Thromboprophylaxis guidelines; surgical admission for renal transplant (all recipients and living-donors)

• Aims
• Background
• Risk Assessment
• Treatment/Management

Aims

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital for renal transplant surgery.

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Background

This is the guidance applicable to all renal transplant recipients and donor nephrectomy.
NICE clinical guideline 92; Venous thromboembolism: reducing the risk was issued in January 2010, updated June 2015 and replaced by NICE guideline NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism in March 2018

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Risk Assessment

Leeds Teaching Hospitals risk assessment tool is used to stratify the risk of VTE for each patient. This can now be found on PPM+.

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Treatment / Management

All new renal transplant recipients and living-donor nephrectomy patients will be risk assessed by the clerking doctor on admission to either ward J49 (male) or J50 (female) before surgery. On admission to hospital all patients should be risk assessed and identified for risk of VTE and risk of bleeding using the Leeds Teaching Hospitals risk assessment tool. This should be completed electronically via PPM+.

Pre-operative anticoagulation with oral anticoagulants is reversed, either by omission of anticoagulant in planned live-donation or pharmacologically when a patient is called for a deceased-donor organ. Follow the guideline ‘Management of Warfarin Reversal in Adults’, which is available through Leeds Health Pathways.

Transplant recipients

Enoxaparin 20mg subcutaneously may be given pre-operatively if requested by the Consultant Surgeon. Consideration is required of whether the patient has received haemodialysis anticoagulation (i.e. unfractionated heparin, low molecular weight heparin,or fondaparinux) prior to surgery.

Patients with complicated vascular anastomoses and those receiving en-bloc kidneys from paediatric donors may be prescribed intravenous heparin 200 units per hour from theatre, typically for three to five days. This is not VTE prophylaxis and does not replace the need for low molecular weight heparin (LMWH). Patients should still receive LMWH in addition.

Other than where an irreversible bleeding risk is identified ALL RECIPIENTS will be prescribed enoxaparin 20mg sub-cutaneously once daily at 6pm until discharge. This choice and dose of low molecular weight heparin applies irrespective of the degree of early graft function. As renal function starts to improve patients should then be switched to enoxaparin 40mg once a day. Patients over 100kg should receive higher doses of LMWH as per guidance see dosing charts below

Enoxaparin Dosing for patients with creatinine clearance (CrCl) over 30mL/min

Enoxaparin Dosing for patients with creatinine clearance (CrCl) less than 30mL/min

Patients with delayed graft function who receive post-operative haemodialysis using either unfractionated heparin or no dialysis anticoagulation REQUIRE thromboprophylaxis on dialysis days.

There are situations where VTE prophylaxis should be omitted:

• Renal transplant biopsy is defined locally as a procedure-related high bleeding risk which warrants omission of enoxaparin for the previous 24 hours when possible.
  • Again prescribers should identify this on the inpatient eMed chart by withholding the evening before dose, annotating the reason in the appropriate box.
  • When not possible to omit in advance, this should be discussed with the consultant surgeon or renal physician covering Renal Transplant.

• Kidney recipients in Leeds generally DO NOT receive epidural or spinal anaesthesia.
  • If it is an option under consideration then enoxaparin must not be given within 12 hours prior to inserting or removing an epidural / spinal anaesthesia.
  • Enoxaparin should not be given until > 4 hours after insertion or removal of an epidural or spinal anaesthesia.

Living-donor transplant nephrectomy patients.

All donors require VTE prophylaxis. Each will be prescribed enoxaparin 40mg sub-cutaneous injection once daily at 6pm (or higher based on weight as detailed in dosing charts above). This should continue until the patient no longer has significantly reduced mobility, which is considered to be until 7 days post-op.

A patient discharged earlier will be prescribed the remainder of the 7 day course on his or her discharge to be administered at home.

Mechanical prophylaxis.

All patients (recipients and donor nephrectomy) will be prescribed below-knee, anti-embolism stockings on admission to be worn and continued until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. Most patients are likely to stop these prior to discharge.

Do not offer anti-embolism stockings to people who have:

• suspected or proven peripheral arterial disease
• peripheral arterial bypass grafting
• peripheral neuropathy or other causes of sensory impairment
• any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
• known allergy to material of manufacture
• severe leg oedema
• major limb deformity or unusual leg size or shape preventing correct fit.
  
  Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.

If the surgical team feels that the patient requires intermittent pneumatic compression then these can be prescribed instead of anti-embolism stockings. These should then however be carried on post-surgery and not be switched to anti-embolism stockings on step down to the ward.

Patients will be reassessed for bleeding risk and VTE risk on the daily, joint consultant-led ward rounds commencing within 24 hours of admission, as per NICE guidance. Patients on LMWH should receive this daily until discharge. It has previously been discussed with the transplant team that renal transplant recipients will not receive extended LMWH to cover 7 days if discharged earlier. The thrombosis steering group is aware of this decision.

Kidney transplant recipients and living-donor transplant nephrectomy patients will not routinely be sent home with mechanical prophylaxis.

Patient Information

All patients should be given verbal and written information on admission of their risk of VTE, what will happen, side effects and how they can reduce the risk. On discharge they should be given verbal and written information on signs and symptoms of VTE and what to do should they occur. They should also be counseled on how and for how long to use their thromboprophylaxis if required on discharge. Leaflet LN004075 contains this information and is available to order from the print unit.

Information for Discharge

Notify the patient's GP if they have been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home

All heparins are porcine based. If patients do not want a porcine based product consider fondaparinux 2.5mg s/c once a day reduced to 1.5mg s/c once a day if CrCl 20-50ml/min) Contra-indicated if CrCl < 20ml/min

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