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A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation. Transplantation 2022; 106:2143-2154. [PMID: 35642975 DOI: 10.1097/tp.0000000000004195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Direct-acting oral anticoagulant (DOAC) use has increased dramatically since their introduction because of the growing evidence of proven efficacy and enhanced safety compared with warfarin and the low-molecular-weight heparins in the general population. Unfortunately, there is a dearth of quality data regarding the safety and efficacy of the DOACs in patients awaiting organ transplant and those who received a solid organ transplant. This review aims to evaluate the available literature and considerations regarding anticoagulation use in transplant recipients, focusing on preoperative, perioperative, and postoperative DOAC use.
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Motokazu M, Kanae K, Yuichiro S, Terutaka N, Kenichi N, Tetsuya F, Noriyoshi M, Yuki M, Tadahiko K, Takashi S. Case Report: Heparin-Induced Thrombocytopenia Treated With Plasmapheresis Before Living-Donor Kidney Transplantation. Transplant Proc 2022; 54:112-115. [PMID: 34986977 DOI: 10.1016/j.transproceed.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin. Additionally, although heparin can affect kidney transplantation, there only have been a few reports on this condition. Here, we report a case wherein surgery was safely performed with preoperative plasmapheresis in a patient with HIT. CASE PRESENTATION The patient was a 48-year-old woman who was on dialysis because of immunoglobulin A nephropathy. Immediately after the initiation of dialysis, the patient experienced repeated arteriovenous fistula occlusion and thrombocytopenia and had a positive HIT antibody test result. Subsequently, she received an ABO-incompatible living-donor kidney transplantation from her spouse. The surgery was performed without using anticoagulants because HIT antibodies disappeared with preoperative plasmapheresis. Eighteen months after surgery, her kidney function remained stable, and there was no recurrence of HIT. CONCLUSION Preoperative plasmapheresis is useful for patients with HIT.
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Affiliation(s)
| | - Koyama Kanae
- Uwajima City Hospital, Uwajima Shi, Ehime ken, Japan
| | - Sawada Yuichiro
- National Hospital Organization Shikoku Cancer Center, Minamiumemotomachi, Matsuyama Shi, Ehime Ken, Japan
| | - Noda Terutaka
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Nishimura Kenichi
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Fukumoto Tetsuya
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Miura Noriyoshi
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Miyauchi Yuki
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Kikugawa Tadahiko
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Saika Takashi
- Department of Urological Science, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
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Di Pilla M, Barco S, Sacco C, Barosi G, Lodigiani C. Acute limb ischemia in a patient with pre-fibrotic myelofibrosis complicated by heparin-induced thrombocytopenia and thrombosis – case report and systematic review of dabigatran use. VASA 2021; 50:151-156. [DOI: 10.1024/0301-1526/a000876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Summary: A 49-year-old man was diagnosed with pre-fibrotic myelofibrosis after acute left lower-limb ischemia requiring amputation and portal vein thrombosis. After surgery he developed heparin-induced thrombocytopenia (HIT) with venous thromboembolism, successfully treated with argatroban followed by dabigatran. Our systematic review of the literature supports the use of dabigatran for suspected HIT.
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Affiliation(s)
- Marina Di Pilla
- Thrombosis and Haemorrhagic Diseases Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milano, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Clara Sacco
- Thrombosis and Haemorrhagic Diseases Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milano, Italy
| | | | - Corrado Lodigiani
- Thrombosis and Haemorrhagic Diseases Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milano, Italy
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Bixby AL, Lichvar AB, Salerno D, Park JM. Use of direct-acting oral anticoagulants in solid organ transplantation: A systematic review. Pharmacotherapy 2020; 41:28-43. [PMID: 33155327 DOI: 10.1002/phar.2485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
The use of direct-acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant-specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single-center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug-drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non-specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug-drug interactions, obesity, and renal function, especially in patients on hemodialysis.
