Can vitamin K be administered to a patient with acute liver failure?

From the Guidelines

Vitamin K can be administered to a patient with acute liver failure, as it is routinely given in a dose of 5-10 mg subcutaneously, regardless of whether poor nutritional status appears to be contributing to the coagulopathy. According to the American Association for the Study of Liver Diseases (AASLD) position paper on the management of acute liver failure 1, vitamin K is given to address any component of coagulopathy related to vitamin K deficiency. The liver's ability to synthesize clotting factors (II, VII, IX, and X) is impaired in acute liver failure, leading to coagulopathy, and vitamin K is essential for the gamma-carboxylation of these clotting factors, making them functionally active.

Key points to consider when administering vitamin K to patients with acute liver failure include:

• The dose of vitamin K recommended is 5-10 mg subcutaneously 1
• Vitamin K supplementation won't correct coagulopathy caused by severely impaired hepatic synthetic function, but it can help address any component related to vitamin K deficiency
• Monitoring of prothrombin time and INR before and after administration is necessary to assess response
• Fresh frozen plasma or other blood products may be necessary for immediate correction of bleeding risk if the liver is too damaged to synthesize clotting factors

It's crucial to weigh the benefits and risks of vitamin K administration in the context of acute liver failure, considering the potential for bleeding complications and the need for invasive procedures. As noted in the AASLD position paper 1, correction of clotting abnormalities with fresh frozen plasma is not necessary in the absence of bleeding, unless an invasive procedure is planned or there is profound coagulopathy.

From the FDA Drug Label

Repeated large doses of vitamin K are not warranted in liver disease if the response to initial use of the vitamin is unsatisfactory. The answer to whether vitamin K can be administered to a patient with acute liver failure is:

• Yes, but with caution, as the drug label does not explicitly contraindicate its use in liver disease.
• However, repeated large doses are not warranted if the initial response is unsatisfactory, implying that the clinician should exercise judgment in dosing and monitor the patient's response closely 2.

From the Research

Administration of Vitamin K in Acute Liver Failure

• The administration of vitamin K in patients with acute liver failure is a topic of debate, with some studies suggesting its use may not be effective in correcting coagulopathy 3.
• A study published in 2019 found that prothrombin complex concentrates (PCCs) were effective in improving coagulation test results in patients with liver disease, including those with acute liver failure, without an excess of thrombotic events 4.
• However, another study published in 2021 found that the administration of vitamin K in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower odds of new bleeding events 5.
• A 2013 study found that vitamin K administration did not affect the measured coagulation parameters in patients with liver disease, suggesting that it may not be routinely indicated in these patients 3.
• A 2017 study found that four-factor prothrombin complex concentrate (4F-PCC) was less effective in reversing coagulopathy in patients with liver disease compared to those without liver disease 6.
• A 2005 study found that intravenous mixed-micellar phylloquinone (vitamin K1) was more effective than oral administration in correcting subclinical vitamin K deficiency in patients with severe acute liver disease 7.

Efficacy and Safety of Vitamin K Administration

• The efficacy of vitamin K administration in patients with acute liver failure is uncertain, with some studies suggesting it may not be effective in correcting coagulopathy 5, 3.
• The safety of vitamin K administration in patients with acute liver failure is also a concern, with some studies suggesting an increased risk of thrombotic events 4, 6.
• However, other studies have found that vitamin K administration is not associated with an increased risk of thrombotic events in patients with liver disease 5, 7.