*Purpose: There remains a gap in the literature for apixaban dosing recommendations for treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) in special patient populations such as renal impairment and solid organ transplant (SOT). The goal of this study is to evaluate apixaban dosing in SOT patients with renal impairment.

*Methods: A single center retrospective, observational chart review was performed in SOT recipients with renal impairment (defined as creatinine clearance (CrCl) less than 60 mL/min) diagnosed with or had history of DVT/PE, treated with apixaban between January 2013 and August 2019. The primary endpoint was the evaluation of apixaban dosing strategies used for treatment of DVT/PE in patients with renal impairment and the incidence of recurrent DVT/PE or bleeding.

*Results: A total of 77 patients were included in this study: 33 kidney recipients, 17 liver recipients, 12 heart recipients, 9 lung recipients, 2 heart-kidney recipients, 2 liver-kidney recipients, 1 lung-kidney recipient and 1 pancreas-kidney recipient. Of these patients, 67% were male with a median CrCl of 41 mL/min and 17% (13/77) were on hemodialysis (HD) at start of apixaban. In terms of dosing strategies, 12% (9/77) of patients received an initial 7 day load and 44% (34/77) received reduced-dose apixaban (2.5 mg twice daily) with renal function being the most common reason for dose reduction. Bleeding occurred in 13% (10/77) of patients at a median CrCl of 33 mL/min, of which 60% (6/10) were on standard-dose apixaban (5 mg twice daily). Recurrent DVT/PE occurred in 6% (5/77) of overall patients at a median CrCl of 44 mL/min, of which 40% (2/5) were on reduced-dose. No statistical difference was found in bleeding or recurrent DVT/PE based on dosing strategy used. A subgroup analysis was performed in HD patients that received standard-dose versus reduced-dose apixaban and bleeding occurred in 60% (3/5) of patients on standard dose compared to 0% (0/8) on reduced-dose. This was found to be significant within this subgroup (p=0.04).

*Conclusions: In this retrospective chart review, we found no difference in the rates of bleeding or recurrent DVT/PE in SOT patients with renal impairment, irrespective of dosing strategy. It appears that standard-dose apixaban may be used safely and effectively for the treatment of DVT/PE in patients with SOT and renal impairment. However, caution should be advised in patients on HD and dose reduction may be considered to reduce the risk of bleeding.

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