*Purpose: Renal transplant recipients (RTRs) may develop deep venous thrombosis (DVT), pulmonary embolism (PE), or atrial fibrillation requiring treatment with oral anticoagulation. There is limited data guiding direct oral anticoagulation (DOAC) use in RTRs and less data regarding the appropriate time to hold DOACs in the setting of a kidney biopsy. The objective of the study was to evaluate the safety and efficacy of apixaban in RTRs and provides guidance on timing of holding apixaban prior to biopsy.

*Methods: A single center retrospective chart review was performed of RTRs 18 years and older who were prescribed apixaban from January 2015 to December 2017. Patients were excluded if they received a non-kidney or multi-organ transplant. Data was collected for one year after apixaban was initiated. The primary endpoint was a composite of major bleed or clotting event. Secondary endpoints included minor bleed, hospitalizations within one year due to any event, average number of days apixaban was held prior to biopsy, and bleeding or clotting events associated with biopsy.

*Results: A total of 57 patients were prescribed apixaban. Five patients received liver transplants and were excluded. Baseline demographics for the remaining 52 patients can be seen in Table 1. During the one year period, four patients (7.7%) had a major event. Two (3.8%) were major bleeds and two (3.8%) were clotting events. There were four minor bleeding events. In total, 52 patients had 57 hospitalizations with seven related to bleeding or clotting. Eighteen patients had biopsies performed. On average, these patients were 640 + 1390 days (range: 1-5399) from transplant when apixaban was initiated. Apixaban was held for a median of two days with one bleeding event post-biopsy and no clotting events. The bleeding event occurred when apixaban was held for one day prior to biopsy.

*Conclusions: Apixaban use in RTRs appears effective in preventing clots and resulted in bleeding rates similar to that of the general population. Holding apixaban two days prior to kidney biopsy was sufficient to prevent post-biopsy bleeding complications without increasing risk for thromboembolism. Future randomized controlled trials are required to confirm these findings.

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