The incidence and risk factors for deep vein thrombosis after kidney transplantation in Korea: single-center experience

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.

Pathophysiological Changes in the Hemostatic System and Antithrombotic Management in Kidney Transplant Recipients

Nowadays, the main cause for early graft loss is renal graft thrombosis because kidney transplant outcomes have improved drastically owing to advances in immunological techniques and immunosuppression. However, data regarding the efficacy of antithrombotic therapy in the prevention of renal graft thrombosis are scarce. Adequate antithrombotic management requires a good understanding of the pathophysiological changes in the hemostatic system in patients with end-stage kidney disease (ESKD). Specifically, ESKD and dialysis disrupt the fine balance between pro- and anticoagulation in the body, and further changes in the hemostatic system occur during kidney transplantation. Consequently, kidney transplant recipients paradoxically are at risk for both thrombosis and bleeding. This overview focuses on the pathophysiological changes in hemostasis in ESKD and kidney transplantation and provides a comprehensive summary of the current evidence for antithrombotic management in (adult) kidney transplant recipients.

The association of venous thromboembolism with blood transfusion in kidney transplant patients

BACKGROUND

Red blood cell transfusion (RBCT) is common after kidney transplantation and could have pro-thrombotic effects predisposing to venous thromboembolism (VTE). The risks for developing of VTE after RBCT in kidney transplant patients are unknown.

STUDY DESIGN AND METHODS

This was a retrospective cohort study of adult kidney transplant recipients from 2002 to 2018. The exposure of interest was receipt of RBCT after transplant. Cox proportional hazards models were used to calculate hazard ratios (HR) for the outcomes of venous thromboembolism [VTE] (deep venous thrombosis [DVT] or pulmonary embolism [PE]) using RBCT as a time-varying, cumulative exposure.

RESULTS

Out of 1258 kidney transplants recipients, 468 (37%) were transfused during the study period. Seventy-nine study participants (6.3%) developed VTE, 72 DVT (5.7%), and 22 PE (1.8%). For the receipt of 1, 2, 3-5, and >5 RBCT, compared to individuals never transfused, the number of events and adjusted HR (95%CI) for VTE were 6 (6.2%) HR 1.57 (0.69-3.58), 9 (7.6%) HR 2.54 (1.30-4.96), 15 (11.9%) HR 2.73 (1.38-5.41), and 23 (18.1%) HR 5.77 (2.99-11.14) respectively; for DVT, it was 6 (6.2%) HR 1.94 (0.84-4.48), 9 (7.6%) HR 2.92 (1.44-5.94), 14 (11.1%) HR 3.29 (1.63-6.65), and 21 (16.5%) HR 6.97 (3.53-13.76), respectively. For PE, among transfused individuals, there were 14 events (3.0%) and the HR was 2.40 (1.02-5.61).

CONCLUSION

The risks for developing VTE, DVT, and PE were significantly increased in kidney transplant patients receiving RBCT after transplant. Receipt of RBCT should prompt considerations for judicious monitoring and assessment for thrombosis.

Incidence and outcome of isolated distal deep vein thrombosis in kidney transplant recipients

Purpose

Isolated distal deep vein thrombosis (IDDVT) is a localized lesion; nonetheless, the risk of proximal vein propagation makes it difficult to decide on the treatment protocol—that is, whether immediate anticoagulation after diagnosis or surveillance via serial imaging should be employed. This study aimed to investigate the appropriate treatment protocol for IDDVT in kidney transplant recipient (KTR).

Methods

Surveillance for venous thromboembolism (VTE) was performed using duplex ultrasonography (DUS) before transplant surgery and at 1 week, 2 weeks, 1 month, 3 months, 6 months, and 1 year after transplant surgery. Dual mechanical prophylaxis was administered to prevent VTE.

Results

In total, 60 out of 829 patients (7.2%) developed VTE, with 49 cases (81.6%) of IDDVT. Among IDDVT patients, 15 patients were treated using anticoagulation-first strategy, whereas the remaining 34 patients were treated using surveillance-first strategy. No patient in either group exhibited thrombus extension into the proximal vein or recurrence within 1 year from transplant surgery.

Conclusion

In Korean KTR, extension of IDDVT into the proximal vein could be prevented safely and effectively by serial DUS surveillance along with the maintenance of mechanical prophylaxis. However, the patients who have high thrombus burden or are difficult to get repeated DUS require the use of anticoagulation in early stages.

Venous Thromboembolism after the Repair of Abdominal Incisional Hernia with a Pedicled Anterolateral Thigh Flap

Incisional hernia often complicates kidney transplant. However, there are few reports showing pitfalls after the repair of incisional hernia following living-donor kidney transplant. A 55-year-old man underwent living-donor kidney transplant from his wife at the Department of Urology at the authors' hospital. He noticed abdominal distension 6 months postoperatively and was diagnosed with incisional hernia by computed tomography (CT) imaging. Clinical examination revealed the extensive distension of the right abdomen; noncontrast abdominal CT showed transverse colon, descending colon, and mesenteric prolapse through a hernial orifice measuring 11 × 14 cm, located slightly cranial to the anterior superior iliac spine. Repair was performed under general anesthesia the following day; the right thigh was the donor site. A pedicled anterolateral thigh flap from the donor site was used for abdominal wall reconstruction. He developed fever, and pain and swelling were noted in the right leg on postoperative day 14. Contrast-enhanced thoracic CT confirmed a diagnosis of pulmonary embolism (PE) and deep vein thrombosis. He was quickly started on an oral factor Xa inhibitor (edoxaban) and continuous intravenous heparin; contrast-enhanced thoracic CT on postoperative day 23 showed that PE had disappeared. At 6 months postoperatively, there was no recurrence of the venous thromboembolism or incisional hernia. The authors reported a case of incisional hernia repair after living-donor kidney transplant with a pedicled anterolateral thigh flap, complicated by deep vein thrombosis and PE. Adequate preoperative evaluation was required to determine optimal surgical techniques and preventive measures in cases with myriad thrombogenic risk factors.

