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Benefits of anticoagulation prophylaxis in children undergoing kidney transplant: systematic review and meta-analysis
Ahmad H Al-Huniti1, Caroline Malcolmson2, Valerie Langlois3
1Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota, USA.
Insights
Primary thromboprophylaxis significantly reduces graft thrombosis in pediatric kidney transplant recipients. However, optimal regimens and bleeding risks require further investigation for safe and effective use.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Hematology
Background:
- Graft thrombosis is a major cause of early allograft loss in pediatric kidney transplant recipients.
- The efficacy and safety of primary thromboprophylaxis remain uncertain in this population.
Purpose of the Study:
- To evaluate the effectiveness and safety of thromboprophylaxis in preventing graft thrombosis in children undergoing kidney transplant.
- To synthesize evidence from existing literature on thromboprophylaxis in pediatric kidney transplantation.
Main Methods:
- Systematic literature review of MEDLINE, Embase, and Cochrane Libraries up to September 2024.
- Meta-analysis of 25 observational studies (2094 patients) assessing graft thrombosis and major bleeding.
- Subgroup analyses were conducted for different thromboprophylaxis protocols.
Main Results:
- Thromboprophylaxis was associated with a significantly reduced risk of graft thrombosis (OR, 0.31; 95% CI, 0.18-0.53) compared to no preventive measures.
- No increased risk of bleeding requiring surgical exploration or graft loss was observed.
- Subgroup analyses supported the findings for heparinoid-only and universal protocols.
Conclusions:
- Primary thromboprophylaxis appears effective in preventing kidney graft loss due to vascular thrombosis in pediatric recipients.
- Potential benefits may be counterbalanced by bleeding risks, with limited clarity on associated risk factors.
- Further research is needed to determine optimal thromboprophylaxis regimens and treatment durations.
Background:
Graft thrombosis is a preventable cause of early allograft loss after pediatric kidney transplant, but the role of primary thromboprophylaxis is uncertain.
Objectives:
This study aimed to determine the effectiveness and safety of thromboprophylaxis in preventing graft thrombosis among children (0-21 years) undergoing kidney transplant.
Methods:
We performed a systematic literature review of MEDLINE, Embase, and Cochrane Libraries from inception until September 2024. The primary outcome assessed by meta-analysis was graft thrombosis, and the secondary outcome was major bleeding (per International Society on Thrombosis and Haemostasis criteria).
Results:
Twenty-five observational studies (21 retrospective and 4 prospective) describing 2094 patients (1659 cases and 435 controls) met eligibility criteria. Thromboprophylaxis was used universally (ie, all kidney recipients in the study) in 64% (1055/1659) or only in high-risk patients (eg, recipient weight <20 kg and age <5 years) in 36% (604/1659). Compared with no preventive measures for thrombosis, thromboprophylaxis was associated with reduced risk of graft thrombosis (odds ratio, 0.31; 95% CI, 0.18-0.53). Subgroup analyses of heparinoid-only, universal thromboprophylaxis, and high risk only protocols revealed similar findings. Thromboprophylaxis was not associated with increased risk of bleeding resulting in surgical exploration or graft loss. The overall risk of bias was moderate. Studies showed high clinical and methodologic heterogeneity in study populations and thromboprophylaxis protocols.
Conclusion:
Primary thromboprophylaxis appears effective in preventing kidney graft loss from vascular thrombosis in pediatric recipients. This benefit may be offset by the risk of bleeding, although clarity on bleeding risk factors is lacking. We identified knowledge gaps, including uncertainty about optimal thromboprophylaxis regimens and treatment duration.
