What is the role of Fresh Frozen Plasma (FFP) in managing coagulopathy in patients with liver failure?

Fresh Frozen Plasma in Liver Failure

FFP should NOT be used prophylactically to correct elevated INR before invasive procedures in patients with liver failure, as it does not reduce bleeding risk and carries significant potential harms including increased portal pressure, volume overload, and transfusion-related complications. 1

Prophylactic FFP for Procedures: Not Recommended

The European Association for the Study of the Liver (EASL) provides a strong recommendation against using FFP to correct prolonged INR before invasive procedures in cirrhotic patients 1. This applies to both low-risk and high-risk procedures 1.

Why FFP Fails in Liver Disease

• FFP contains both procoagulant AND anticoagulant proteins in balanced proportions, so transfusion frequently fails to normalize prothrombin time in cirrhotic patients 1
• Ex vivo studies demonstrate FFP only minimally improves thrombin generation capacity in liver disease, and actually worsened hemostatic capacity in one-third of patients 1
• A Cochrane review found no studies demonstrating efficacy of prophylactic FFP in preventing bleeding during procedures in cirrhotic patients 1
• Clinical studies show only 10-12.5% of patients achieve adequate PT correction with standard FFP doses (2-6 units) 2
• INR is a poor predictor of bleeding risk in liver disease, as it only measures select procoagulant factors and ignores anticoagulant proteins 1

Significant Risks of FFP in Liver Disease

FFP transfusion carries potentially life-threatening complications that are particularly problematic in cirrhotic patients 1:

• Increased portal pressure from volume expansion, paradoxically increasing bleeding risk 1
• Transfusion-related acute lung injury (TRALI), the leading cause of transfusion-related mortality 1
• Transfusion-associated circulatory overload (TACO) with 5-15% mortality rate 1
• Allergic/anaphylactic reactions (1:591 to 1:2,184 units transfused) 1
• Infection transmission, hemolytic reactions, and red cell alloimmunization 1

When FFP IS Indicated in Liver Disease

Active Major Hemorrhage

FFP has a role in active major bleeding when administered in balanced ratios with red blood cells (typically 1:1 or 1:1.5 ratio) until coagulation test results are available 1. This represents treatment of active hemorrhage, not prophylaxis.

Specific Clinical Scenarios

FFP may be appropriate for 1:

• Disseminated intravascular coagulation (DIC) with active bleeding or high bleeding risk
• Warfarin reversal in active bleeding when prothrombin complex concentrates unavailable
• Thrombotic thrombocytopenic purpura as replacement fluid during apheresis

Dosing When FFP Is Used

When FFP is genuinely indicated, the therapeutic dose is 15 ml/kg to achieve minimum 30% factor concentration 1, 3. Standard 2-4 unit transfusions are typically inadequate 2.

Alternative Approaches

For Procedures

• No routine correction needed for most procedures, as technical factors and liver disease complications predict bleeding better than coagulation tests 1
• Consider viscoelastic testing (TEG/ROTEM) to guide management rather than INR 1
• A randomized trial showed only 1 bleeding episode among 60 patients undergoing procedures, and that patient had received FFP 1

For Active Bleeding

• Prothrombin complex concentrates (PCCs) may be more effective than FFP for correcting PT/INR, though evidence is limited 1, 4, 5
• Recombinant factor VIIa can rapidly normalize PT in refractory cases, though use remains controversial 6
• Fibrinogen concentrate or cryoprecipitate for documented hypofibrinogenemia 1

Critical Clinical Pitfalls

• Do not use INR alone to guide transfusion decisions in liver disease—it does not reflect true hemostatic balance 1
• Avoid prophylactic FFP simply because laboratory values are abnormal without bleeding 1, 3
• Do not use FFP for volume expansion—crystalloids or colloids are appropriate 1, 3
• Recognize that elevated INR in liver disease represents rebalanced hemostasis, not simply deficiency 1
• Historical practice of routine FFP before procedures in liver disease is not evidence-based and potentially harmful 7