Background and Objectives: Liver transplantation is often associated with significant intraoperative bleeding, exposing patients to extensive use of allogeneic blood products. Intraoperative blood salvage (IBS) is a solution to mitigate this effect; however, its oncologic and infectious safety remains a matter of debate. This narrative review aims to synthesize the current evidence regarding the efficacy and safety of IBS and provide risk-based practical recommendations.

Methods: A critical search and synthesis of cohort studies, prospective investigations, and systematic reviews/meta-analyses was conducted, with a focus on: reduction in allogeneic blood product utilization, oncologic outcomes, infectious safety, and moderating factors such as leukocyte depletion filtration (LDF).

Findings: Selective application of IBS tailored to bleeding risk and surgical field conditions consistently reduces the need for allogeneic transfusion, and the hematologic quality of salvaged products is acceptable. In hepatocellular carcinoma, the body of evidence suggests that IBS —particularly with standard use of LDF— is comparable to allogeneic transfusion strategies in terms of recurrence and survival, although cautionary signals have been reported in high-risk subgroups, such as patients with elevated alpha-fetoprotein levels. From an infectious standpoint, in living donor liver transplantation, bile is frequently sterile and LDF effectively reduces contamination; however, in deceased donor transplantation, the performance of LDF may be inadequate in the presence of a high bacterial load.

Conclusions: IBS represents a safe and effective option for reducing allogeneic exposure in many liver transplant recipients. Decision-making in high-risk subgroups should be guided by individualized risk assessment.