1. VCU Death and Complications Conference

2. Introduction Complication Procedure Primary Diagnosis
Post operative bleeding, reoperation
Procedure
Deceased donor kidney transplant
Primary Diagnosis
Hypertension
Give a synopsis of each case to start the presentation.

3. Clinical History
HPI: 44 yo f with renal failure due to severe HTN since childhood. She has had 3 previous kidney transplants.
PMH/PSH:
1989, 1999, 2007 kidney transplant
1999 AV and MV mechanical St. Jude valves, on Coumadin
2007 Left transplant nephrectomy
2008 Right femoral AVG
Hyperparathyroidism, OSA, infectious endocarditis
1989 CKT
1999 LRKT from sister
1999 AV and MV mechanical valve replacement due to endocarditis from line infection
2007 midline LRKT, left nephrectomy transplant kidney
2008 R femoral AVG
1989 status post cadaveric kidney transplant which failed due to chronic allograft nephropathy
1999 status post living-related kidney transplant from her sister which failed due to chronic nephropathy.
2007 status post living-related kidney transplant from her daughter failed due to acute humoral rejection status post IV IF and plasmapheresis x3 months without improvement in her renal function.
-calcitriol (calcitriol 0.25 mcg oral capsule)(Hx): 1CAP, daily
-calcium acetate (PhosLo Gelcap 667 mg oral capsule)(Hx): 3CAP, three times a day
-calcium carbonate (Tums)(Hx): , three times a day
-ergocalciferol (Vitamin D)(Hx):
-multivitamin (Nephrocaps oral capsule)(Hx): 1CAP, daily
-warfarin (Coumadin)(Hx):

4. Hospital Course INR 2.4 on admission INR 4.8 on POD #2
2mg Vitamin K  INR 1.5
Heparin gtt with goal ptt 60-70
POD#4, Coumadin restarted
POD#6: 2g drop in Hgb, hypotension, tenderness over incision, left flank pain, INR 2.3, PTT 79
US: large collection of blood in left retroperitoneum, obscuring and compressing transplant kidney; flow present in renal vein and artery

5. Hospital Course Return to OR for exploration POD#8, Hgb drop 8.9 7.1
~250 mL of blood surrounding the transplant kidney. Good flow in artery and vein, kidney slightly mottled, but viable. No active bleeding.
Biopsy: mild tubulitis, not clearly rejection
POD#8, Hgb drop 8.9 7.1
CT scan: large collection of blood in retroperitoneum, no mass effect on kidney; hematocrit effect with layering
2 U PRBC, 2 U FFP
Large left-sided retroperitoneal hemorrhage extending from the inferior spleen to the superior aspect of the transplant kidney. It does not appear to exert mass effect on the transplant kidney. The JP drain courses along the posterior inferior aspect of the hematoma, and may not be adequately draining the hematoma. Hematocrit effect from blood in different stages within this hematoma implies relative acuity. Active extravasation cannot be assessed due to lack of IV contrast medium.
2. Mesenteric stranding in trace amount of fluid around left lower quadrant. Transplant kidney in the left lower quadrant. No hydronephrosis.

6. transplant kidney, JP drain
superior to transplant kidney
just inferior to spleen

7. Hospital Course
POD#11
2g hgb drop, hypotension, INR 1.5, PTT 30’s
Repeat US with large collection of blood around transplant kidney (400mL)
Second return to OR
1L blood evacuated, no focal areas of active bleeding
POD#14 Current Hgb stable 9.1, 8.9, hemodynamically stable, INR 1.4

8. Analysis of Complication
Was the complication potentially avoidable?
Yes, could have held anticoagulation or could have avoided surgery
Would avoiding the complication change the outcome for the patient?
Most likely, yes. No transfusions, no reoperation, no compression of transplant kidney.
What factors contributed the complication?
Anticoagulation, surgical dissection

9. Discussion points Mechanical valves Anticoagulation
Management of post operative bleeding
Perinephric hematoma, transplant kidney

