Treatment of refractory cholestatic pruritus after liver transplantation with albumin dialysis

Abstract

Albumin dialysis has been shown to improve the outcome in patients with cholestatic liver failure caused by chronic liver disease. This study reports 7 liver transplant recipients who were treated with albumin dialysis for intractable pruritus of different origin (ductopenic graft rejection, non-anastomotic strictures, and recurrence of hepatitis C). Treatment with histamine (H1) blockers, opioid antagonists, and cholestyramine had not been effective. The Molecular Adsorbent Recirculating System (MARS; Teraklin, Rostock, Germany) was used for albumin dialysis. All patients presented with numerous scratch marks, 6 of whom had a pronounced icterus. Six patients (86%) responded to 3 consecutive treatments with significant reduction of pruritus. The mean pruritus score, which was quantified by a visual analog scale (VAS), decreased from 9.7 ؎ 0.5 to 3.7 ؎ 0.

Molecular Adsorbents Recirculating System dialysis in children with cholestatic pruritus

“…These might include central sensitization of pruriceptors, which may allow for nonpruritogenic stimuli to be perceived as pruritus, and disturbed central neurotransmission in concert with an individual genetic predisposition [9,27,28]. Bile acid removal was high in all children and similar to that reported in adults [19][20][21]23]. In contrast, bilirubin removal was low and related to the low pretreatment serum levels.…”

“…MARS appears particularly suitable for patients with cholestatic pruritus not yet suffering from severe coagulopathy, as, in contrast to plasmapheresis, removal of protein-bound hepatic toxins is achieved without exposure of the patient to foreign proteins. Several reports in adults and a single case report in a child suggest relief of pruritus by MARS [19][20][21][22][23][24]. However, in face of the high costs and technical burden, MARS is still infrequently applied.…”

Albumin liver dialysis as pregnancy-saving procedure in cholestatic liver disease and intractable pruritus

“…However, MARS was also reported as a valuable and safe procedure for intractable pruritus either after orthotopic liver transplantation or in patients with primary biliary cirrhosis [9][10][11] . To date, 25 cases of successful use of the MARS in patients with refractory pruritus have been reported [9][10][11][12][13] . The mechanisms by which MARS ameliorates pruritus remain unclear.…”

Review article: non‐biological liver support in liver failure

“…[62][63][64][65][66][67] MARS has led to a rapid and well-sustained response in patients with primary biliary cirrhosis (62.6), benign recurrent intrahepatic cholestasis, 64 post-transplant biliary stenosis, 63, 65 chronic hepatitis C infection 66 and druginduced cholestatis. 67 Potential mechanisms of response probably reside in the removal of bile acids or plasma opioids, such as met-enkephalins.…”

“…67 Potential mechanisms of response probably reside in the removal of bile acids or plasma opioids, such as met-enkephalins. 65,66,68 Anecdotal reports have also described successful use of MARS for overdose or toxicity with non-dialysable protein-bound substances, such as Amanitapoisoning, phenytoin toxicity and others. 42,69 as well as for progressive intrahepatic cholestasis because of chronic graft-vs.-host disease 70 or heart failure with associated forward-and backward-induced liver failure.…”