Venous Thromboembolism and the Risk of Death and Graft Loss in Kidney Transplant Recipients

BACKGROUND

The implications of venous thromboembolism (VTE) for morbidity and mortality in kidney transplant recipients are not well described.

METHODS

We conducted a retrospective study using linked healthcare databases in Ontario, Canada to determine the risk and complications of VTE in kidney transplant recipients from 2003 to 2013. We compared the incidence rate of VTE in recipients (n = 4,343) and a matched (1:4) sample of the general population (n = 17,372). For recipients with evidence of a VTE posttransplant, we compared adverse clinical outcomes (death, graft loss) to matched (1:2) recipients without evidence of a VTE posttransplant.

RESULTS

During a median follow-up of 5.2 years, 388 (8.9%) recipients developed a VTE compared to 254 (1.5%) in the matched general population (16.3 vs. 2.4 events per 1,000 person-years; hazard ratio [HR] 7.1, 95% CI 6.0-8.4; p < 0.0001). Recipients who experienced a posttransplant VTE had a higher risk of death (28.5 vs. 11.2%; HR 4.1, 95% CI 2.9-5.8; p < 0.0001) and death-censored graft loss (13.1 vs. 7.5%; HR 2.3, 95% CI 1.4-3.6; p = 0.0006) compared to matched recipients who did not experience a posttransplant VTE.

CONCLUSIONS

Kidney transplant recipients have a sevenfold higher risk of VTE compared to the general population with VTE conferring an increased risk of death and graft loss.

Role of microRNA-26a in the diagnosis of lower extremity deep vein thrombosis in patients with bone trauma

The present study aimed to investigate the role and mechanism of action of microRNA (miR)-26a in deep vein thrombosis (DVT). Peripheral blood was collected from 45 patients with DVT and 40 healthy controls. Levels of miR-26a, chemokine C-C motif ligand (CCL)2 mRNA and CCL7 mRNA were detected using reverse transcription-quantitative polymerase chain reaction and the value of miR-26a in the clinical diagnosis of DVT was assessed using receiver operating characteristic curve analysis. The correlation of miR-26a with CCL2 and CCL7 levels was analyzed using Spearman's rank correlation. In addition, miR-26a and protein kinase C δ (PRKCD) were overexpressed in human umbilical vein endothelial cells (HUVECs) and PRKCD expression was knocked down by small interfering (si)RNA. Western blotting was conducted to detect the expression of PRKCD and p65. Furthermore, a dual-luciferase reporter gene assay was performed. The results of the current study demonstrated that the expression of miR-26a was significantly downregulated in the peripheral blood of patients with DVT compared with healthy controls (P<0.05) and negatively correlated with CCL2 and CCL7 levels (P<0.05). Furthermore, it was demonstrated that miR-26a markedly inhibited the expression of PRKCD, significantly decreased levels of CCL2 and CCL7 mRNA (P<0.05) and inhibited activation of the NF-κB signaling pathway. Overexpression of PRKCD in HUVECs inhibited the effects of miR-26a and markedly upregulated the phosphorylation of p65. The present study indicated that miR-26a directly targets PRKCD mRNA and that miR-26a may be a useful biomarker in the clinical diagnosis of DVT. Thus, the present findings suggest that miR-26a regulates the NF-κB signaling pathway by binding to PRKCD mRNA, inhibits the expression of CCL2 and CCL7 and reduces the risk of DVT.

Cardiovascular disease risk in patients receiving organ transplantation: a national cohort study

Although organ transplantation is the definitive treatment for end-stage organ failure, the post-transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75-11.44), 3.32 (2.29-3.77), and 1.4 (1.15-1.7) and the overall standardized mortality ratios were 5.23 (4.54-6.03), 1.48 (1.34-1.63), and 3.95 (3.64-4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57-16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post-transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high-risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.

Association of Coagulation Factors VIII/XI/XIII Polymorphisms With Coagulation Factor Activities and Deep Vein Thrombosis After Artificial Joints Replacement

The study aims at investigating the effects of coagulation factors VIII/XI/XIII polymorphisms in coagulation factor activities and deep vein thrombosis (DVT). A total of 130 patients with history of artificial joint replacement surgery were recruited, including 65 patients with DVT (cases) and 65 patients without DVT (controls). Cases and controls had comparable age, sex, and body mass index. Activities of VIII/XI and XIII were, respectively, detected by 1 phase anticoagulation method and microtitrimetry. Polymorphisms of VIII rs1800291 (3591C>G), XI rs2289252 (25264C>T), and XIII rs5985 (103G>T) were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Activities of VIII/XI were significantly increased in cases than in controls (P < 0.001 for VIII, P = 0.024 for XI). Activity of XI was significantly increased by 11.11% in CT + TT mutant type (25264C>T) compared with wild-type CC (95% confidence interval (CI), 2.28-19.95). In univariate analysis, incidence of DVT for CT mutant was 2.41-fold compared with wild-type CC (95% CI, 1.16-5.03). T allele had 1.83-fold increased risk of DVT than C allele (95% CI, 1.06-3.14). In multivariate analysis, incidence of DVT for CT + TT mutant type was 2.39-fold compared with wild type (95% CI, 1.07-5.35). Distributions of VIII gene 3951C>G and genotypes were not significant between groups (both P > 0.05). The mutation rate of VIII gene 103G>T was low in study population (0.77%) and was not significant between groups. XI 25264C>T genotype is significantly associated with XI activity. T mutation of this locus significantly increases XI activity and is a risk factor for DVT.