From the Guidelines
Fresh frozen plasma (FFP) should not be used routinely to correct coagulopathy due to liver disease prior to peritoneal catheter insertion, as the risks often outweigh the benefits in stable patients. The use of FFP in this context is generally not recommended, as liver disease causes complex hemostatic changes that laboratory tests do not fully capture, and many patients maintain adequate hemostatic function despite abnormal test results 1. The British Society of Gastroenterology guidelines suggest that FFP is rarely indicated, and its use is often unnecessary, ineffective, and potentially hazardous 1.
The American Gastroenterology Association also recommends that blood products, including FFP, should be used sparingly in patients with liver disease, as they can increase portal pressure and carry a risk of transfusion-associated circulatory overload, transfusion-related acute lung injury, infection transmission, alloimmunisation, and/or transfusion reactions 1.
Instead of relying on conventional coagulation tests, a more individualized approach considering the patient's clinical status, degree of coagulopathy, and specific procedural risks is recommended 1. Alternative approaches, such as using thromboelastography (TEG) or rotational thromboelastometry (ROTEM), can provide a more accurate assessment of coagulation status and help reduce unnecessary prophylactic transfusions 1.
In patients with active bleeding or those at very high bleeding risk with severely abnormal coagulation parameters, FFP may be considered, but its use should be reserved for these specific situations, and the risks and benefits should be carefully weighed 1. The recent guidelines from the European Association for the Study of the Liver (EASL) also suggest that measures aimed at reducing the pre-procedural INR in patients with cirrhosis who are not taking vitamin K antagonists are very controversial, and PCCs should be used with caution due to the risk of thrombosis 1.
Overall, the use of FFP in patients with liver disease prior to peritoneal catheter insertion should be approached with caution, and a more individualized approach considering the patient's clinical status and specific procedural risks is recommended. Key points to consider include:
- FFP is not recommended for routine use in patients with liver disease prior to peritoneal catheter insertion
- Conventional coagulation tests, such as INR and PT, do not fully capture the complex hemostatic changes in liver disease
- Alternative approaches, such as TEG or ROTEM, can provide a more accurate assessment of coagulation status
- FFP may be considered in patients with active bleeding or those at very high bleeding risk with severely abnormal coagulation parameters, but its use should be reserved for these specific situations.
From the Research
Coagulopathy Correction in Liver Disease
The use of fresh frozen plasma (FFP) to correct coagulopathy due to liver disease prior to peritoneal catheter insertion is a topic of interest.
- FFP is traditionally used for correction of coagulopathy to manage and prevent bleeding in patients with liver disease 2.
- However, studies have shown that FFP infusions using the number of units commonly employed in clinical practice infrequently correct the coagulopathy of patients with chronic liver disease 3.
- Alternative therapies such as prothrombin complex concentrates (PCCs) and recombinant factor VIIa have been explored, with PCCs offering an attractive alternative to FFP due to their ready availability and avoidance of large-volume transfusion 2.
- Recombinant factor VIIa has been shown to quickly normalize the prothrombin time and maintain improved hemostasis in patients with liver failure, even when coagulopathy has been refractory to FFP 4.
Indications for FFP Use
FFP may be used to correct coagulopathy in patients with liver disease prior to invasive procedures, such as peritoneal catheter insertion.
- The goal of therapy is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis 5.
- FFP infusion is more often effective and is recommended in patients with liver disease before invasive procedures or surgery, as such patients require transient correction in their prothrombin time 5.
- However, the use of FFP should be weighed against the potential risks and benefits, and alternative therapies should be considered in patients with severe coagulopathy or those who are refractory to FFP treatment 6, 5.
Alternative Therapies
Alternative therapies to FFP include:
- Prothrombin complex concentrates (PCCs) 2
- Recombinant factor VIIa 4, 5
- Cryoprecipitate therapy for patients with severe coagulopathy and hypofibrinogenemia 6, 5
- Plasma exchange for patients who cannot be treated with FFP due to volume overload risk 5
- Vitamin K replacement for patients with coagulopathy related to biliary obstruction, bacterial overgrowth, or malnutrition 6