Ripert T, Menard J, Schoepen Y, Nguyen P, Rieu P, Staerman F
Department of Urology, CHU Robert Debre, REIMS, Champagne Ardennes, France.
Transplant Proc. 2009 Dec;41(10):4193-6. doi: 10.1016/j.transproceed.2009.07.106.
Renal allograft vascular thrombosis is a complication that often results in graft loss. Since there are no guidelines on immediate postoperative thromboprophylaxis, we performed a telephone survey of clinical practice in all renal transplantation centers in France.
Each center considered 4 cases relating to renal transplant candidates on dialysis with an increasing risk of thrombosis: Case 1: patient with no identified risk factors; Case 2: patient with an earlier incidence of deep vein thrombosis; Case 3: patient with ischemic heart disease on antiplatelet therapy; Case 4: patient with atrial fibrillation taking a vitamin K antagonist (VKA) with lupus nephritis syndrome.
The treatments proposed by the centers (%) were: Case 1: No anticoagulation therapy (57.1%), calcium heparin at prophylactic doses (P-dose) (40%), or unfractionated heparin (UFH); (P-dose; 2.9%). Case 2: No anticoagulation therapy (34.3%), calcium heparin (P-dose; 51.4%), or UFH (P-dose; 5.7%). Case 3: (A) Interruption of aspirin (65.7%), and either no anticoagulation therapy (21.7%) or substitution of aspirin by calcium heparin (P-dose; 56.6%) or by UFH (P-dose; 8.7%). (B) No interruption of aspirin (34.3%), and either no additional prophylaxis (58.3%) or calcium heparin (P-dose; 33.3%). Case 4: Interruption of VKA (100%), and UFH at a curative dose (68.6%), UFH (P-dose; 14.3%), or calcium heparin (P-dose; 11.4%).
Practices varied widely in the absence of studies of sufficiently high power. There is a need for a preoperative classification of thrombotic and hemorrhagic risk among renal transplant candidates and for consensus guidelines.
肾移植血管血栓形成是一种常导致移植肾丢失的并发症。由于术后即刻血栓预防尚无指南,我们对法国所有肾移植中心的临床实践进行了电话调查。
每个中心考虑4例与透析中肾移植候选者相关的病例,其血栓形成风险逐渐增加:病例1:无明确危险因素的患者;病例2:既往有深静脉血栓形成的患者;病例3:接受抗血小板治疗的缺血性心脏病患者;病例4:患有狼疮性肾炎综合征且正在服用维生素K拮抗剂(VKA)的房颤患者。
各中心提出的治疗方案(%)如下:病例1:不进行抗凝治疗(57.1%)、预防性剂量的钙肝素(P剂量)(40%)或普通肝素(UFH)(P剂量;2.9%)。病例2:不进行抗凝治疗(34.3%)、钙肝素(P剂量;51.4%)或UFH(P剂量;5.7%)。病例3:(A)停用阿司匹林(65.7%),不进行抗凝治疗(21.7%)或用钙肝素(P剂量;56.6%)或UFH(P剂量;8.7%)替代阿司匹林。(B)不停用阿司匹林(34.3%),不进行额外预防(58.3%)或钙肝素(P剂量;33.3%)。病例4:停用VKA(100%),治疗剂量的UFH(68.6%)、UFH(P剂量;14.3%)或钙肝素(P剂量;11.4%)。
在缺乏足够大样本研究的情况下,实践差异很大。需要对肾移植候选者的血栓形成和出血风险进行术前分类并制定共识指南。