Therapeutic plasma exchange for urgent rivaroxaban reversal

Varun Kumar, Joseph Allencherril, Arthur Bracey, Alice J. Chen, Wilson W. Lam

Research output: Contribution to journalArticlepeer-review


Direct oral anticoagulants, which include the factor Xa inhibitor rivaroxaban, have some advantages over vitamin K antagonists in regard to stroke prevention in patients with atrial fibrillation. However, no antidotes to reverse the effect of oral anticoagulants are commercially available, which can complicate treating patients in whom reversal is urgent. We faced this challenge in a kidney transplant candidate, a 65-year-old man with end-stage renal disease who had been taking rivaroxaban for paroxysmal atrial fibrillation. When a deceased-donor kidney became available, we needed to rapidly reduce the patient’s bleeding risk, while minimizing the cold ischemic time of the donor kidney. Therefore, we decided to take an experimental approach and perform therapeutic plasma exchange. The patient’s plasma anti-factor Xa level decreased from 0.4 IU/mL immediately before treatment to 0.21 IU/mL afterward, indicating that rivaroxaban had been actively removed from circulation. Waste fluid showed significant anti-Xa activity, indicating that the risk of rebound anticoagulation had been mitigated. The patient subsequently underwent successful kidney transplantation. To our knowledge, this is the first report of therapeutic plasma exchange to reverse the effects of rivaroxaban in a patient undergoing urgent surgery. This treatment may also be suitable for patients who have life-threatening, large-volume bleeding, especially in the presence of substantial kidney or liver dysfunction.

Original languageEnglish (US)
Pages (from-to)96-98
Number of pages3
JournalTexas Heart Institute Journal
Issue number2
StatePublished - Apr 2018
Externally publishedYes


  • Anticoagulants/ antagonists & inhibitors/ pharmacokinetics/therapeu-tic use
  • Drug monitoring
  • Factor Xa inhibitors
  • Factor Xa/adverse effects/ metabolism
  • Plasma exchange
  • Rivaroxaban/adverse effects
  • Treatment outcome

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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