title: Evaluation of Heparin Anticoagulation Protocols in Post-Renal Transplant Recipients (EHAP-PoRT Study).
abstract: BACKGROUND
  Disturbances in hemostasis are common among renal transplant recipients. Because of the risk of thromboembolism and graft loss after transplant, a prophylactic heparin protocol was implemented at St Paul's Hospital in Vancouver, British Columbia, in 2011. Therapeutic heparin is sometimes prescribed perioperatively for patients with preexisting prothrombotic conditions. There is currently limited literature on the safety and efficacy of heparin use in the early postoperative period.
  
  
  OBJECTIVE
  The primary objectives were to document, for patients who underwent renal transplant, the incidence of major bleeding and of thrombosis in those receiving therapeutic heparin, prophylactic heparin, and no heparin anticoagulation in the early postoperative period and to compare these rates for the latter 2 groups. The secondary objectives included a comparison of the risk factors associated with major bleeding and thrombosis.
  
  
  METHODS
  Adult patients who received a renal transplant at St Paul's Hospital between January 2008 and July 2013 were included in this retrospective cohort study. Electronic health records and databases were used to divide patients into the 3 heparin-use cohorts, to identify cases of major bleeding and thrombosis, and to characterize patients and events. The Fisher exact test was used for the primary outcome analysis, and descriptive statistics were used for all other outcomes.
  
  
  RESULTS
  A total of 547 patients were included in the analysis. Major bleeding was observed in 6 (46%) of the 13 patients who received therapeutic heparin; no cases of thrombosis occurred in these patients. Major bleeding occurred in 8 (3.0%) of the 266 patients who received prophylactic heparin and 9 (3.4%) of the 268 who received no heparin (p > 0.99). Thrombosis occurred in 1 (0.4%) and 3 (1.1%) of these patients, respectively (p = 0.62). Major bleeding occurred more frequently among patients with a low-target heparin protocol, but 61% of values for partial thromboplastin time were above target. A larger proportion of deceased-donor transplant recipients who had major bleeding were taking antiplatelet agents, relative to living-donor transplant recipients.
  
  
  CONCLUSIONS
  Therapeutic use of heparin increased the risk of bleeding among renal transplant recipients, but there were no cases of thrombosis. Prophylactic use of heparin did not increase the risk of bleeding and prevented proportionately more cases of thrombosis relative to no anticoagulation; this result supports the continued use of prophylaxis.
authors.affiliation: BSc(Pharm), ACPR, was, at the time of this study, a Pharmacy Resident with Lower Mainland Pharmacy Services in Vancouver, British Columbia. She is now a Clinical Pharmacist with Providence Health Care and a student in the graduate Doctor of Pharmacy program at the University of British Columbia, Vancouver, British Columbia.
authors.forename: Joan Chung Yan
authors.initials: JC
authors.lastname: Ng
authors.affiliation: BSc(Pharm), ACPR, PharmD, is a Clinical Pharmacy Specialist, Transplant, with Providence Health Care, and a Clinical Assistant Professor with the University of British Columbia, Vancouver, British Columbia.
authors.forename: Marianna
authors.initials: M
authors.lastname: Leung
authors.affiliation: MD, FRCPC, is Renal Program Director with Providence Health Care, Medical Director of Kidney Transplantation with the BC Transplant Society, and Clinical Professor with the University of British Columbia, Vancouver, British Columbia.
authors.forename: David
authors.initials: D
authors.lastname: Landsberg
keywords: hemorrhage; heparin; kidney transplantation; postoperative anticoagulation; thrombosis