Con: Antifibrinolytics Are Not Safe and Effective in Patients Undergoing Liver Transplantation

Abstract

s l t g ESPITE IMPROVEMENTS in the operative care of patients undergoing liver transplantation, significant blood oss requiring transfusion continues to be a common event.1,2 In 002, the United Network for Organ Sharing instituted the odel for End-Stage Liver Disease scoring system as the tratification method for the allocation of cadaveric donor livers n the United States.3 As intended, this has resulted in more ompromised patients (ie, patients with more severe coagulopahy, worse renal function, and more compromised liver funcion) presenting for transplant. Transplantation in this more ompromised patient population, as expected, has been shown o be associated with increased blood loss and the increased ransfusion of blood components.1,4 With the morbidity assoiated with the transfusion of blood components well estabished, any intervention that might significantly reduce blood oss would be expected to be beneficial.5-9 In addition, the eduction of transfusion rates could have significant impact on esource utilization and on both the direct and indirect costs elated to transfusion.10,11 The use of antifibrinolytic medications during liver translantation was popularized by Kang et al12 in the midto late 980s. The rationale for this use came not simply from the eneral desire to reduce blood loss but as a specific response to ntraoperative thromboelastographic monitoring, which howed that 40% of patients developed severe fibrinolysis on eperfusion of the newly grafted liver.13 This fibrinolysis is aused mainly by increased levels of tissue-type plasminogen ctivator.14 Since that time, antifibrinolytics have been used outinely by numerous centers throughout the world in the care f liver transplant patients. All of the clinically available antibrinolytics, aprotinin, epsilon aminocaproic acid (EACA), nd transexamic acid (TA), have been used in this role. The fficacy of these agents in reducing blood loss during liver