Reply: Optimizing prognostic utility of ROTEM-assessed low fibrinolytic activity in liver transplantation-key methodological adjustments

To the editor, We sincerely thank Dai et al for their thoughtful comments regarding our recently published study entitled “Evaluation of Low Fibrinolytic Activity by Rotational Thromboelastometry and Outcomes in Liver Transplantation: A Single-Centre Prospective Study.” We greatly appreciate the opportunity to further discuss several methodological and pathophysiological aspects related to the assessment of fibrinolytic activity during orthotopic liver transplantation (OLT).[1] We are pleased that the authors recognized the potential clinical relevance of our findings, particularly the observed association between rotational thromboelastometry (ROTEM)-defined low fibrinolytic activity (LFA), splanchnic thrombotic complications, and short-term mortality. We fully agree that fibrinolysis assessment in end-stage liver disease represents a highly complex and evolving field characterized by substantial biological and methodological heterogeneity.[1] First, Dai et al correctly emphasize the inherent limitations of relying exclusively on ROTEM maximum lysis (ML) for fibrinolytic phenotyping. Indeed, viscoelastic testing (VET)-derived fibrinolytic parameters may not fully capture the complexity of endogenous fibrinolytic regulation, particularly in critically ill patients with profound alterations in coagulation, endothelial activation, and inflammatory pathways.