Re-Evaluation of the Role of Antifibrinolytic Therapy with Lysine Analogs in Liver Transplantation in The Post-Aprotinin Era

Purpose of review: Hemorrhage, blood and blood product transfusions and the need for surgical re-exploration for bleeding can have a detrimental effect on patient outcome during liver surgery. Following the suspension of aprotinin from the market only the antifibrinolyticstranexamic acid (TA) and epsilon-aminocaproic acid (EACA) are left as pharmacological options to reduce hemostatic activation and associated bleeding complications. Considering the apparent usefulnes of aprotinin in liver surgery and transplantation, its loss has left a void within the armamentarium of drugs available to reduce blood loss. The need for large independent safety studies has become evident. The current review focuses on the drugs that are available, the safety and efficacydata that supports their use and the indications warranting further trailsRecent findings Both TA and EACA are effective in reducing blood loss and transfusion requirements in liver surgery. Analysis of data is complicated as the dosing regimens, especially for tranexamic acid, varies enormously and the agents are highly overdosed in most relevant trials. New data indicates that in a dose-dependent fashion, TA is associated with an increase in adverse events with transient renal failure highlighted as a particular problem. It appears that all the anti-fibrinolyticshave side effects that may impact on morbidity and mortality and it may be that aprotinin is no worse. The use of these agents needs to be balanced against benefitespecially in the management of high risk cases.