Blood conservation strategies in liver transplantation: Past, present, and future

Table 1 Phase-integrated, three-pillar, 9 matrix framework spanning the pre-, intra-, and post-transplant periods

Phase of care	Pillar 1: Red cell mass optimization	Pillar 2: Blood loss minimization	Pillar 3: Anemia tolerance optimization
Pre-transplant	Screen all candidates for anemia early in transplant evaluation. Identify and correct iron, vitamin B12, and folate deficiencies. Treat inflammation- or renal-related anemia where feasible. Avoiding unnecessary pre-transplant transfusions that may increase sensitization and complications	Perform structured bleeding risk assessment (portal hypertension, coagulopathy, thrombocytopenia). Optimize coagulation status without prophylactic plasma or platelet transfusion. Plan surgical and anesthetic strategies anticipating high-risk bleeding	Assess cardiopulmonary reserve and end-organ function. Optimize oxygen delivery (nutrition, respiratory function, cardiac status). Educate the team on restrictive transfusion thresholds
Intra-operative	Avoiding prophylactic or trigger-based transfusion without physiologic indication. Using goal-directed transfusion guided by viscoelastic testing. Preserve autologous red cell mass wherever feasible	Employ meticulous surgical technique and low-CVP anesthesia. Use antifibrinolytics when indicated. Apply viscoelastic coagulation monitoring (TEG/ROTEM) to guide hemostatic therapy. Consider cell salvage where appropriate	Accept lower hemoglobin levels with stable hemodynamics and adequate oxygenation. Maintain normothermia, acid-base balance, and adequate perfusion. Base transfusion decisions on physiologic parameters rather than laboratory values alone
Post-transplant	Support erythropoiesis through nutritional supplementation. Treat ongoing anemia causes (renal dysfunction, inflammation, infection). Minimize phlebotomy-related blood loss	Monitor closely for surgical site bleeding and coagulopathy. Avoid routine correction of abnormal coagulation tests without clinical bleeding. Use targeted hemostatic therapy if bleeding occurs	Follow restrictive transfusion strategies in the ICU and ward. Optimize oxygenation, ventilation, and hemodynamic support. Avoid transfusion-related complications that may impair graft function

CVP: Central venous pressure; ICU: Intensive care unit; TEG: Thromboelastography; ROTEM: Rotational thromboelastometry.