Introduction: Perioperative bleeding remains a major challenge during orthotopic liver transplantation (OLT), largely due to hyperfibrinolysis and coagulation abnormalities. Although tranexamic acid (TXA) effectively reduces bleeding in several surgical settings, its routine prophylactic use during liver transplantation remains controversial because of uncertain efficacy and concerns regarding thromboembolic complications.
Introduction:
Perioperative bleeding remains a major challenge during orthotopic liver transplantation (OLT), largely due to hyperfibrinolysis and coagulation abnormalities. Although tranexamic acid (TXA) effectively reduces bleeding in several surgical settings, its routine prophylactic use during liver transplantation remains controversial because of uncertain efficacy and concerns regarding thromboembolic complications.
Why was this study needed?:
Current evidence supporting routine prophylactic TXA use during OLT is limited and inconsistent.
It is unclear whether prophylactic TXA reduces major perioperative bleeding and transfusion requirements.
Safety concerns, particularly thromboembolic complications, have limited widespread adoption.
Identifying patient subgroups most likely to benefit could enable a more personalized approach to antifibrinolytic therapy.
Results:
In this randomized, placebo-controlled trial, prophylactic TXA did not significantly reduce the overall incidence of major perioperative bleeding during liver transplantation. However, patients receiving TXA required fewer intraoperative red blood cell transfusions and had a shorter hospital stay. Importantly, benefits were more pronounced in lower-risk recipients, including those with low MELD 3.0 scores and Child–Pugh A cirrhosis. Rates of thromboembolic events and mortality were comparable between the TXA and placebo groups, supporting an acceptable safety profile.
Clinical Impact:
These findings do not support routine prophylactic TXA administration for all liver transplant recipients. Instead, TXA may offer meaningful clinical benefits in carefully selected lower-risk patients by reducing transfusion requirements and accelerating postoperative recovery without increasing thromboembolic risk. The study reinforces the need to move from universal prophylaxis toward individualized antifibrinolytic strategies based on patient risk profiles.
Bottom Line:
Routine prophylactic tranexamic acid is not justified for all liver transplant recipients, but selected lower-risk patients may benefit through reduced blood transfusion requirements and shorter hospitalization without compromising safety. Larger trials are needed to define patient groups most likely to benefit.
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