Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ PREOPERATIVE IDENTIFICATION AND PROPHYLAXIS OF THE HYPERCOAGULABLE PATIENT +++ Clinical Considerations1 ++ Renal artery thrombosis, renal artery stenosis, and renal vein thrombosis are serious complications, requiring prompt diagnosis and management. Uncommon but can lead to graft loss. Vascular thrombosis presentation: Sudden anuria or oliguria, tenderness, swelling, ipsilateral extremity edema. Ultrasound with Doppler is the initial study of choice. Ultrasound findings: Edematous and enlarged kidney, decreased echogenicity, altered parenchymal architecture. Doppler findings: Peaked systolic signals with retrograde signal on diastole and absent venous signal. +++ Major Clinical Thrombophilic Risk Factors ++ History of ≥2 arteriovenous access thromboses Prior allograft thrombosis Multiple miscarriages (in the setting of antiphospholipid syndrome and hereditary thrombophilia) Prior deep vein thrombosis (DVT) or pulmonary embolism (PE) Collagen vascular diseases Diabetic nephropathy Positive family history of thrombosis +++ Additional Clinical Risk Factors ++ Estrogen replacement Malignancy Age over 40 years Obesity Nephrotic syndrome Chronic tobacco use Hepatitis C virus +++ Mechanical Risk Factors2 ++ Arterial diameter size (differs with body size) Multiple renal arteries Stenosis of the donor renal artery Atherosclerosis in donor or recipient Surgical trauma Acute rejection Prolonged cold ischemia time with reperfusion damage +++ Pharmacologic Risk Factors ++ Erythropoietin can increase thrombosis risk Calcineurin inhibitors like cyclosporine A (CSA) and tacrolimus (FK-506) increase thrombophilia CSA can increase factor VIII and tissue factor (TF), in addition to reducing protein C Antithymocyte globulins (ATGs) can cause platelet activation, thrombosis, and thrombocytopenia +++ Types of Hereditary and Acquired Thrombophilia ++ Activated protein C (APC) resistance (factor V Leiden [FVL]) Prothrombin gene mutation Decreased Proteins C and S and antithrombin III (ATIII) deficiency Lipoprotein(a) Antiphospholipid syndrome (APLS): Elevation of Beta 2 glycoprotein 1 (B2GP1), and/or anticardiolipin (ACL), and/or lupus anticoagulant positivity. Heparin-induced thrombocytopenia (HIT) +++ Reported Effects of Hereditary and Acquired Thrombophilia ++ FVL: 3 X increased risk of DVT 3.3 X increased risk of graft loss when compared to those without FVL Prothrombin gene mutation 3.1× increased risk of DVT 7.4× increased risk of graft loss Protein S deficiency is associated with renal graft loss and arterial and venous thromboses. Hyperhomocysteinemia increases the occurrence of coronary artery disease threefold if levels of homocysteine surpass 30 μmol/L. It may increase the occurrence of DVT, but increase in graft loss has not been reported. APLS: Up to 19% serology positive prevalence in chronic renal failure (CRF). APLS in combination with hepatitis C virus (HCV) infection with high titers exceeding 40 IgG phospholipid units (GPL) has been found to increase incidence of graft loss and DVT. Risk is enhanced in patients with a prior history of thrombosis. +++ Incidence of Posttransplant Thrombosis3 ++ Renal transplant is associated with an 8% risk of DVT/PE within the ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free a profile for additional features.