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Affiliation(s)
- Alexandra L Bixby
- Department of Pharmacy Services, University of Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alicia B Lichvar
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA.,Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
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Nishida H, Fukuhara H, Yamagishi A, Hosoya N, Ichiyanagi O, Sakurai T, Naito S, Yamanobe T, Kato T, Tsuchiya N. Living kidney transplantation without perioperative anticoagulation therapy for a patient with heparin-induced thrombocytopenia. IJU Case Rep 2020; 3:86-89. [PMID: 32743478 PMCID: PMC7292195 DOI: 10.1002/iju5.12148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/28/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Heparin-induced thrombocytopenia is an antibody-mediated acquired prothrombotic state induced by heparin exposure. The risk of thromboembolic diseases in kidney transplantation with heparin-induced thrombocytopenia without perioperative anticoagulation has not been determined. CASE PRESENTATION A 64-year-old male hemodialysis patient with heparin-induced thrombocytopenia was referred to our hospital for living kidney transplantation. Anti-heparin-induced thrombocytopenia antibody was positive at the time of referral; however, it turned negative 4 months after heparin cessation during hemodialysis sessions. Living kidney transplantation by donation from his wife was performed using the standard technical procedure. Both heparinization and application of medical equipment containing heparin were avoided; however, no anticoagulant was administered intra- and postoperatively. The graft kidney functioned immediately, and no thromboembolic event related to heparin-induced thrombocytopenia occurred. CONCLUSION Kidney transplantation without perioperative anticoagulation therapy after disappearance of anti-heparin-induced thrombocytopenia antibody is a well-tolerated treatment option for patients with end-stage kidney disease.
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Affiliation(s)
- Hayato Nishida
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Hiroki Fukuhara
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Atsushi Yamagishi
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Noriyuki Hosoya
- Department of UrologyTsuruoka Municipal Shonai HospitalYamagataJapan
| | - Osamu Ichiyanagi
- Department of UrologyYamagata Prefectural Kahoku HospitalYamagataJapan
| | - Toshihiko Sakurai
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Sei Naito
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Takuya Yamanobe
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Tomoyuki Kato
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
| | - Norihiko Tsuchiya
- Department of UrologyYamagata University Faculty of MedicineYamagataJapan
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Lichvar AB, Pierce DR, Salerno D, Klem P, Waldman G, Park JM. Utilization of direct-acting oral anticoagulation in solid organ transplant patients: A national survey of institutional practices. Clin Transplant 2020; 34:e13853. [PMID: 32163212 DOI: 10.1111/ctr.13853] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/12/2020] [Accepted: 03/05/2020] [Indexed: 01/05/2023]
Abstract
The safety and efficacy of direct-acting oral anticoagulants (DOACs) and reversal strategies are not well established in the solid organ transplant population. This was a survey of pharmacists to assess DOAC and urgent reversal practices among adult transplant programs in the United States. A 27-question survey was distributed to members of transplant pharmacy organization listservs between 5/28/19 and 6/30/19. A total of 115 responses were received from kidney (43.5%), heart (20.0%), lung (18.3%), liver (13.9%), and pancreas (4.4%) transplant programs. DOAC use prior to transplant was mostly prohibited in thoracic programs (77.3%) but more permissive in kidney transplant programs (64.0%). If permitted, apixaban (57.8%) was most preferred. At transplant surgery, reversal of DOAC was performed "as needed" (20.9%) or was not routine (18.3%). DOAC use post-transplant was more permissive (94.3%). A majority of responders follow FDA recommended dosing in the setting of drug-drug interactions (51.1%). Major factors influencing DOAC prescribing decisions included renal function, drug-drug interactions, and insurance. High clinical practice variability exists regarding DOAC utilization and urgent reversal strategies in pre-, peri-, and post-transplant stages. While more research is needed to refine the clinical landscape, many institutions are using DOAC therapy under the perception that they pose a similar risk of bleeding compared to a non-transplant population.
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Affiliation(s)
- Alicia B Lichvar
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA.,Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Dana R Pierce
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - David Salerno
- Liver Transplantation and Hepatobiliary Surgery, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Patrick Klem
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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