|
Humar A, Key N, Ramcharan T, Payne WD, Sutherland DE, Matas AJ. Kidney retransplants after initial graft loss to vascular thrombosis. Clin Transplant 2001; 15:6-10. [PMID: 11168309 DOI: 10.1034/j.1399-0012.2001.150102.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Vascular thrombosis early after a kidney transplant is an infrequent but devastating complication. Often, no cause is found. These recipients are generally felt to be good candidates for a retransplant. However, their ideal care at the time of the retransplant and their outcomes have not been well documented. We studied outcomes in 16 retransplant recipients who had lost their first graft early posttransplant (< 1 month) to vascular thrombosis. METHODS Of 2,003 kidney transplants between I January 1984 and 30 September 1998, we identified 32 recipients who had lost their first graft early posttransplant to vascular thrombosis. Of these 32 recipients, 16 were subsequently retransplanted and detailed chart reviews were done. RESULTS Of the 16 retransplant recipients, 12 lost their first graft to renal vein thrombosis and 4 to renal artery thrombosis. Thrombosis generally occurred early (mean, 3.6 d). Five recipients underwent a complete hematologic workup to rule out a thrombophilic disorder before their retransplant: 4 had a positive result (presence of antiphospholipid antibodies, n = 3; increased homocysteine levels, n = 1). These 4 recipients, along with 1 other recipient who had a strong family history of thrombosis, underwent thrombosis prophylaxis at the time of their retransplant. Prophylaxis consisted of low-dose heparin for the first 3-5 d posttransplant, followed by acetylsalicylic acid or Coumadin. Of the 16 retransplant recipients, none developed thrombosis. Of the 5 who underwent thrombosis prophylaxis, none had significant bleeding complications. At a mean follow-up of 5.4 yr, 10 (63%) recipients have functioning grafts. Causes of graft loss in the remaining 6 recipients were death with function (n = 5, 31%) and acute rejection (n = 1.6%). Graft and patient survival rates after these 16 retransplants were equivalent to results after primary transplants. The incidence of acute and chronic rejection was also no different (p = ns). CONCLUSION Vascular thrombosis in the absence of obvious technical factors should prompt a workup for a thrombophilic disorder before a retransplant. Recipients with an identified disorder should undergo prophylaxis at the time of the retransplant. Results in these retransplant recipients are equivalent to those seen in primary transplant recipients.
Collapse
Affiliation(s)
- A Humar
- Department of Surgery, University of Minnesota, Minneapolis 55455, USA
| | | | | | | | | | | |
Collapse
|