Use of Apixaban for Venous Thromboembolism Prophylaxis in an Older Hemodialysis Patient After Total Knee Replacement: A Case Report

Objective:Unusual or unexpected effect of treatment Background:Total knee arthroplasty (TKA) is associated with a significant risk of venous thromboembolism (VTE), making postoperative thromboprophylaxis essential.In patients with end-stage renal disease (ESRD) who are on hemodialysis, the choice of anticoagulant is complicated by altered drug metabolism.Although oral vitamin K antagonists (eg, warfarin) and unfractionated heparin are commonly used, there are some challenges that minimize their utilization.Direct oral anticoagulants such as apixaban can overcome these challenges, and pharmacokinetic data support their use in ESRD, but clinical evidence supporting the safety and efficacy of apixaban is limited. Case Report:We describe the case of a 78-year-old woman with ESRD on regular hemodialysis who underwent elective right TKA.Her postoperative course was notable only for a hemoglobin drop consistent with expected surgical blood loss, and she remained stable with no signs of bleeding or infection.Initial prophylaxis was provided with unfractionated heparin during her hospital stay.Considering her advanced age, need for hemodialysis at another center, and the logistical challenges of warfarin monitoring, apixaban 2.5 mg twice daily was selected as an off-label discharge option for VTE prophylaxis.The patient tolerated apixaban well, with no reported bleeding or thromboembolic complications during follow-up or dialysis sessions. Conclusions:Apixaban appears to be a safe alternative for VTE prophylaxis after TKA in selected dialysis patients; however, its use remains off-label.More robust data are needed to guide clinical decision-making.