Treatment of resistant pruritus from cholestasis with albumin dialysis: Combined analysis of patients from three centers

doi:10.1016/j.jhep.2010.02.031

Journal of Hepatology

Volume 53, Issue 2, August 2010, Pages 307-312

https://doi.org/10.1016/j.jhep.2010.02.031 Get rights and content

Background & Aims

Albumin dialysis using molecular adsorbent recirculating system (MARS) is a new procedure for treating resistant pruritus from cholestasis, but it is usually published as a case report or a short series. Therefore, we analyzed patients with resistant pruritus treated with MARS from three centers, to assess the changes on pruritus and the indices of cholestasis.

Methods

Twenty patients (12 female, mean age: 51 ± 3.4 years) with chronic cholestatic liver disease or chronic liver-graft rejection were evaluated. The severity of pruritus was assessed using a visual analogue scale (VAS) before and after treatment, and 30 days thereafter. Liver tests, including total bilirubin, alkaline phosphatase, gamma-glutamyl-transferase, cholesterol, triglycerides, and total bile acid were also determined, as well as the number of sessions and the coupled procedure (dialysis or perfusion).

Results

Albumin dialysis resulted in a decrease of pruritus (VAS: from 70.2 ± 4.8 to 20.1 ± 4.2, p <0.001), which partially resumed after 30 days (38.7 ± 6.6). VAS decreased by 72% immediately after treatment and by 51% after 1 month. Pruritus decreased in all but one patient. MARS resulted in a significant bile acid decrease of 41% after treatment and by 37% after 1 month. The effect of MARS on pruritus and markers of cholestasis was similar in patients with different diseases and was independent of the coupled procedure. The improvement of pruritus in individuals was positive in 75% of patients. No major adverse effects were observed.

Conclusions

Albumin dialysis using MARS is an effective procedure for managing resistant pruritus in most patients with chronic cholestasis and graft rejection.

Introduction

Pruritus is a common distressing symptom in patients with cholestasis, particularly in primary biliary cirrhosis (PBC) and in some liver transplanted patients with graft rejection [1], [2]. Pruritus can be so severe that it may lead to sleep deprivation and interference with quality of life, and when resistant to the common treatments is an indication for liver transplantation in patients with chronic cholestatic diseases [3], [4], [5].

Current therapeutic options for cholestatic pruritus are directed towards the elimination of presumed peripheral pruritogens by anion exchange resins such as cholestyramine [6] and colestipol or enzyme-inducing agents such as rifampicin [7]. The opioid antagonists, naloxone [8] and naltrexone [9], as well as sertraline [10] have also been shown to alleviate pruritus from cholestasis. In patients who do not respond to medical therapies, different invasive procedures, such as hemodialysis [11], charcoal hemoperfusion [12], and plasmapheresis [13], [14], [15] have been used with positive, although uncertain results, due to the small number of patients evaluated. More recently, the therapeutic effects of various methods of extracorporeal albumin dialysis [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], mainly the molecular adsorbent recirculating system (MARS), have been published [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27]. However, from these case reports or short series (the highest has included seven patients) [21], it is difficult to ascertain the actual efficacy of the procedure in patients with cholestatic pruritus. Therefore, the current study analyses the effect of MARS in a series of 20 patients with resistant pruritus from cholestasis, including the overall feeling of satisfaction with the procedure and the changes induced on the indices of cholestasis.

Section snippets

Patients

We have assessed the effects of MARS on pruritus in 20 patients (12 female, mean age: 51 ± 4.3 years) with chronic cholestatic disease (12 patients) and in liver transplanted patients with chronic graft rejection (eight patients). Partial information from patients three and four from Tenerife and Barcelona, respectively, has already been published [19], [20]. All the patients have severe pruritus and they had been previously treated with current non-invasive procedures such as resins, rifampicin,

Results

The clinical and biochemical baseline characteristics of the 20 patients are depicted in Table 1. All the cases had severe pruritus before MARS treatment and biochemical determinations of severe cholestasis with high alkaline phosphatase and gamma-glutamyl-transferase levels. Total bilirubin was normal (below 1.2 mg/dl) in 11 patients (55%), and total bile acids were elevated in all 13 evaluated cases. Patients with chronic cholestatic diseases and graft rejection were similar with respect to

Discussion

The most relevant data of this combined analysis, which includes the largest series of patients with resistant pruritus of cholestasis treated with albumin dialysis using MARS, is that the severity of pruritus decreased in all the patients but one, and that the overall performance of the procedure was considered satisfactory enough in 75% of the cases. The decrease in pruritus intensity was observed in most cases with only two MARS sessions, thus totaling an average of 15 h of treatment during

Funding

This study was supported in part by the Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, and SAF-05/3649, and SAF-08/04012, Ministerio de Ciencia e Innovación, Spain.

Conflicts of interest

The authors who have taken part in this study declared that they do not have anything to disclose regarding conflict of interest with respect to this manuscript.

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Research ArticleTreatment of resistant pruritus from cholestasis with albumin dialysis: Combined analysis of patients from three centers

Background & Aims

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Funding

Conflicts of interest

J Hepatol

Gastroenterology

Lancet

Gastroenterology

Hepatol Res

Am J Med

Transplant Proc

Transplant Proc

J Hepatol

Transplantation for primary biliary cirrhosis

Semin Liver Dis

Liver transplantation for cholestatic liver disease: screening and assessment of risk factors

Liver Transpl Surg

American association for study of liver diseases. Primary biliary cirrhosis

Hepatology

Naloxone ameliorates the pruritus of cholestasis: results of a double-blind randomized placebo-controlled trial

Ann Intern Med

Sertraline as a first-line treatment for cholestatic pruritus

Hepatology

Research Article
Treatment of resistant pruritus from cholestasis with albumin dialysis: Combined analysis of patients from three centers