What is the recommended dose of Fresh Frozen Plasma (FFP) for treating bleeding in the setting of liver failure?

From the Guidelines

For patients with bleeding in the setting of liver failure, the use of Fresh Frozen Plasma (FFP) is not recommended for routine correction of coagulopathy, as it does not significantly improve hemostatic capacity and carries potential life-threatening risks, as stated in the most recent guidelines 1. The administration of FFP in this context is associated with risks such as volume overload, transfusion reactions, and transfusion-associated circulatory overload (TACO), which are particularly concerning in patients with liver failure who may have ascites or portal hypertension.

• The evidence suggests that FFP transfusion in patients with cirrhosis and a prolonged INR frequently does not lead to a full normalization of the prothrombin time, and ex vivo studies have shown that FFP only minimally improves thrombin generating capacity in patients with cirrhosis 1.
• The guidelines recommend against the use of FFP for routine correction of coagulopathy in patients with liver disease, unless significant coagulopathy is identified, and emphasize the importance of weighing the potential benefits against the risks of FFP transfusion 1.
• In general, the initial dose of FFP for treating bleeding in other contexts is typically 10-15 mL/kg body weight, which generally translates to 2-4 units for an average adult, but this may not be applicable in the setting of liver failure due to the lack of efficacy and increased risks 1. The decision to use FFP in patients with bleeding in the setting of liver failure should be made on a case-by-case basis, taking into account the individual patient's risk factors, coagulation parameters, and clinical condition, and considering alternative treatments such as specific factor concentrates or other hemostatic agents.

From the Research

Recommended Dose of Fresh Frozen Plasma (FFP) for Treating Bleeding in Liver Failure

• The recommended dose of FFP is not explicitly stated in the provided studies, but the studies suggest that the dose of FFP may vary depending on the patient's condition and the desired outcome.
• A study from 1976 2 found that a single dose of FFP (12 ml/kg body-weight) was the least effective therapeutic regimen, while a combination of FFP (8 ml/kg body-weight) and prothrombin complex concentrates was more effective in correcting coagulation defects.
• Another study from 2003 3 reported that patients received FFP at a mean infusion rate of 39.7 mL/kg/day, but the study did not specify the optimal dose.
• A 2018 study 4 found that patients receiving 6 units or more of FFP showed significant improvement in International Normalized Ratio (INR), suggesting that larger volumes of FFP may be required to achieve significant improvement in coagulation parameters.

Efficacy of FFP in Correcting Coagulation Defects

• The studies suggest that FFP may not be effective in correcting mild to moderate coagulation defects in liver diseases, and large volumes may be required to cause significant improvement 4.
• A 2012 study 5 found that thrombin generation in patients with cirrhosis did not appreciably change after in vitro addition of pooled normal plasma, despite shortening of prothrombin time (PT) and activated partial thromboplastin time (APTT).
• A 2020 study 6 found that FFP transfusion enhanced thrombin generation in some patients, but also decreased thrombin generation in 34% of cases, suggesting that the efficacy of FFP in correcting coagulation defects may be limited and variable.

Clinical Implications

• The decision to transfuse FFP should be carefully weighed, considering the risks associated with transfusion and the potential benefits 4, 6.
• The use of FFP in combination with other pro-coagulant agents, such as prothrombin complex concentrates, may be more effective in correcting coagulation defects than FFP alone 2.