What is the recommended dose of vitamin K (Vit K) injection for a patient with liver disease?

Vitamin K Injection Dose for Liver Disease

Vitamin K administration in liver disease has minimal to no efficacy in correcting coagulopathy caused by hepatic synthetic dysfunction, and when indicated (primarily in cholestatic liver disease or true vitamin K deficiency), the recommended dose is 10 mg administered intravenously by slow injection. 1, 2

Understanding Why Vitamin K Usually Doesn't Work in Liver Disease

The coagulopathy of liver disease reflects impaired hepatic synthesis of clotting factors, not vitamin K deficiency. 1 Patients with cirrhosis exist in a "rebalanced" hemostatic state with deficiencies in both procoagulant and anticoagulant factors, making them vulnerable to both bleeding and thrombosis despite abnormal lab values. 1, 3

Key evidence demonstrating limited efficacy:

• Subcutaneous vitamin K does not modify coagulation parameters in liver disease 1
• A 2023 study of 85 hospitalized patients with chronic liver disease (76.5% Child-Pugh C) showed vitamin K resulted in only a -0.07 absolute change in INR 4
• A 2013 study of 89 patients demonstrated vitamin K administration did not significantly improve FVII, protein C, or protein S levels across all stages of liver dysfunction 5
• A 2017 retrospective study found only 16.7% of cirrhotic patients achieved the effectiveness endpoint (30% INR decrease or INR ≤1.5) after IV vitamin K 6

When Vitamin K IS Indicated

Vitamin K can only be effective in three specific scenarios: 1, 2

1. Cholestatic liver disease (jaundiced patients with fat malabsorption) 1, 2
2. Prolonged antibiotic therapy causing true vitamin K depletion 1, 2
3. Severe malnutrition or malabsorption creating genuine vitamin K deficiency 1, 2

Dosing When Indicated

Standard dose: 10 mg IV administered by slow injection 1, 2

Critical administration details:

• Must be given by slow injection to minimize risk of anaphylactoid reactions (3 per 100,000 doses, potentially causing bronchospasm and cardiac arrest) 1
• Never exceed 10 mg per dose - higher doses create a prothrombotic state and prevent re-anticoagulation for days 1
• Takes more than 12 hours to begin correcting hemostatic defects, with detectable action in 1-2 hours 2, 7
• Reassess INR after 12-24 hours 1, 2

Alternative route: 10 mg oral administration is acceptable but has similar limited efficacy 1, 2

Diagnostic Trial Approach

If uncertain whether coagulopathy is from vitamin K deficiency versus pure hepatic synthetic dysfunction: 1, 2

• Administer 10 mg vitamin K (IV or oral) as a diagnostic trial 1, 2
• Recheck INR after 12-24 hours 1, 2
• Improvement in INR by ≥0.5 within 24-72 hours confirms a vitamin K deficiency component 1, 2
• PIVKA-II (Protein Induced by Vitamin K Absence-II) is the most sensitive and specific marker for true vitamin K deficiency 1

What NOT to Do

The American Association for the Study of Liver Diseases explicitly recommends AGAINST routine vitamin K administration to correct coagulopathy in cirrhotic patients at risk of bleeding, as it does not effectively improve hemostatic parameters or reduce bleeding risk in hepatic synthetic dysfunction. 1

Additional pitfalls to avoid:

• Do not use INR as a guide for bleeding risk in cirrhosis - it reflects synthetic function, not hemostatic capacity 1
• Repeated large doses of vitamin K are not warranted in liver disease if initial response is unsatisfactory 7
• Failure to respond indicates the condition is inherently unresponsive to vitamin K 7

Management of Specific Clinical Scenarios

For Invasive Procedures (No Active Bleeding)

No correction needed when: 1, 2

• Platelet count >50 × 10⁹/L 1
• Local hemostasis is possible 1

For high-risk procedures where local hemostasis is impossible and platelets 20-50 × 10⁹/L: 1

• Consider platelet concentrates or TPO-R agonists on case-by-case basis 1
• Vitamin K alone is insufficient 1

For Active Clinically Significant Bleeding

Targeted blood product replacement with thresholds: 1, 2

• Hematocrit ≥25% 1, 2
• Platelets >50 × 10⁹/L 1, 2
• Fibrinogen >120 mg/dL 1, 2

Avoid excessive fresh frozen plasma - substantially increases portal pressure 1

For VKA-Associated Life-Threatening Bleeding (Different Context)

If patient is on warfarin and has major bleeding: 8

• Give 5-10 mg IV vitamin K by slow injection 8
• Administer four-factor prothrombin complex concentrate 8, 1
• This is the ONE scenario where vitamin K dosing may be lower (5-10 mg range) 8

Evidence Quality Note

The FDA label explicitly warns: "Repeated large doses of vitamin K are not warranted in liver disease if the response to initial use of the vitamin is unsatisfactory. Failure to respond to vitamin K may indicate that the condition being treated is inherently unresponsive to vitamin K." 7 This aligns with multiple recent guidelines and research studies demonstrating minimal clinical benefit in hepatic synthetic dysfunction. 1, 4, 5, 6