Case 102

1. Prepared by Rebecca Wingfield, MD and reviewed by Lorraine N. Blagg, MA, MLS(ASCP)SBB

Clinical Vignette:
An adult patient with history of recurrent deep vein thrombosis/pulmonary embolism (DVT/PE) and orthotopic heart transplant was found to have moderate cellular rejection on routine follow up biopsy. Immunogenetics antibody screen revealed new HLA donor specific antibodies (DSA). Patient was admitted to the hospital and started on IV steroids. A repeat biopsy one week later revealed mild cellular rejection and newly identified antibody-mediated rejection. The apheresis team was consulted and the decision was made to start the patient on therapeutic plasma exchange.

The patient's home apixaban dose, which was prescribed for history of recurrent DVT/PE, was continued during hospitalization. The primary care team has concerns about maintaining adequate anticoagulation and reaches out to the apheresis team to coordinate anticoagulant administration with the therapeutic plasma exchange procedure.

What recommendation should be made to the clinical team regarding timing of apixaban administration?