Apixaban Use Before Kidney Transplantation: Is Reversal Necessary?

The use of apixaban prior to kidney transplantation is on the rise. However, optimal perioperative management remains uncertain, particularly regarding the need for preoperative reversal with four-factor prothrombin complex concentrate (4F-PCC). Prior reports suggest clinically relevant bleeding without reversal, but potential thrombotic consequences of prophylactic 4F-PCC warrant caution. We hypothesized that withholding preoperative 4F-PCC in patients taking apixaban before kidney transplantation would not increase early postoperative surgical-bed bleeding. METHODS: This retrospective, two-center study included adult kidney transplant recipients (KTRs) from January 2019 to September 2025 who had taken apixaban within 48 h before surgery. Patients were stratified by receipt versus nonreceipt of preoperative 4F-PCC. The primary endpoint was surgical-bed bleeding within 3 days of transplant. A one-sided noninferiority test (margin of 15%) was used for the primary endpoint. RESULTS: Fifty KTRs were included, and 14 (28%) received preoperative 4f-PCC and 36 (72%) did not. The median time since the last known apixaban dose was 21 h (interquartile range [IQR], 16-24 h) before transplant. Surgical-bed bleeding occurred in 7.1% in the preoperative 4F-PCC cohort and in 5.6% of the no preoperative 4F-PCC cohort (differences, 1.6%; upper one-sided confidence interval [CI], 21.5%; p = 0.11), suggesting similar event rates but not confirming noninferiority. No significant differences were observed between groups in transfusion requirements, delayed graft function, kidney function, venous thromboembolism (1 in the reversal group; 0 in the non-reversal group), or reoperation. Two deaths occurred in the reversal group. CONCLUSIONS: Withholding preoperative 4F-PCC in apixaban-treated KTR appears safe, with surgical-bed bleeding rates comparable to those in patients who received preoperative 4F-PCC. Findings support individualized rather than routine preoperative reversal strategies to balance bleeding and thrombotic risks.