Perioperative Bleeding Risk of Direct Oral Anticoagulants Versus Warfarin in Kidney Transplantation

Background: Direct oral anticoagulants (DOACs) are commonly used for the treatment/prevention of thromboembolism. Data supporting the best practices for anticoagulation management, specifically with DOACs, at the time of solid organ transplant is limited. This study was designed to compare the perioperative bleeding risk of warfarin vs DOACs in kidney transplant recipients. Methods: This was a single center, retrospective, cohort study evaluating patients on either a DOAC or warfarin prior to kidney transplant. The primary outcome compared a composite of perioperative bleeding risk at 30 days of major bleeding and clinically relevant non-major bleeding. Secondary outcomes evaluated the incidence of type of bleeds, thromboembolism, hospital length of stay, blood product receipt, and patient/graft survival. Results: 67 kidney transplant recipients were included (n = 39 warfarin and n = 28 DOAC). The primary outcome of the composite of incidence of bleeding was no different between groups (21.4% vs 28.2% in DOAC vs warfarin groups, P = 0.52). More warfarin patients met criteria for major bleeding (20.5% vs 14.3%, P = 0.13) but this was not statistically significant. Minor bleeds were similar between DOAC vs warfarin groups (7.7% vs 7.1%, P = 0.99). Hospital length of stay was longer for warfarin patients (median [IQR] days 8 [5-12.3] vs 5 [4-6], P < 0.0001). There was no difference in the other outcomes. Conclusions: This study found no difference in risk of bleeding between groups, however warfarin patients required higher volumes of blood products and had longer hospital length of stays. This study supports DOAC use in the perioperative setting for kidney transplant recipients.