FFP Should NOT Be Used Routinely in Liver Failure with Raised INR
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, as it does not reduce bleeding risk and carries significant potential harms including increased portal pressure, volume overload, and transfusion-related complications. 1
Why INR is Misleading in Liver Disease
The elevated INR in liver failure does not predict bleeding risk because it fundamentally misrepresents the hemostatic state:
INR was designed exclusively for monitoring warfarin therapy, not for assessing bleeding risk in liver disease. 1, 2 The scale is not validated for cirrhosis and ignores the concurrent reduction in anticoagulant proteins that occurs alongside decreased procoagulant factors. 2
Liver disease creates a "rebalanced" hemostatic system where both procoagulant and anticoagulant proteins are reduced proportionally, not a simple deficiency state. 1, 2 This means an elevated INR reflects altered synthesis but not increased bleeding tendency.
No studies demonstrate that INR predicts procedure-related bleeding in cirrhotic patients. 1 A Cochrane review found zero evidence supporting prophylactic FFP use to prevent bleeding during procedures in this population. 1
Why FFP Fails and Causes Harm
Ineffectiveness
- FFP frequently fails to normalize PT/INR in cirrhotic patients because it contains both procoagulant and anticoagulant proteins in balanced proportions. 1, 2 Ex vivo studies show FFP only minimally improves thrombin generation capacity and actually worsened hemostatic capacity in one-third of patients. 1
Significant Risks
Volume expansion increases portal pressure, paradoxically increasing bleeding risk rather than reducing it. 1, 2 This is particularly dangerous in patients with portal hypertension.
Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related mortality. 2 Transfusion-associated circulatory overload (TACO) occurs in up to 8% of transfusions with a 5-15% mortality rate. 1, 2
Additional complications include allergic/anaphylactic reactions (1:591 to 1:2,184 units), infection transmission, hemolytic reactions, and red cell alloimmunization. 1, 2
When FFP IS Indicated
FFP has legitimate but limited roles in liver disease:
Active major bleeding requiring massive transfusion protocol: Administer FFP in balanced ratios with red blood cells (typically 1:1 or 1:1.5 ratio) until coagulation test results are available. 1
Disseminated intravascular coagulation (DIC) with active bleeding or high bleeding risk. 1
Warfarin reversal in active bleeding when prothrombin complex concentrates are unavailable. 1
Thrombotic thrombocytopenic purpura as replacement fluid during apheresis. 1
When genuinely indicated, the therapeutic dose is 15 ml/kg to achieve minimum 30% factor concentration. 1
Alternative Management Strategies
For Preprocedural Management
No routine correction is needed for most procedures. 1, 2 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, 2 Studies show viscoelastic-guided strategies reduce blood product use from 100% to 17% without increasing bleeding complications. 2
Less stringent preprocedural parameters (INR ≤2.0, platelets ≥25 × 10⁹/L) are associated with fewer hemorrhagic complications compared to historical cut-offs. 2
If Correction is Truly Needed
Prothrombin complex concentrates (PCCs) are more effective than FFP at correcting INR (80-87% achieving INR <1.5 versus 27% with FFP), with faster administration and lower volume. 3, 4, 5 However, EASL discourages routine PCC use due to concerns about thrombotic risk (5.5% thromboembolic events in one series). 3
For documented hypofibrinogenemia, use fibrinogen concentrate or cryoprecipitate rather than high-volume FFP. 1, 2
Critical Clinical Pitfalls to Avoid
Never use INR alone to guide transfusion decisions in liver disease—it does not reflect true hemostatic balance. 1, 2 The INR represents rebalanced hemostasis, not simply deficiency.
Do not give prophylactic FFP simply because laboratory values are abnormal without bleeding. 1, 2 This practice is ineffective and potentially harmful.
Never use FFP for volume expansion—use crystalloids or colloids instead. 1 FFP is not a volume expander and causes more harm than benefit in this role.
Do not attempt to "normalize" INR before procedures in stable cirrhotic patients. 1, 2 Most procedures can be performed safely with elevated INR when proper technique is used.