Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Jul 29, 2020; 10(7): 206-214
Published online Jul 29, 2020. doi: 10.5500/wjt.v10.i7.206
Anticoagulation in simultaneous pancreas kidney transplantation - On what basis?
Jeevan Prakash Gopal, Frank JMF Dor, Jeremy S Crane, Paul E Herbert, Vassilios E Papalois, Anand SR Muthusamy
Jeevan Prakash Gopal, Frank JMF Dor, Jeremy S Crane, Paul E Herbert, Vassilios E Papalois, Anand SR Muthusamy, Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
Frank JMF Dor, Jeremy S Crane, Paul E Herbert, Vassilios E Papalois, Anand SR Muthusamy, Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
Author contributions: Muthusamy ASR conceived the study; Gopal JP collected the data, performed the analysis and wrote the manuscript; Dor FJMF, Crane JS, Herbert PE, Papalois VE, and Muthusamy ASR contributed to the data generation, reviewed the manuscript and made critical corrections to the manuscript.
Institutional review board statement: This study was reviewed and approved by the Imperial College Healthcare NHS Trust.
Informed consent statement: All the patients in the study have given their consent for clinical management as per the trust informed consent policy. Hence this study does not require individual patient consent.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Anand SR Muthusamy, FRCS, Consultant Transplant Surgeon, Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom. anand.muthusamy@nhs.net
Received: January 16, 2020
Peer-review started: January 16, 2020
First decision: February 25, 2020
Revised: March 26, 2020
Accepted: June 14, 2020
Article in press: June 14, 2020
Published online: July 29, 2020
Processing time: 188 Days and 9 Hours
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% vs 39.25% in the CCT group (P = 0.14, Fisher’s exact test). The median length of hospital stay was 18 days in the TEG group vs 31 days in the CCT group (P = 0.03, Mann Whitney test). The 1-year pancreas graft survival was 100% in the TEG group vs 82.35% in the CCT group (P = 0.07, log rank test) and, the 1-year kidney graft survival was 100% in the TEG group vs 92.15% in the CCT group (P = 0.23, log tank test).

CONCLUSION

TEG is a promising tool in guiding judicious use of anticoagulation with concomitant prevention of graft loss due to thrombosis, and reduces the length of hospital stay.

Keywords: Anticoagulation; Pancreas transplantation; Thromboelastography; Thrombosis; Hypercoagulability

Core tip: Early post-operative graft thrombosis and graft loss are the Achilles heel of pancreas transplantation and routine prophylactic anticoagulation seems to be the logical remedy. Do all patients need the same dose of anticoagulation? We have compared the outcomes of thromboelastogram directed and conventional coagulation test based anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients and highlighted the needs and advantages of individualized anticoagulation based on thromboelastogram.