Elsevier

Journal of Hepatology

Volume 45, Issue 6, December 2006, Pages 887-891
Journal of Hepatology

Case report
Plasma separation and anion adsorption transiently relieve intractable pruritus in primary biliary cirrhosis

https://doi.org/10.1016/j.jhep.2006.08.008Get rights and content

Background/Aims

Pruritus can be a severely disabling symptom in patients with primary biliary cirrhosis who do not respond to treatment with ursodeoxycholic acid, anion exchangers, enzyme inducers, or opiate antagonists. The aim of this study was to assess the clinical efficacy of plasma separation and anion adsorption in the treatment of intractable pruritus of cholestasis.

Methods

Three patients with primary biliary cirrhosis and intractable pruritus defined by severity of pruritus ⩾7 on a rating scale between 0 (no pruritus) and 10 (maximal pruritus) on at least 4 of 7 days despite medical treatment were treated with plasma separation and anion adsorption on three consecutive days. Fatigue was assessed using the Fisk Fatigue Severity Score and quality of life was assessed by the PBC-40, a disease specific health related quality of life measure.

Results

Improvement in pruritus, fatigue, and quality of life was transiently observed in all patients. Serum bile acid levels showed no association with intensity of pruritus, and the bile acid pattern was not altered. The treatment was well tolerated by all patients.

Conclusions

Plasma separation and anion adsorption seem to be a safe and effective therapeutic option for patients with primary biliary cirrhosis suffering from intractable pruritus.

Introduction

Pruritus is a common complication of cholestatic liver diseases, particularly of primary biliary cirrhosis (PBC) [1]. It may dramatically impair the patient’s quality of life by limiting normal activities, causing sleep deprivation and even suicidal sensations [2]. The pathogenesis of cholestasis-associated pruritus remains poorly understood and may be multifactorial. Peripherally acting pruritogens and altered central neurotransmission have been implicated as causing pruritus in cholestasis [3]. Current therapeutic interventions for cholestatic pruritus are thus directed towards elimination or inactivation of putative peripheral pruritogens by anion exchange resins such as cholestyramine and colestipol or enzyme-inducing agents such as rifampicin or modulation of altered central neurotransmission by opioid or serotonin receptor antagonists [3]. In patients who do not respond to medical therapies, invasive procedures, such as nasobiliary drainage or partial external diversion of bile [4], [5], [6], [7], ileal diversion [8], hemodialysis [9], charcoal hemoperfusion [10], plasmapheresis and plasma perfusion [11], [12], [13], and extracorporeal albumin dialysis [14], [15], have been tried in small numbers of patients.

The present pilot study reports on the effect of plasma separation and anion adsorption via a peripheral vein in patients with PBC suffering from severe, otherwise intractable pruritus.

Section snippets

Patients

Three patients with clinical, biochemical, and histological characteristics of primary biliary cirrhosis (Table 1) and intractable pruritus defined by severity of pruritus ⩾7 on a scale between 0 and 10 on at least 4 of 7 days despite treatment with cholestyramine (⩾8 g/day), rifampicin (300–600 mg/day), and naltrexone (50 mg/day), each for >4 weeks, were included in the pilot study. All patients had undergone nasobiliary drainage of bile at least once in the past [7].

Plasma separation and anion adsorption

Plasma separation and anion

Safety

Plasma separation and anion adsorption were well tolerated by all patients. No adverse effects were reported. No significant hemodynamic abnormalities or bleeding events were observed during and after the treatment.

Pruritus

All three patients reported a rapid improvement of pruritus as assessed by a rating scale from 0 (no pruritus) to 10 (unbearable or maximal imaginable pruritus) (Fig. 1B). The reduction in pruritus over the first week was 80% in patient 1, 21% in patient 2, and 37% in patient 3 (mean

Discussion

In this pilot study, we show that severe intractable pruritus in patients with PBC was successfully treated with plasma separation and anion adsorption through anion exchange resin columns. The treatment was well tolerated and no adverse effects were observed. All patients reported a rapid, but temporary attenuation of pruritus intensity paralleled by an improvement in fatigue and quality of life suggesting that pruritus is a symptom, which contributes to fatigue and reduced quality of life in

Acknowledgement

The supply of columns for 2 of 3 patients by Diamed Medizintechnik GmbH (Cologne, Germany) is gratefully acknowledged.

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