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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| Category | Group Criteria | Anticoagulation Protocol | | Low Risk | No biochemical thrombophelia or previous thrombotic events | VTE prophylaxis and aspirin for one week | | Moderate Risk | Biochemical 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 place | Low dose iv heparin for 48 to 72 hours, followed by clopidrogel x 1 month | | High Risk | History 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 contraindicated | Intraoperative iv heparin to continue and bridge to warfarin | Results| Event | Low Risk | Moderate Risk | High Risk | Total | P Value | | N | 92 (67%) | 37 (27%) | 8 (6%) | 137 (100%) | | | VTE | 0 | 0 | 0 | 0 | | | Allograft Thrombosis | 1 | 1 | 0 | 2 | NS | | Bleeding Complication | 3 (3%) | 2 (5%) | 1 (12.5%) | 6 (4%) | | | PRBC Transfusion | 10 (12%) | 11 (27%)* | 1 (12.5%) | 22 (16%) | * p < 0.05 |
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