Comparison of Efficacy, Safety, and Survival Outcomes of Anticoagulation and Antiplatelet Strategies Post Liver Transplantation: A Systematic Review and Network Meta-Analysis

BackgroundLiver transplantation (LT) is the definitive treatment for end-stage liver disease, but remains complicated by thrombotic events such as hepatic artery and portal vein thrombosis. This network meta-analysis compares the efficacy and safety of different antithrombotic strategies post-LT, as well as dosing and duration to inform individualized, evidence-based management. MethodsMedline and Embase were searched to 22 November 2024 for RCTs and cohort studies reporting outcomes of postoperative antithrombotic methods in liver transplant patients. Random-effects frequentist network meta-analysis pooled odds ratios (OR), 95% confidence interval (CI) values, and P-score to rank the antithrombotic medications. ResultsAmong 18 studies involving 8,856 patients, aspirin (OR: 0.30, 95%CI: 0.18 - 0.51, p=0.04) and UFH (OR: 0.31, 95%CI: 0.12 - 0.84, p<0.01) use were associated with lowest overall thrombotic risk relative to the control group. Aspirin was ranked the highest for HAT prevention (P-score = 0.88) and had no significant bleeding risk. Low molecular weight heparin (LMWH) was ranked highest for DVT prevention (P-score = 0.67) but also second for worst associated bleeding risk (P-score = 0.43) after VKA (OR: 3.53, 95%CI: 1.86 - 6.71, p<0.01, P-score = 0.01). LMWH also ranked worse than control in prevention of PVT. DOACs were ranked first for the lowest associated bleeding risk and third for reduction in overall thrombotic risk. None of the antithrombotic medications showed any significant association with overall patient mortality. ConclusionsAspirin remains a mainstay of arterial thromboprophylaxis. DOACs appear promising for thromboprophylaxis post-LT, with the lowest bleeding risk. Targeted rather than routine prophylaxis, guided by individual risk profiles, likely maximises post-LT outcomes.