Eliquis (Apixaban) Does Not Disqualify Patients from Kidney Transplantation
Being on apixaban (Eliquis) is not a contraindication to kidney transplantation, and patients should be evaluated for transplant candidacy based on standard criteria regardless of anticoagulation therapy. The decision to continue, modify, or temporarily discontinue apixaban perioperatively should be made in collaboration with the transplant team based on bleeding risk and thromboembolic risk assessment.
Transplant Eligibility and Anticoagulation
Kidney transplantation outcomes in patients requiring anticoagulation are similar to those without anticoagulation needs, and the presence of conditions requiring anticoagulation (such as atrial fibrillation or prior venous thromboembolism) should not exclude patients from transplant evaluation 1.
The KDIGO guidelines for kidney transplant recipients do not list anticoagulation therapy as a contraindication to transplantation, and in fact recommend aspirin use in transplant recipients with atherosclerotic cardiovascular disease unless contraindications exist 1.
Patients with a history of venous thrombosis may actually have increased risk of graft thrombosis post-transplant, but this is an indication for careful perioperative anticoagulation management rather than transplant exclusion 1.
Apixaban Use in Kidney Transplant Recipients
Apixaban has been successfully used in kidney transplant recipients with good safety and efficacy profiles 2. In a retrospective cohort study of 23 renal transplant recipients, 8 patients (35%) were treated with apixaban for indications including atrial fibrillation and deep venous thrombosis 2.
During a median follow-up of 24 months, graft function and hematological parameters remained stable in patients treated with apixaban, with no thrombotic events occurring while on therapy 2.
Bleeding complications were rare, occurring in only 2 of 23 patients in the transplant cohort, and apixaban was deemed safe and efficient in this population 2.
Perioperative Management Considerations
The key clinical decision is not whether to transplant, but how to manage anticoagulation perioperatively. This requires assessment of:
- The indication for anticoagulation (atrial fibrillation, VTE, mechanical valve - note that mechanical valves are contraindicated for all NOACs including apixaban) 3
- Thromboembolic risk during interruption
- Surgical bleeding risk
- Timing of last dose relative to surgery
- Renal function and drug clearance 3, 4
Apixaban has 27% renal clearance, the lowest among direct oral anticoagulants, making it theoretically preferable in patients with renal impairment 3, 4.
For patients with end-stage renal disease on hemodialysis awaiting transplant, apixaban 2.5 mg twice daily produces plasma levels similar to standard dosing in patients with normal renal function 3, 4.
Post-Transplant Anticoagulation
Anticoagulation can be safely resumed post-transplant once adequate hemostasis is achieved, typically within 24-72 hours depending on the surgical complexity and bleeding risk 2.
Drug-drug interactions with calcineurin inhibitors (tacrolimus, cyclosporine) must be monitored, particularly when apixaban is used concomitantly with strong CYP3A4 inhibitors or inducers 3, 5.
Concomitant use of dual P-glycoprotein and strong CYP3A4 inhibitors (such as azole antifungals commonly used in transplant recipients) may require dose adjustment or alternative anticoagulation strategies 3, 5.
Common Pitfalls to Avoid
Do not automatically exclude transplant candidates based solely on anticoagulation requirements - this represents outdated practice not supported by current guidelines 1.
Do not assume standard apixaban dosing is appropriate post-transplant - verify renal function and adjust dosing accordingly, particularly in the early post-transplant period when graft function may be evolving 3, 4.
Do not overlook drug-drug interactions - transplant recipients on azole antifungals or other CYP3A4/P-glycoprotein inhibitors require careful monitoring and potential dose adjustment 3, 5.
Do not treat all anticoagulants equally - apixaban's lower renal clearance makes it preferable to other DOACs in patients with renal impairment, but warfarin remains a viable alternative if well-managed 3, 2.