From the Guidelines
To prevent bleeding in recipients of ABO-incompatible (ABOI) kidney transplants, maintaining fibrinogen levels above 1.5 g/L is crucial, and treatment with fibrinogen concentrate or cryoprecipitate is recommended if major bleeding is accompanied by hypofibrinogenemia, with an initial supplementation of 3–4 g, as suggested by the most recent guideline 1. The management of fibrinogen levels is critical in ABOI kidney transplants due to the potential depletion of coagulation factors, including fibrinogen, during plasma exchange procedures used to remove blood group antibodies.
- Key considerations include:
- Regular monitoring of fibrinogen levels before transplantation, immediately post-operatively, and daily for at least the first week after transplantation.
- Administration of cryoprecipitate or fibrinogen concentrate when fibrinogen levels fall below the recommended threshold.
- A comprehensive approach to immunosuppression, including rituximab, tacrolimus, mycophenolate mofetil, and corticosteroids.
- Careful monitoring of coagulation parameters, including PT, PTT, and platelet count. As noted in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1, the recommendation for treatment with fibrinogen concentrate or cryoprecipitate if major bleeding is accompanied by hypofibrinogenemia is based on a Grade 1C recommendation, emphasizing the importance of this approach in clinical practice. Other guidelines, such as those mentioned in 1 and 1, also support the maintenance of fibrinogen levels above 1.5 g/L, but the most recent and highest quality study 1 provides the most direct and relevant guidance for the management of fibrinogen levels in the context of ABOI kidney transplants.
From the Research
Prevention of Bleeding in ABO-Incompatible Kidney Transplants
Fibrinogen Levels and Bleeding Complications
- The provided studies do not directly address the prevention of bleeding in recipients of ABO-incompatible kidney transplants in relation to fibrinogen levels 2, 3, 4, 5, 6.
- However, it is mentioned that ABO-incompatible kidney transplantation is associated with an increased incidence of bleeding complications 2.
- A study found that bleeding was more common after ABO-incompatible transplantation, with a relative risk of 1.92 (95% confidence interval, 1.36 to 2.72; P<0.001) 6.
- The studies suggest that ABO-incompatible kidney transplantation is a well-established procedure with good outcomes, but it is still evolving and requires careful management to prevent complications such as bleeding 3, 4, 5.
- The use of rituximab and other desensitization techniques has improved the outcomes of ABO-incompatible kidney transplantation, but the risk of infections and bleeding complications remains a concern 4, 5, 6.