Prothrombinex((R))-VF in chronic liver disease: Friend or foe

Objective: Management of coagulopathy in chronic liver disease (CLD) poses a challenge for critical care physicians. Prothrombinex (R)-VF is a low-volume product with rapid onset of action. Evidence for its efficacy and safety in CLD is limited and cases of acute intravascular coagulation and fibrinolysis (AICF) and/or disseminated intravascular coagulation (DIC) have been reported. Our objective was to evaluate the role of Prothrombinex (R) VF in reversal of coagulopathy and the incidence AICF/DIC, thromboembolic events and mortality. Methods: This was a retrospective, multi-centre study of Prothrombinex (R) VF use in CLD across 11 hospitals over a 2-year period, excluding those on therapeutic anticoagulation. Patients were subclassified into acute on chronic liver failure (ACLF), acute decompensation (ADC) and compensated cirrhosis. Reversal of coagulopathy was defined as international normalised ratio (INR) < 1.5 x upper limit normal (ULN), prothrombin time < 1.5x ULN, activated partial thromboplastin time < 1.5 x ULN and fibrinogen > 1 g/L. Markers of AICF/ DIC were recorded. Results: Thirty CLD patients were included, and the median model for end-stage liver disease score was 23.5. Acute bleeding was the most common indication for Prothrombinex((R))-VF (60%). All had baseline coagulopathy and the majority did not achieve reversal. Key indicators of AICF/DIC were mainly observed in those with ACLF; bleeding from mucosa or lines (53%), worsening hypofibrinogenaemia (60%), worsening thrombocytopaenia (60%). The ADC and compensated cirrhosis groups were relatively unaffected. Incidence of venous thromboembolism was 6%. Overall mortality was 43% and 70% in ACLF. Conclusion: Prothrombinex((R))-VF did not lead to meaningful reversal of coagulopathy and should be used with caution in CLD. Patients with ACLF were more likely to develop AICF/ DIC following Prothrombinex((R))-VF,although the association is uncertain. Further studies are needed to evaluate the safety and efficacy of Prothrombinex((R))-VF use in CLD.