Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?

Abstract

BACKGROUND Despite technical refinements, early pancreas graft loss due to thrombosis continues to occur. Conventional coagulation tests (CCT) do not detect hypercoagulability and hence the hypercoagulable state due to diabetes is left untreated. Thromboelastogram (TEG) is an in-vitro diagnostic test which is used in liver transplantation, and in various intensive care settings to guide anticoagulation. TEG is better than CCT because it is dynamic and provides a global hemostatic profile including fibrinolysis. AIM To compare the outcomes between TEG and CCT (prothrombin time, activated partial thromboplastin time and international normalized ratio) directed anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients. METHODS A single center retrospective analysis comparing the outcomes between TEG and CCT-directed anticoagulation in SPK recipients, who were matched for donor age and graft type (donors after brainstem death and donors after circulatory death). Anticoagulation consisted of intravenous (IV) heparin titrated up to a maximum of 500 IU/h based on CCT in conjunction with various clinical parameters or directed by TEG results. Graft loss due to thrombosis, anticoagulation related bleeding, radiological incidence of partial thrombi in the pancreas graft, thrombus resolution rate after anticoagulation dose escalation, length of the hospital stays and, 1-year pancreas and kidney graft survival between the two groups were compared. RESULTS Seventeen patients who received TEG-directed anticoagulation were compared against 51 contemporaneous SPK recipients (ratio of 1: 3) who were anticoagulated based on CCT. No graft losses occurred in the TEG group, whereas 11 grafts (7 pancreases and 4 kidneys) were lost due to thrombosis in the CCT group ( P = 0.06, Fisher’s exact test). The overall incidence of anticoagulation related bleeding (hematoma/ gastrointestinal bleeding/ hematuria/ nose bleeding/ re-exploration for bleeding/ post-operative blood transfusion) was 17.65% in the TEG group and 45.10% in the CCT group ( P = 0.05, Fisher’s exact test). The incidence of radiologically confirmed partial thrombus in pancreas allograft was 41.18% in the TEG and 25.50% in the CCT group ( P = 0.23, Fisher’s exact test). All recipients with partial thrombi detected in computed tomography (CT) scan had an anticoagulation dose escalation. The thrombus resolution rates in subsequent scan were 85.71% and 63.64% in the TEG group vs the CCT group ( P = 0.59, Fisher’s exact test). The TEG group had reduced blood product usage {10 packed red blood cell (PRBC) and 2 fresh frozen plasma (FFP)} compared to the CCT group (71 PRBC/ 10 FFP/ 2 cryoprecipitate and 2 platelets). The proportion of patients requiring transfusion in the TEG group was 17.65% ...

Thromboelastography in the Perioperative Period: A Literature Review

“…Regarding the use of blood products, the studies revealed different results. TEG parameters reduced the usage of blood products [156][157][158]; however, in comparison to other conventional tests or clinician-directed transfusion system, no differences were observed except for Sujka et al who found TEG-directed transfusion system reduced only FFP use between other blood products [150,159,160]. Coakley et al investigated both TEG and ROTEM parameters and found that ROTEM improved clinicians' decisions compared to TEG usage [161].…”

“…This controversy was seen also in the prediction of liver cirrhosis [ 148 , 163 ]. TEG’s usage was not associated with mortality or survival rates [ 156 , 160 ]. On the other hand, it decreased hospital stay length and reoperation needs [ 147 , 160 ] (Table 8 ).…”

“…TEG’s usage was not associated with mortality or survival rates [ 156 , 160 ]. On the other hand, it decreased hospital stay length and reoperation needs [ 147 , 160 ] (Table 8 ).…”

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

“…Donor factors (including age, weight, and gender) and perioperative factors (cold ischemic time, warm ischemic time, preservation solution, exocrine drainage, and arterial reconstruction) are known to affect thrombosis risk [ 103 , 129 , 135 ]. There is also evidence in retrospective studies that anticoagulation does prevent allograft thrombosis in these patients, but this must be balanced with the risk of rebleeding and risk of repeat exploratory laparotomy caused by excess anticoagulation [ 129 , 131 , 132 , 135 , 136 , 137 , 138 , 139 , 140 ]. For each case, an assessment of thrombotic risk should be made based on donor factors, recipient factors and perioperative factors, and a degree of anticoagulation should be begun commensurate with this calculated risk.…”

“…TEG allows rapid, real-time assessment of both clot formation as well as fibrinolysis making it ideal for titration of anticoagulation in the perioperative period [ 141 , 142 ]. In a retrospective study, Gopal et al demonstrated that there was reduced bleeding (18% vs. 45%, p = 0.05) and reduced length of hospital stay (18 vs. 31 days, p = 0.03) in anticoagulation titrated using TEG vs. standard coagulation tests (prothrombin time and activated partial thromboplastin time), respectively [ 137 ]. Regular preoperative monitoring of platelet function through the collagen-epinephrine closure time (Col/Epi) and collagen-ADP assay (Col/ADP) could be beneficial, but more work is needed to evaluate their clinical value.…”