(970) Prothrombin Complex Concentrate for Apixaban Reversal Prior to Deceased Donor Kidney Transplant

Introduction: An increasing number of patients have undergone deceased donor kidney transplant (DDKT) while on apixaban. The uncertain timing of deceased donor kidney availability further complicates peri- and post-transplant anticoagulation management. Peri-operative reversal of apixaban to mitigate bleeding complications in this setting remains controversial with high practice variability amongst transplant programs due to lack of high-quality evidence.

Description: A 73-year-old male with atrial fibrillation and hypertensive nephropathy presented for DDKT having taken apixaban 5 mg an estimated 10.5 hours prior to transplant. Apixaban was reversed pre-emptively at the start of the DDKT per hospital protocol using four-factor prothrombin complex concentrate (4F-PCC) at a weight-based dose of 50 units/kg and total dose of 4,829 units. The kidney was successfully transplanted with an estimated blood loss of 150 mL. Hemoglobin decreased by 15.4% from baseline to 24 hours post-operation. No blood products or further intra- or post-operative 4F-PCC doses were required. He was initiated on subcutaneous heparin and sequential compression device for deep vein thrombosis prophylaxis. Post-operative labs were notable for a potassium of 6.8 mmol/L with electrocardiogram changes which resolved after urgent dialysis. He additionally had intermittent hypotension for which norepinephrine was titrated. The evening of the transplant he experienced cardiac arrest after a witnessed aspiration event. Ultimately, advanced cardiac life support was terminated after 25 minutes due to persistent asystole. Autopsy was completed with findings of a pulmonary embolism that had presumably led to his clinical deterioration and death with indistinguishable chronicity of the clot.

Discussion: There is currently no available evidence to guide apixaban management prior to DDKT. Weight-based dosing of 4F-PCC reversal may achieve adequate hemostasis, but the thromboembolic event we observed may serve as a signal to investigate safety outcomes further.