The prophylactic use of tranexamic acid in orthotopic liver transplantation: A randomized placebo-controlled study

Perioperative bleeding during orthotopic liver transplantation (OLT) is primarily driven by hyperfibrinolysis and impaired coagulation, resulting in elevated morbidity, mortality, and transfusion requirements. Although tranexamic acid (TXA) has been shown to reduce bleeding in various surgical settings, its prophylactic efficacy and safety in OLT remain unclear. We conducted a double-blinded, randomized controlled trial involving 138 adult patients undergoing OLT, who were assigned to receive either TXA (10 mg/kg bolus followed by a 1 mg/kg/h infusion) or placebo (0.9% saline). The primary outcome was the incidence of major bleeding within 24 hours of the surgical incision. Secondary outcomes included red blood cell transfusion volume, hospital length of stay, and postoperative complications. The overall incidence of major bleeding did not differ significantly between groups [TXA: 48.5% vs. placebo: 62.9%; relative risk (RR) 0.77 [95% CI 0.56-1.04]; p =0.09]. However, significant reductions were observed in subgroups with MELD 3.0 scores ≤9 ( p =0.01) and Child-Pugh A classification ( p =0.01). The TXA group had lower median intraoperative red blood cell transfusions (0 unit [IQR 0-3] vs. 2 units [IQR 0-5]; p =0.01) and shorter hospital length of stay (20 days [IQR 14-31] vs. 25 days [IQR 18-37]; p =0.04). No significant differences were found in thromboembolic complications or mortality. In conclusion, prophylactic TXA does not significantly reduce the incidence of major perioperative bleeding in OLT but may benefit lower-risk subgroups by reducing transfusion requirements and shortening hospital stays, without increasing thromboembolic or mortality risks. These findings suggest a selective role for TXA in OLT, warranting larger confirmatory trials to guide targeted use.