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Outcomes of a Perioperative Anticoagulation Protocol in Renal Transplantation
*Arielle Perez, *John P Vella, *Deborah A Hoch, *Juan Palma-Vargas, *Timothy Hayes, James F. Whiting
Maine Medical Center, Portland, ME

Objective: Determine the safety and efficacy of a risk stratified protocol for perioperative anticoagulation in renal transplant patients.
Design: Retrospective review of a prospectively implemented QI protocol
Setting: Tertiary teaching hospital
Patients: 137 consecutive adult renal transplant patients
Interventions: A risk based perioperative anticoagulation protocol was developed based on literature review and expert opinion and is seen in the table below.
Main Outcome Measures: Rate of thrombotic complications, bleeding complications, transfusions and protocol compliance.
Results: The results are seen in the table below. There was a statistically higher transfusion rate in the moderate risk group. There was also a statistically significant decline in overall transfusion over the three years of the study (27% in 2012, 16% in 2013, and 6% in 2014). Complete compliance with the protocol was poor ranging from 28% in 2012 to 51% in 2014, but the vast majority of protocol violations were related to postoperative aspirin in the low risk group. Compliance in the high risk group was 100%.
Conclusions: A perioperative anticoagulation protocol in renal transplant patients appears safe, although efficacy in preventing VTE and allograft thrombosis cannot be evaluated without much larger numbers of patients.
Risk Stratified Protocol
CategoryGroup CriteriaAnticoagulation Protocol
Low RiskNo biochemical thrombophelia or previous thrombotic eventsVTE prophylaxis and aspirin for one week
Moderate RiskBiochemical thrombophelia w/o thrombotic event OR on coumadin for vascular access thromboses OR intraoperative vascular problem of mild or moderate severity OR IVC filter in placeLow dose iv heparin for 48 to 72 hours, followed by clopidrogel x 1 month
High RiskHistory of significant thrombotic event with or without biochemical thrombophelia OR severe intraoperative vascular event OR indication for chronic A/C where short term discontinuation of A/C is contraindicatedIntraoperative iv heparin to continue and bridge to warfarin

Results
EventLow RiskModerate RiskHigh RiskTotalP Value
N92 (67%)37 (27%)8 (6%)137 (100%)
VTE0000
Allograft Thrombosis1102NS
Bleeding Complication3 (3%)2 (5%)1 (12.5%)6 (4%)
PRBC Transfusion10 (12%)11 (27%)*1 (12.5%)22 (16%)* p < 0.05


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