10. Mechanical valve thrombosis
Highest risk of stroke/embolism/valve thrombosis
Mitral position
Caged-ball valve
Two or more prosthetic valves
Overall risk of valve thrombosis per year
% on coumadin
2.2% on ASA
9-22% no anticoagulation (lower in some studies)
% calculated absolute risk for 6-8 day post op warfarin interruption
oral anticoagulant therapy: a practical guide for clinicians
Perioperative anticoagulation management in patients who are receiving
James D. Douketis*
Department of Medicine, McMaster University, Hamilton, Ontario, Canada
St. Joseph’s Hospital, Room F-538, 50 Charlton Avenue East, Hamilton, Ontario, Canada, L8N 4A6
Thrombosis research 2009
Prosthetic mitral valves are more thrombogenic
than aortic prostheses because of greater vascular
stasis around the mitral valve [35].
Providing reliable estimates of the absolute risk of
thromboembolic events in such patients during temporary
interruption of warfarin therapy is problematic because most
data are based on studies performed 15–25 years ago and
mainly involve patients with first-generation prosthetic heart
valves. Nonetheless, it is estimated that the incidence of a
thromboembolic event in patients with a prosthetic heart
valve who are not receiving anticoagulant therapy is
between 9% and 22% per year [36,37]. If one interpolates
this risk to a 6–8 day perioperative period, when warfarin
therapy is interrupted, this corresponds to an absolute risk of
thromboembolism of 0.17–0.42%. Few studies have investigated
the perioperative risk of thromboembolism so as to
corroborate these risk estimates (Table 1). In four studies
involving 271 patients with mostly first-generation prosthetic
heart valves who underwent 300 procedures, 4 (1.3%)
patients had a perioperative thromboembolic event despite
bridging anticoagulant therapy [7–10]. In a retrospective
study of 235 patients with newer prosthetic valve types (191
bileaflet, 51 tilting disc), of whom 164 had bridging anticoagulant
therapy with full-dose UFH or LMWH, a higher
rate of thromboembolism was reported [11]. In this study, 4
of 177 (2.3%) patients with a aortic valve prosthesis, 9 of 51
(18%) patients with a mitral valve prosthesis, and 3 of 7
(43%) patients with two prosthetic valves had a thromboembolic
event. However, limitations of this study included
inadequate information about clinical follow-up and the
adequacy of perioperative anticoagulation. Two small, but
well-designed, prospective cohort studies of bridging anticoagulant
therapy with full-dose LMWH reported one
thromboembolic event in 24 (4.2%) patients [5,6]. Overall,
the discrepant findings from these studies underscore the
need for large, well-designed, prospective studies to provide
reliable estimates of the risk of thromboembolism in patients
with a mechanical heart valve who have interruption of
warfarin and receive bridging anticoagulant therapy. Based
on the available evidence, a classification scheme that
stratifies patients with a mechanical heart valve according
to the thromboembolic risk, and a suggested anticoagulation
management strategy for each risk category, is provided in
Table 2.
Douketis, James D. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians., Thrombosis research 2009

11. Chest 2008;133;299S-339S
Recommendations:
Coumadin discontinued 5 days prior to surgery, with reversal of INR to 1.5 or less
FFP and low dose vitamin K for emergency reversal
Good intraoperative hemostasis
Coumadin restarted hours after surgery
Anticipated partial effect within 48 hours
In high risk cases, heparin bridge recommended
several strategies with hours, therapeutic vs. low dose depending on bleeding risk
In the postoperative period, the use of therapeuticdose
LMWH administered can vary. The 3 principal
management approaches that have been studied are:
(1) to administer therapeutic-dose LMWH within a
fixed time period after a procedure (within initial
24 h); (2) to administer therapeutic-dose LMWH
within a varied time period after a procedure (24 to
72 h), with the initiation depending on the procedurerelated
bleeding risk and the adequacy of postoperative
hemostasis; and (3) to replace therapeutic-dose
LMWH with low-dose LMWH in select patients
who are undergoing a procedure associated with a
high bleeding risk.

