Introduction: The development of coagulopathy in acute liver failure (ALF) is universal. The severity of the coagulopathy is often assessed by determination of the prothrombin time and International Normalized Ratio (INR). Discussion: In more than 1,000 ALF cases, the severity of the coagulopathy was moderate in 81% (INR 1.5-5.0), severe in 14% (INR 5.0-10.0), and very severe in 5% (INR > 10.0). Certain etiologies were associated with more severe coagulopathy, whereas ALF caused by fatty liver of pregnancy had the least severe coagulopathy. Methods: Management consisted of transfusions of FFP in 92%. Overall, FFP administered during the first week of admission amounted to 13.7 ± 15 units. Results: Patients who received an ICP monitor had significantly more FFP transfused than those managed without ICP monitor (22.7 ± 2.4 vs. 12.3 ± 0.8 units FFP; P < 0.001). Only a minority of patients developed gastrointestinal bleeding or had an intracranial pressure monitor installed. Conclusion: Further research is necessary to explore the reasons clinicians transfuse ALF patients with large amounts of FFP in the absence of active bleeding or invasive procedures. © 2008 Humana Press Inc.