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
ARTICLE HIGHLIGHTS
Research background

Pancreas allograft thrombosis is the most common non-immunological cause for early graft loss. Hence, prophylactic anticoagulation has become the routine practice. Conventional coagulation tests (CCT) are slow in titrating anticoagulation especially in the early post-operative period and also don’t detect hypercoagulable state that is inherent to diabetes and is left unaddressed. Thromboelastogram (TEG) is a dynamic, rapid and reliable tool that provides a complete picture of coagulation. TEG based anticoagulation in pancreas transplantation has been proven to identify patients at risk of thrombotic graft loss thereby enabling safe anticoagulation with least morbidity and mortality.

Research objective

Despite these studies, there is no clear consensus for the basis of anticoagulation. Therefore, we aimed to compare the outcomes between TEG and CCT based anticoagulation in simultaneous pancreas and kidney (SPK) transplantation.

Research 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/hour 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.

Research results

For the first time we have compared TEG and CCT directed anticoagulation in pancreas transplantation. There were no thrombotic graft losses in the TEG group whereas 7 pancreases and 4 kidneys were lost in the CCT group. The incidence of anticoagulation related bleeding was less (17.65% TEG vs 45.10%CCT, P = 0.05) and also the median length of hospital stay was reduced (18 days TEG vs 31 days CCT, P = 0.03) in TEG group compared to the CCT group.

Research conclusions

TEG based anticoagulation prevents thrombotic graft loss without concomitant increase in the incidence of anticoagulation related bleeding and also reduces the length of hospital stay. Hereby our findings re-confirm the published literature.

Research perspectives

Future prospective studies with more patient numbers will be more beneficial for generating a robust evidence base.