Response to the article "Perioperative standards for the treatment of coagulation disorders and usage of blood products in patients undergoing liver transplantation used in the Clinic for Transplant Surgery in Wrocław".

We read with interest the article by Łukaszewski et al. published in Advances in Clinical and Experimental Medicine:1211-1215, published online on July 18th, 2018, as ahead of print). As enthusiasts of promoting global assays of hemostasis, we would like to commend the authors for their commitment and effort in their implementation and clinical application. As the authors rightly pointed out in the article, perioperative care of liver transplantation (OLTx) patients is challenging for transplant team members due to the risk of severe changes in global hemostasis. Łukaszewski et al. presented a single center experience in using rotational thromboelastometry (ROTEM) to monitor hemostasis during liver transplantation. In our center, this method has been used routinely since 2008. So far it has been used in over 400 patients undergoing OLTx. Considering the potential contribution to thrombotic complications (including portal vein thrombosis after liver transplantation), we believe that antifibrinolytic treatment should be reserved for patients with active bleeding and hyperfibrinolysis confirmed by ROTEM. The available literature indicates an increased risk of thrombotic complications in patients receiving antifibrinolytic therapy. This raises an important question for the authors about the reason for using Exacyl® in all 12 of the cases presented, even in patients who did not require any blood product transfusion. We hope that our letter will open up further discussion on this subject, which is undoubtedly crucial for OLTx patients' safety.