When should low fibrinogen be corrected in patients with cirrhosis?

When to Correct Low Fibrinogen in Cirrhosis Patients

Routine correction of low fibrinogen in cirrhosis patients is discouraged for both invasive procedures and prophylaxis, and should only be considered in the context of active, uncontrolled bleeding when levels fall below 100-120 mg/dL. 1

Key Principle: Fibrinogen Reflects Disease Severity, Not Bleeding Risk

The fundamental issue is that low fibrinogen in cirrhosis is primarily a marker of hepatic synthetic dysfunction rather than a direct cause of bleeding. 1 A retrospective study of 237 critically ill cirrhosis patients demonstrated that cryoprecipitate transfusion to correct low fibrinogen had no independent effect on bleeding complications or mortality, despite successfully raising fibrinogen levels by 27.8 mg/dL. 1, 2 This challenges the assumption that fibrinogen deficiency itself drives bleeding pathophysiology in cirrhosis. 1

Clinical Scenarios and Management

Before Invasive Procedures

Do not routinely correct fibrinogen deficiency before procedures, regardless of the fibrinogen level. 1 The 2022 EASL guidelines provide a strong recommendation (97% expert agreement) against routine fibrinogen correction to decrease procedure-related bleeding. 1 This applies even to high-risk procedures, as:

• Studies have not demonstrated that correcting fibrinogen reduces clinically relevant bleeding 1
• Fibrinogen levels do not reliably predict post-procedural bleeding risk 1
• The association between low fibrinogen (<100 mg/dL) and bleeding may reflect disease severity rather than causation 1

During Active Bleeding

Consider fibrinogen replacement only when:

• The patient has active, uncontrolled bleeding that cannot be managed with standard hemostatic measures 3
• Fibrinogen levels fall below 100-120 mg/dL 1
• Bleeding persists despite appropriate treatment of the underlying cause (e.g., variceal bleeding controlled with endoscopy and vasoactive drugs) 1

The most commonly accepted threshold in clinical practice for actively bleeding cirrhosis patients is >120 mg/dL. 1

Variceal Bleeding Specifically

If hemostasis is achieved with portal hypertension-lowering drugs and endoscopic treatment, correction of fibrinogen is not indicated. 1 Only if hemorrhage control fails should fibrinogen correction be considered on a case-by-case basis. 1

Product Selection When Replacement Is Needed

When fibrinogen replacement is deemed necessary:

Fibrinogen concentrate is preferred over cryoprecipitate because: 1

• Lower volume (50 mL vs 250 mL), reducing risk of volume overload and increased portal pressure 1
• Standardized fibrinogen content 1
• No need for cross-matching 1
• Avoids unnecessary von Willebrand factor (already elevated in cirrhosis and may pose thrombotic risk) 1

The main limitation is cost. 1

Evidence Supporting Restrictive Approach

In vitro data show fibrinogen >100 mg/dL provides greater clot stability, but no specific threshold was identified for clinical benefit. 1 More importantly:

• A randomized trial in liver transplantation failed to show benefit from preemptive fibrinogen administration 1
• Patients with congenital afibrinogenemia may be asymptomatic or even thrombotic, contrasting with predictable bleeding in hemophilia 1
• Cirrhosis creates a "rebalanced hemostasis" where both pro- and anti-coagulant factors are reduced 3, 4

Critical Pitfalls to Avoid

• Do not transfuse based solely on laboratory values without active bleeding 3, 4
• Do not assume abnormal fibrinogen levels indicate bleeding risk before procedures 1
• Recognize that fibrinogen <100 mg/dL is associated with bleeding but causation is unproven 1
• Avoid volume overload from blood products, which can paradoxically increase portal pressure and worsen bleeding 5, 6

Special Populations

In critically ill cirrhosis patients with acute decompensation or acute-on-chronic liver failure: Fibrinogen levels correlate with disease severity and outcomes, but replacement still does not improve mortality or bleeding complications. 7, 2 Fibrinogen concentrate may improve in vitro clot quality in these patients, but clinical benefit remains unproven. 1, 7