Personalizing Antifibrinolytic Use in Liver Transplantation : Liver Transpl | Jul 2026

Introduction:

Bleeding remains a major challenge during liver transplantation despite advances in surgical techniques, anesthesia, and perioperative care. Antifibrinolytic agents have long been used to reduce intraoperative blood loss and transfusion requirements. However, evolving transplant practices and improved understanding of coagulation have prompted re-evaluation of routine prophylactic antifibrinolytic therapy.

Problem Statement:

Historically, antifibrinolytics were frequently administered empirically to liver transplant recipients because of the perceived high risk of hyperfibrinolysis. However, not all patients develop clinically significant fibrinolysis, raising concerns about unnecessary treatment, thrombotic complications, and indiscriminate use of these agents. The challenge is identifying which patients are most likely to benefit from targeted antifibrinolytic therapy.

Summary:

This editorial discusses the transition from routine empirical antifibrinolytic administration toward a personalized approach in liver transplantation. The author highlights that contemporary perioperative management, including improved surgical techniques, restrictive transfusion practices, and widespread use of viscoelastic coagulation monitoring, has substantially changed the bleeding profile of liver transplantation. As a result, universal prophylactic antifibrinolytic therapy may no longer be appropriate for all recipients. Instead, individualized treatment based on patient-specific bleeding risk, intraoperative coagulation status, and real-time assessment of fibrinolysis is increasingly favored. Viscoelastic testing offers an opportunity to identify clinically significant hyperfibrinolysis and guide targeted administration of antifibrinolytic agents, potentially maximizing benefit while minimizing unnecessary drug exposure and thrombotic risk. The editorial emphasizes that precision-based hemostatic management aligns with the broader movement toward personalized perioperative medicine. Future research should focus on refining risk stratification models, validating biomarker- and viscoelastic-guided treatment algorithms, and defining the subgroup of liver transplant recipients who derive the greatest benefit from antifibrinolytic therapy. Overall, the article argues that the era of routine empirical prophylaxis is giving way to individualized, evidence-based coagulation management, with the goal of optimizing patient safety while preserving the hemostatic advantages of antifibrinolytic treatment in liver transplantation.