**3. Treating thrombocytopenia**

Blood loss is a major concern during liver transplantation due to the precarious hemostatic condition of these patients combined to a surgical procedure at high risk for bleeding. Since the beginnings of LT, surgical techniques and anesthetic patient management have improved and the blood loss and transfusion needs have decreased. Despite life-saving benefits, transfusion has also related complications and platelet transfusion has been identified as an independent risk factor for postoperative complications. Risks related to platelet concentrate administration are allergic reactions, alloimmunization, bacterial sepsis, and transfusion-related acute lung injury (TRALI), and nowadays to a lesser extent viral transmission [23]. Therapeutic rather than prophylactic administration of platelets concentrate is recommended with a possible threshold of 50,000/mm<sup>3</sup> during surgery associated with diffuse bleeding [24].

In a study analyzing possible complications related to platelet administration during LT, Pereboom [25] has shown that patients who received platelet concentrates had lower patient and graft survival than patients who had only blood loss or low level of thrombocytes but were not transfused with platelets. Their main complication was related to platelet transfusion and at the same time the specific cause of death was TRALI. TRALI is more frequently associated with plasma-rich blood products such as platelet concentrates and fresh frozen plasma and this might be related to the growth of inflammatory mediators in the stored platelets. It has been shown that cytokine levels are 1000-fold greater in stored platelets when compared to healthy volunteers and this might be related to the fact that platelets need to be kept at room temperature that also makes them prone to bacterial contamination. One could argue that transfusion needs are related to sicker patients but the author has shown that survival rates for those patients with severe blood loss and a low platelet count are similar to reference population if they were not transfused with platelet concentrates [25].

Despite the general consensus that platelet transfusions are related to worse outcome, there is a type of LT, the living-related LT where recipients might benefit from exogenous thrombocytes. Kim et al. on a series of 227 living-related LT conducted a study to define the effects of platelet transfusion on the liver regeneration and reached the conclusion that it has a beneficial effect [26].

The use of blood products and fibrinogen concentrate following a thrombelastometry-guided protocol (TEG/ROTEM) has led to a decrease in overall transfusion requirements, platelet concentrates as well, by offering a picture of the complete coagulation process with information on the dynamics of clot formation [27, 28].

Eltrombopag is an oral thrombopoietin-receptor agonist still looking for its place in the treatment of thrombocytopenia in chronic liver disease. It has got an indication for patients with chronic HCV infection for the initiation or maintenance of interferon therapy. Afdhal et al. published in the name of the ELEVATE study group a paper showing that eltrombopag reduced the need for platelet transfusion in liver disease patients undergoing invasive procedures [29].
