Fresh Frozen Plasma Transfusion in Acute Variceal Haemorrhage

Results From a Multicentre Cohort Study

Arpan Mohanty; Devika Kapuria; Andrew Canakis; Honghuang Lin; Maelys J. Amat; Graziella Rangel Paniz; Nicholas T. Placone; Reggie Thomasson; Hemant Roy; Eric Chak; Gyorgy Baffy; Michael P. Curry; Loren Laine; Tarun Rustagi

Disclosures

Liver International. 2021;41(8):1901-1908. 

In This Article

Abstract and Introduction

Abstract

Background: Fresh frozen plasma (FFP) transfusion is often used in the management of acute variceal haemorrhage (AVH) despite best practice advice suggesting otherwise.

Objective: We investigated if FFP transfusion affects clinical outcomes in AVH.

Design, Setting and Patients: We performed a retrospective cohort study of 244 consecutive, eligible patients admitted to five tertiary health care centres between 2013 and 2018 with AVH.

Main outcome measurements: Multivariable regression analyses were used to study the association of FFP transfusion with mortality at 42 days (primary outcome) and failure to control bleeding at 5 days and length of stay (secondary outcomes).

Results: Patients who received FFP transfusion (n = 100) had higher mean Model for End Stage Liver Disease (MELD) score and more severe variceal bleeding than those who did not received FFP transfusion (n = 144). Multivariable analysis showed that FFP transfusion was associated with increased odds of mortality at 42 days (odds ratio [OR] 9.41, 95% confidence interval [CI] 3.71–23.90). FFP transfusion was also associated with failure to control bleeding at 5 days (OR 3.87, 95% CI 1.28–11.70) and length of stay >7 days (adjusted OR 1.88, 95% CI 1.03–3.42). The independent association of FFP transfusion with mortality at 42 days persisted when the cohort was restricted to high-risk patients and in patients without active bleeding.

Limitations and conclusions: Fresh frozen plasma transfusion in AVH is independently associated with poor clinical outcomes. As this an observational study, there may be residual bias due to confounding; however, we demonstrate no benefit and potential harm with FFP transfusions in AVH.

Introduction

Acute variceal haemorrhage (AVH) is a decompensating event in cirrhosis with high morbidity and mortality.[1] Despite recent evidence suggesting otherwise, fresh frozen plasma (FFP) is frequently used for management of AVH, especially in the setting of elevated international normalised ratio (INR) and prothrombin time (PT).[2–4] These tests, however, were not designed for detecting hemostatic derangements in cirrhosis, where haemostasis is a delicate rebalance due to parallel decline in procoagulant and anticoagulant factors in compensated cirrhosis, but can tip in either direction on decompensation.[2] INR and PT do not measure the deficit of liver derived anticoagulant factors and, have variable test results across laboratories. Therefore they are inappropriate to assess bleeding risk or guide transfusion strategies in cirrhosis.[3]

Fresh frozen plasma transfusion is commonly used in the management of gastrointestinal haemorrhage associated with an elevated INR such as in the setting of vitamin K antagonist use, however, there is scarce data to support its use in cirrhosis. Studies suggest that FFP transfusions do not affect coagulation potential, as measured by thrombin generation in cirrhosis.[4–6] Furthermore, the large volume of FFP needed to achieve the commonly used target INR of 1.5 is clinically impractical and can be detrimental as blood volume expansion may exacerbate portal hypertension and worsen AVH and ascites.[7–9] Therefore, most guidelines from gastroenterology and hepatology groups do not recommend the use of FFP in AVH.[1,10–12] Although there have been biological studies on the effect of FFP transfusion on thrombin potential in cirrhosis, its effect on clinical outcomes in AVH is not known. A randomised controlled trial to study this effect may face difficulty in enrolment, due to deep seated transfusion practices; similar to a trial studying the effect of FFP transfusion prior to invasive procedures.[13] We, therefore, performed a multicentre retrospective cohort study to assess whether FFP transfusion affects mortality and bleeding outcomes in patients with cirrhosis and AVH.

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