Correspondence (letter to the editor): Some Observations on the Prophylactic Recommendation

I wish to thank the authors for their clear introduction to the recent clinical practice guideline “The Prophylaxis of Venous Thromboembolism” (1). I do, however, wish to share some observations with regard to the prophylactic recommendation in living donors of kidneys and livers. In Table 2 of the article (1), perioperative prophylaxis with heparin is recommended in this setting. The guideline recommendation for thromboprophylaxis in living kidney donors is based on a urological randomized study from 2007 reported by Osman et al. (2), which included a total of 75 patients, allocated to three groups. The groups were randomized to thromboprophylaxis in the form of low molecular weight heparin or unfractionated heparin, or no prophylaxis, respectively. The presented study results, however, relate exclusively to the outcomes of the recipients, not those of the donors. In my opinion, a generalized recommendation for perioperative thromboprophylaxis in living donor nephrectomy can therefore not be made on the basis of this study. In the context of my own literature search, I did not find any other evidence relating to this particular research question either. Regarding thromboprophylaxis in living liver donors, neither the article (1) nor the long version of the clinical practice guideline include relevant references.

Regarding the patient population at our clinic, the risk of developing a venous thromboembolism is assessed by means of a clinical exam and medical history, in accordance with the S3 guideline. In living kidney donors, nephrectomy is undertaken by using minimally invasive retroperitoneoscopic surgery, which usually takes 90–120 minutes. This procedure is therefore in the low-risk category for developing venous thromboembolism (VTE). Donor nephrectomy requires no perioperative medication-based thromboprophylaxis. In our clinic, this is given only after balancing individual patients’ risks, and in the form of low molecular weight heparin. The main emphasis is on early postoperative mobilization of patients, independently of their individual risk of VTE. Since high risk patients are excluded in the context of donor selection, I think that general medical thromboprophylaxis is not indicated in living kidney donation.