Role of Fresh Frozen Plasma (FFP) in Immune Thrombocytopenic Purpura (ITP)
Fresh Frozen Plasma (FFP) has a specific but limited role in the management of Immune Thrombocytopenic Purpura (ITP), primarily in cases of thrombotic thrombocytopenic purpura (TTP) with plasmapheresis, but is not indicated for routine management of consumptive coagulopathy from ITP. 1, 2
Appropriate Indications for FFP Use
- FFP is indicated for thrombotic thrombocytopenic purpura (TTP), usually administered with plasmapheresis, preferably using pathogen-inactivated FFP 1
- FFP can be effective in TTP due to congenital deficiency of von Willebrand factor-cleaving protease, where even 5% of normal protease activity may be sufficient to degrade large VWF multimers 3
- Intensive plasma exchange therapy with FFP as replacement fluid has shown initial response rates of 80% in some ITP patients, though prolonged remissions were only observed in acute ITP cases 4
FFP in Consumptive Coagulopathy
- FFP is indicated for acute disseminated intravascular coagulation (DIC) with active bleeding 1
- For consumptive coagulopathy, FFP should be administered early to prevent dilutional coagulopathy 1
- In massive hemorrhage with consumptive coagulopathy, standard FFP doses of 15 ml/kg may be inadequate; at least 30 ml/kg would be a reasonable first-line response 1
FFP Dosing and Administration
- The recommended therapeutic dose of FFP is 15 ml/kg to achieve minimum 30% concentration of plasma factors 1, 5
- FFP should be ABO-compatible with the patient; if blood group is unknown, group AB FFP is preferred 1
- Once thawed, FFP can be used for up to 24 hours if stored at 4°C, and must be used within 30 minutes once out of refrigeration 1
Limitations and Considerations
- FFP transfusion for mild abnormalities of coagulation (PT 13.1-17 seconds or INR 1.1-1.85) fails to normalize PT in 99% of patients 6
- There is very limited role for FFP in managing mild-moderate coagulation abnormalities in non-bleeding critically ill patients before invasive procedures 1
- FFP should not be used simply as routine circulatory volume replacement 1
Alternative Approaches for ITP Management
- For hypofibrinogenemia (fibrinogen <1.0 g/L) associated with ITP, cryoprecipitate may be more appropriate than FFP 1
- Cryoprecipitate contains concentrated factor VIII, von Willebrand factor, fibrinogen, factor XIII and fibronectin 1
- During major hemorrhage, fibrinogen should be maintained >1.5 g/L (>2 g/L in obstetric hemorrhage) 1
Monitoring and Follow-up
- Regular monitoring of coagulation parameters is essential as coagulopathy during massive hemorrhage evolves rapidly 1
- Platelet count should be maintained at minimum 75×10⁹/L in patients with massive hemorrhage 1
- Following treatment for massive hemorrhage, patients should be admitted to critical care for monitoring of coagulation, hemoglobin, blood gases, and assessment for overt or covert bleeding 1
Potential Complications
- FFP transfusion carries risks including transfusion-related acute lung injury (TRALI), allergic reactions, and infectious disease transmission 7
- To reduce TRALI risk, male-only plasma in component therapy has been implemented in the UK since 2003 1
- For patients born after 1996, FFP is sourced outside the UK and undergoes viral inactivation to reduce variant Creutzfeldt-Jakob disease risk 1