The safety of tranexamic acid administration in total knee arthroplasty: a population‐based study from Taiwan

Abstract

Summary Tranexamic acid is an effective treatment to reduce blood loss. We performed a retrospective observational study to evaluate safety in unilateral total knee arthroplasty. We utilised Taiwan's national health insurance database to identify relevant patients and to retrieve information on peri‐operative blood transfusions and tranexamic acid administration within 60 days of follow‐up. We examined changes in the rate of transfusions and adverse events with respect to tranexamic acid administration using logistic regression. We observed a total of 226,719 knee arthroplasty cases during 2010–2019. Transfusion and tranexamic acid administration rates were 38.9% (88,258) and 42.9% (97,237), respectively. Tranexamic acid was associated with a 50% decrease in blood transfusions (RR: 0.50, 95%CI: 0.48–0.51). After propensity‐score matching, tranexamic acid was not associated with pulmonary embolism; deep vein thromboembolism; artery vein thromboembolism; acute myocardial infarction; ischaemic stroke; or in‐hospital mortality, but was significantly associated with acute kidney injury. Patients with existing chronic kidney disease suffered a high absolute risk of kidney injury irrespective of tranexamic acid administration (832 per 10,000, 95%CI 797–869). Tranexamic acid was also associated with surgical site infection. There was strong interaction between blood transfusion; tranexamic aid administration; and development of surgical site infection. In conclusion, tranexamic acid use was associated with decreased blood transfusion and was not associated with thromboembolic events. However, careful consideration is required before use in patients with pre‐existing renal disease. Further, our observed interaction between patients given tranexamic acid who subsequently require transfusion requires careful consideration with respect to enhanced prophylaxis against surgical site infection.

Tranexamic acid in total knee arthroplasty

“…In this issue of Anaesthesia , Hsu et al. [5] present retrospective observational safety information on all patients receiving a total knee arthroplasty (TKA) in Taiwan. The authors used a population‐based database to retrieve data from more than 220,000 patients over a 10‐year period, of which approximately 43% received TXA.…”

“…In the article by Hsu et al. [5], there was no fixed protocol as to dose or route of administration of TXA, and 44% of patients received between 1 g and 2 g. Studies have generally concluded that when TXA is administered to patients undergoing TKA, the optimal regimen is either 1 g intravenously before application of a tourniquet, or 1 g via the intra‐articular route during surgery.…”

“…In this issue of Anaesthesia, Hsu et al [5] present retrospective observational safety information on all patients receiving a total knee arthroplasty (TKA) in Taiwan.…”

“…Whilst Ling et al [13] found that the combination of intravenous and intra-articular TXA was more efficacious than either alone, this is doubtless because there is a dose dependent effect of TXA, and 2 g is probably too high a dose to be administered in knee surgery. In the article by Hsu et al [5], there was no fixed protocol as to dose or route of administration of TXA, and 44% of patients received between 1 g and 2 g. Studies have generally concluded that when TXA is administered to patients undergoing TKA, the optimal regimen is either 1 g intravenously before application of a tourniquet, or 1 g via the intra-articular route during surgery.…”

“…It has been used in lifethreatening haematuria in patients [20] but could also play a role in the development of acute ureteric clots, leading to cortical necrosis of the kidney [21]. Hsu et al found mixed results in their study and felt that any TXA-associated renal effect is probably only mild or moderate [5]. It would, therefore, be sensible to consider whether to administer TXA for TKA in patients with renal impairment on an individual risk-benefit basis.…”