13. Anticoagulation held, mean of 15 +/- 4 days 24 Mechanical valves
28 patients with prosthetic heart valves hospitalized for major bleeding
Anticoagulation held, mean of 15 +/- 4 days
24 Mechanical valves
20 patients with St. Jude valves
12 mitral valves (11 St Jude)
12 aortic valves (5 St Jude)
4 both aortic and mitral (all St. Jude)
Thromboembolic events: zero at 6 month follow up
One patient sudden death at 4 months, no post
Major bleeding defined as requiring hospitalization, reversal of warfarin with vitamin K, FFP
Included GI bleed, retroperitoneal hemorrhage, ICH, SDH
Mean of 15 +/- 4 days off anticoagulation
5 pts were reversed with Vit K
7 pts were reversed with FFP
Coumadin restarted in 22 of 24 pts prior to DC, had discharge
No thromboembolic events
3 pts lost to FU
1 sudden home, no post
1 on ASA, no coumadin
Twenty-eight patients with prosthetic heart valves receiving warfarin were hospitalized
for major hemorrhage from 1990 to The mean 6 SD age was years (15 men and 13
women). Twenty patients had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic
valves, 2 patients had Starr Edwards valves, and 2 patients had Bjork-Shiley valves. Valves were
in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aortic
positions in 4 patients. The average interval from valve surgery to index bleeding was 7 years.
Twenty-five patients had GI or retroperitoneal hemorrhage, 2 patients had an intracranial
hemorrhage, and 1 patient had a subdural hematoma.
Interventions: Vitamin K was administered to five patients and fresh frozen plasma was given to
seven patients to reverse anticoagulation. The mean duration of anticoagulation withholding was
days.

14. Page kidney Described by Irvine Page in 1939
Compression of animal kidneys with cellophane
Seen with subcapsular/perinepheric hematoma, uroma
Renal hypoperfusion
Microvascular ischemia
Hypertension due to activation of renin angiotensin system
AKI, renal failure
Evaluate by US, duplex US, CT scan
Reversible by evacuation of hematoma, decapsulation, nephrectomy
Acute Renal Failure and Severe Hypertension from a Page Kidney Post-Transplant Biopsy Division of Nephrology, Feinberg School of Medicine, Northwestern University, Chicago TheScientificWorldJOURNAL August 3, 2010

15. Learning points
Mechanical valve type and location important for risk of thrombosis and need for anticoagulation.
Anticoagulation may be held for life threatening bleed, but must be continually re-evaluated.
Perinepheric hematoma that is compressing or obstructing transplant kidney should be evacuated to prevent ischemia and graft failure.
4. Assessment of postoperative bleeding risk
The assessment of postoperative bleeding risk is based
on the following considerations: (1) the adequacy of postoperative
hemostasis; (2) the risk of bleeding and clinical
consequences of bleeding associated with surgery or an
invasive procedure.
Patients with unexpected postoperative bleeding
Major bleeding, defined as bleeding associated with
transfusion of >2 U of packed red blood cells, reoperation,
or bleeding into the intracranial, intrathoracic or retroperitoneal
cavity [71], can be separated into surgical and
nonsurgical bleeding. Surgical bleeding at the wound site
is the most common source of bleeding [72–74] and usually
results from delayed wound healing or intraoperative blood
vessel injury. Bleeding can also occur from stress-induced
peptic ulceration or a hemorrhagic stroke. The anticoagulant
management in such patients depends on the cause and
location of bleeding although, in general, anticoagulants
should be withheld until the bleeding source has been
identified and treated. If the cause of bleeding is reversible,
as with the repair of a severed blood vessel that inadvertently
occurred during surgery, anticoagulant therapy can be
resumed probably within 24 h. In patients with gastrointestinal
bleeding, anticoagulants can be withheld for as
little as 2 days in patients with a self-limiting Mallory–
Weiss tear, to as long as 21 days in patients with a large
gastric ulcer [75,76]. In patients with intracranial bleeding,
resumption of anticoagulants can occur within 1–4 weeks,
depending on the extent of bleeding and radiologic evidence
of healing [77–79].