*Purpose: The bleed rates from the apixaban pivotal trial were 12.1% for non-major and 3.8% major bleeds. However outcomes in transplant recipients are less defined, with wide ranges of results reported. Transplant patients are at risk for poor outcomes due to anatomic changes, varying renal function, drug interactions.

*Methods: This is a retrospective single center analysis of the safety and efficacy of apixaban in adult transplant recipients from March 7, 2011 – May 31, 2018. Primary objectives were incidence of overall bleeding and treatment failure (new/increased thrombus) and bleeding during 6-month follow-up or apixaban was held. No-bleed (NB) and with-bleed (WB) patient demographics were compared using Chi-Square and non-parametric median tests, with associations assessed using univariate OR analysis.

*Results: 162 pts met inclusion criteria (NB: 135 vs WB: 27 pts), with a median (IQR) time to apixaban initiation at 2.4 (0.2-7.2) years post-transplant. 6 (4%) of pts failed treatment (time from apixaban to thrombosis of 56 (34-102) days). Bleeding rates were 17% overall and 3% for major bleeds (time from apixaban to bleed: 25 (11-83) days), with rates per transplant type in the table below.

Characterization of bleed severity: 1 bleed-related death (0.62%), 5 major (hemoglobin decrease ≥2 g/dL, blood transfusion ≥2 units, critical symptomatic bleeding), 9 pts (5.6%) hospitalized or visited an ED, 18 pts (11.1%) held apixaban. Characterization of bleed location: 2 (1%) intracranial, 9 (6%) GI/internal, 7 (4%) epistaxis, 9 (4%) other. Between the NB vs WB pts, there were no significant differences for age, apixaban indication, or renal dysfunction, except for AKI-on-CKD. While significantly more WB pts had apixaban started inpatient, there were trends towards less WB pts getting apixaban loading doses (22 vs 7%, p=0.06), or aspirin (46 vs 33%, p=0.09). OR analysis showed associations with increasing age (OR 1.04; 1.01-1.09; p=0.03), AKI-on-CKD (OR 5.06; 1.5-17; p=0.01), lung transplant (OR 5.07; 1.4-18; p=0.01), inpatient apixaban start (OR 3.63; 1.2-11; p=0.03).

*Conclusions: Apixaban is safe and effective in the majority of transplant patients, with bleeding rates comparable to the general population. However, caution should be used in pts with increasing age, renally lability, may be clinically unstable, or received lung transplants.

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