From the Guidelines
In patients with cirrhosis, elevated INR is not a reliable indicator of bleeding risk, and routine correction with fresh frozen plasma (FFP) is not recommended for asymptomatic patients with cirrhosis and elevated INR. The liver cannot adequately produce clotting factors, resulting in prolonged prothrombin time and elevated INR values. Unlike warfarin-induced INR elevations, cirrhosis-related high INR often coexists with decreased anticoagulant proteins, creating a rebalanced hemostasis rather than a bleeding tendency 1. This is supported by the EASL clinical practice guidelines, which state that correction of a prolonged INR with FFP is not recommended to decrease the rate of procedure-related clinically relevant bleeding in patients with cirrhosis undergoing invasive procedures 1.
Key Points
- Elevated INR in cirrhosis reflects impaired liver synthetic function rather than true coagulopathy
- Routine correction with FFP is not recommended for asymptomatic patients with cirrhosis and elevated INR
- FFP should be reserved for active bleeding or before invasive procedures
- Vitamin K may help if deficiency contributes to the elevated INR, but typically has minimal effect in advanced cirrhosis
- Prothrombin complex concentrates may be used for urgent INR correction before procedures
Management
In patients with cirrhosis, INR should be interpreted alongside other markers like albumin, bilirubin, and clinical signs of decompensation, as it's more valuable as a prognostic indicator than as a bleeding risk predictor 1. The use of viscoelastic tests, such as TEG and ROTEM, may provide more accurate information on haemostatic status in patients with cirrhosis, but their role in clinical practice is still evolving 1.
Risks of FFP Transfusion
FFP transfusion carries significant risks, including transfusion-related acute lung injury, transfusion-associated circulatory overload, allergic/anaphylactic reactions, and transmission of infections 1. Therefore, FFP should be used judiciously and only when necessary.
Monitoring and Prevention
Patients with cirrhosis should be monitored for bleeding complications, and preventive measures, such as thromboprophylaxis with low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs), may be considered in patients at high risk of venous thromboembolism (VTE) 1. However, the use of these agents should be individualized and based on the patient's underlying risk factors and clinical condition.
From the Research
High INR from Cirrhosis Functionality
- The international normalized ratio (INR) is a test used to measure blood clotting, and high INR values can indicate a higher risk of bleeding in patients with cirrhosis 2, 3, 4, 5, 6.
- Studies have shown that fresh frozen plasma (FFP) transfusion can slightly improve coagulation test values in patients with cirrhosis, but it may not be effective in all cases and can even worsen coagulation in some patients 2, 3, 4.
- The use of prothrombin complex concentrate (PCC) has also been studied as an alternative to FFP, but there is limited evidence to support its use in patients with cirrhosis 3.
- Some studies suggest that INR testing may not be required for diagnostic or therapeutic paracentesis, as well as diagnostic endoscopy, and that plasma transfusion should be avoided for these procedures 5.
- The management of coagulopathy in patients with cirrhosis undergoing invasive procedures is a complex issue, and there is a need for further research to develop evidence-based guidelines for the use of FFP, PCC, and other pro-coagulant agents 2, 3, 4, 5.
Coagulopathy Management
- The model for end-stage liver disease (MELD) score is used to prioritize patients for liver transplantation, and it includes INR as one of its components 6.
- However, the use of INR in the MELD score can be problematic due to variability in thromboplastin reagents used in different laboratories 6.
- An alternative calibration of thromboplastin reagents using plasmas from patients with cirrhosis instead of vitamin K antagonist patients may help to reduce this variability 6.
- A Delphi study found that there is a lack of consensus on the management of coagulopathy in patients with cirrhosis, and that further research is needed to develop evidence-based guidelines for the use of pro-coagulant agents and other interventions 5.