Is Fresh Frozen Plasma (FFP) indicated in Acute-on-Chronic Liver Failure (ACLF) with coagulopathy?

FFP is NOT Indicated for Prophylactic Correction of Coagulopathy in ACLF

Fresh frozen plasma should not be used to correct laboratory coagulation abnormalities in ACLF patients in the absence of active bleeding or planned invasive procedures. 1

Key Principle: Abnormal Labs ≠ Bleeding Risk in Liver Disease

• Standard coagulation tests (PT, APTT, INR) are poor predictors of bleeding in critically ill patients with advanced liver disease and do not reflect the true hemostatic status of these patients 1
• The coagulopathy of liver disease represents a rebalanced hemostatic system, not simply a deficiency state 1

When FFP IS Indicated in ACLF

FFP should be reserved for specific clinical scenarios:

Active Bleeding with Documented Coagulopathy

• Administer FFP when there is active bleeding AND documented coagulopathy (INR >2.0 or PT >1.5 times normal) 1, 2
• Use in major hemorrhage protocols, often in 1:1 or 1:1.5 ratio with red blood cells until coagulation results are available 1
• Therapeutic dose: 15 ml/kg to achieve minimum 30% concentration of plasma factors 2, 3

High-Risk Invasive Procedures

• FFP may be considered for patients with active bleeding AND INR >1.5 undergoing invasive procedures 2
• However, evidence shows that prophylactic FFP before procedures in non-bleeding patients does NOT reduce bleeding complications 4

Critical Evidence Against Prophylactic Use

Ineffectiveness Data

• FFP infusions using standard volumes (2-6 units) correct coagulopathy in only 10-12.5% of chronic liver disease patients 5
• In a randomized trial of critically ill patients with INR 1.5-3.0 undergoing invasive procedures, prophylactic FFP showed no difference in bleeding complications compared to no FFP 4
• FFP transfusion fails to correct PT in non-bleeding patients with mild abnormalities 1

Risks of FFP in ACLF

• Volume overload is the most common adverse event, particularly problematic in ACLF patients who often have fluid retention and ascites 6
• Transfusion-related acute lung injury (TRALI) risk 7
• Allergic reactions and infectious disease transmission 7
• No evidence that correction of coagulation abnormalities benefits non-bleeding patients 1

Alternative Approaches

For Active Bleeding

• Consider prothrombin complex concentrates (PCC) as an alternative to FFP, which avoid large-volume transfusion and may provide better INR correction 6, 8
• Recombinant factor VIIa has shown efficacy in refractory coagulopathy of liver failure, normalizing PT within 1 hour 9
• Fibrinogen concentrate or cryoprecipitate if fibrinogen <80-100 mg/dL with bleeding 2

For Procedures

• Proceed with low-risk procedures without prophylactic FFP correction, as bleeding risk is not predicted by INR elevation alone 1, 4
• Reserve FFP for high-risk procedures only when bleeding occurs or patient has additional bleeding risk factors 1

Common Pitfalls to Avoid

• Do not transfuse FFP solely to "normalize" laboratory values - this practice persists despite lack of evidence and exposes patients to unnecessary risks 1
• Do not use FFP for volume replacement - it is not indicated for this purpose 1
• Do not assume elevated INR equals bleeding risk - the hemostatic balance in liver disease is complex and not captured by standard tests 1