The Use of Kcentra^® in the Reversal of Coagulopathy of Chronic Liver Disease

Abstract

We aim to describe our experience with the four-factor prothrombin complex concentrates (4F-PCC) Kcentra at differing doses in patients with liver cirrhosis requiring emergent hemostasis in the setting of major or life-threatening bleeding. An automated query of patients who received Kcentra between January 2014 and March 2016 was performed. Patients who had clinically significant bleeding and received Kcentra for treatment of coagulopathy of chronic liver disease (CCLD) were included in the study. Baseline patient demographics, administration indication, pertinent laboratory values, and other reversal therapies were collected. Four patients met inclusion for analysis. One patient presented with hemopericardium, cardiac tamponade, and shock, and 3 patients presented with intracranial hemorrhage. Each patient experienced an improvement in international normalized ratio (INR) and at least a period of clinical hemostasis after Kcentra administration without complications referable to Kcentra. Kcentra may be a safe, rapid, and effective treatment option for hemorrhagic emergencies associated with CCLD. Further research is needed to determine the ideal monitoring and dosing regimen for use in CCLD.

Hemostatic Balance in Pediatric Acute Liver Failure: Epidemiology of Bleeding and Thrombosis, Physiology, and Current Strategies

“…It has a low volume of administration and higher concentration of factors compared to plasma, which makes it an attractive alternative to FFP for factor repletion. There are several reports using PCC for patients with liver disease, some using a standard dose such as 25 units/kg, and others using an INR-based dosing regimen, similar to what would be used in vitamin K antagonist reversal (44). Caution is advised with administration of PCC given the lack of natural anticoagulants in this product compared to plasma, and the possibility of provoking thrombosis.…”

Transfusion strategies in patients with cirrhosis

“…suggests that PCC effectively reduce INR in patients with cirrhosis but it is still unclear whether this correlates with a reduction in bleeding. 57,58 Kwon et al retrospectively studied patients with cirrhosis who had received PCC, FFP, and rVFIIa prophylactically for a procedure. They found that those who had received PCC had significantly less pRBC and platelet transfusions and lower rates of volume overload compared to FFP.…”

“…The remainder of literature on PCC in cirrhotic patients is limited to retrospective studies and case reports, with studies on its use in acute hemorrhagic events being even more rare. The literature suggests that PCC effectively reduce INR in patients with cirrhosis but it is still unclear whether this correlates with a reduction in bleeding . Kwon et al retrospectively studied patients with cirrhosis who had received PCC, FFP, and rVFIIa prophylactically for a procedure.…”

High-Dose 4-Factor Prothrombin Complex Concentrate for Warfarin-Induced Intracranial Hemorrhage

“…Although there are a number of published reports of a variety of 4FPCC dosing strategies for patients with warfarin-related bleeds, ours is the first to look at an aggressive HD strategy to treat WICH stratified based on both INR and an assessment of whether or not a patient has a lifethreatening condition. [12][13][14][15][16] Notably, the median 4FPCC dose in our HD group was only 25 U/kg (2000 units), far less than the maximum dose of 50 U/kg (maximum of 5000 units). Similar to our findings, Abdoellakhan et al found that 96% of patients treated with a median of 1750 units of 4FPCC achieved INR 1.5, whereas only 68% of patients treated with a median of 1000 units of 4FPCC obtained this goal (P ¼ .01).…”

“…3 Institutional dosing strategies, however, vary, and while some hospitals adhere to the 4FPCC package insert recommendations, others utilize alternative dosing strategies. 8,[12][13][14][15] Due to the lack of consensus on the optimal 4FPCC dosing strategy and concerns that WICH is the most serious of all warfarin-related bleeds, we developed our own protocol for emergent reversal of WICH. We then performed this quality assessment to compare the efficacy and safety of the 4FPCC package insert dosing strategy (SD) with our institutional guideline for HD 4FPCC for patients with WICH.…”