This letter to the editor describes the case of a 42-yr old dialysis patient who was suddenly offered a kidney transplant. The patient was also taking the oral anticoagulation apixaban twice daily for atrial fibrillation, including just before being notified of the upcoming transplant. The initial apixaban level was 149,000 ng/mL and the anti-factor Xa activity was 0.93 IU/mL. During the following 8 hr pre-op preparations (including awaiting the arrival of the kidney), these levels fell to 125ng/nL and 0.74 IU/mL respectively but were still well above the internal recommendations for transplantation to avoid severe bleeding complications (anti-factor Xa activity < 0.3, preferably < 0.2 IU/mL). Therefore, it was decided to perform intermittent hemodiafiltration plus CytoSorb®. During the use of CytoSorb® the apixaban levels fell to 65 then 38 ng/mL and the anti-factor Xa activity to 0.27 then 0.17 IU/mL at 2 and 3 hrs of use. Subsequent surgery was performed without bleeding complications. Although post-op levels were not done in this patient, in a subsequent patient with the same approach there was no evidence of a rebound in levels. In summary, use of CytoSorb® for apixaban removal in a patient awaiting urgent kidney transplantation resulted in a complication free surgery and a good outcome. The authors conclude that the existing disadvantage of poorer antagonization by Andexanet alfa due to high costs and a short half-life with the risk of rebound can be quickly compensated for by preoperatively using the procedure described in this case report.
Open-access publication: https://pubmed.ncbi.nlm.nih.gov/39324964/