Treatment of Pruritus in Cholestatic Jaundice by Bilirubin- and Bile Acid-Adsorbing Resin Column Plasma Perfusion A. A. ALARABI, B. WIKSTROM, L. LOOF & B. G. DANIELSON Dept. of Internal Medicine, University Hospital, Uppsala, Sweden

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Alarabi AA, Wikstrom B, Loof L, Danielson BG. Treatment of pruritis in cholestatic jaundice by bilirubin- and bile acid-adsorbing resin column plasma perfusion. Scand J Gastroenterol 1992,27, 223226 The efficacy of plasma perfusion through a new anionic resin, BR-350, for palliation of intractable pruritus secondary to intrahepatic cholestasis was studied in four patients. The treatment was given in a daily 2-h session on 3 consecutive days and was followed by repeated treatment periods each 3rd to 4th week. The patients experienced symptomatic improvement during the first treatment period, and the treatment was well tolerated. Adsorption of bile acids across the filter was efficient and resulted in a bile acid concentration gradient pre- to post-resin of 92%. Thus plasma perfusion through the ion resin BR-350 is an effective and safe treatment for symptomatic relief of intractable pruritus in cholestatic liver disease and may reduce hospitalization time and increase the quality of life.

Key words: Adsorption resin column; bile acid; bilirubin; cholestasis; pruritus Abdelmoniem A . Alarabi, M . D . , Dept. of Internal Medicine, University Hospital, S-751 85 Uppsala, Sweden

Pruritus is a common and most distressing symptom in patients with intrahepatic cholestatic liver disease. Although the pathophysiology of cholestatic pruritus is unknown, deposition of bile salts in the skin has been considered to have a causative role (1). Various therapies have been tried in attempts to relieve pruritus, including cholestyramine (2) and ursodeoxycholic acid (3). However, some patients are not relieved from pruritus by drug therapy. Other approaches of treatment like charcoal hemoperfusion (4) and plasmapheresis (5,6) have been reported to be beneficial. These techniques, however, have the drawback of removing blood components unselectively. Previous reports (7-9) showed high and selective affinities for bilirubin and bile acids when plasma perfusion was performed with anion exchange resin columns. A high selectivity for bile acids (as reported for the Plasorba BR-350 resin column) is theoretically an advantage when resin columns are used for palliation of pruritus. However, the clinical experience from anion resin therapy for this particular indication is limited. In the present preliminary study we report our experience from symptomatic relief of intractable pruritus in cholestatic jaundice when plasma perfusion was performed across a bilirubin-adsorbing resin column. PATIENTS AND METHODS

Patients Four patients (three female, one male) aged 41-72 years were included in this study. All patients had intrahepatic cholestasis confirmed by serum biochemistry, abdominal ultrasonography , or endoscopic retrograde cholangiography and liver biopsy. The diagnosis and serum levels of bilirubin

and bile acids of each patient are shown in Table I. All patients were incapacitated from severe pruritus resistant to treatment with cholestyramine. For grading of pruritus we suggested a special scale by which we could get a crude measurement of the objective feeling of each patient (Table I). The procedure of the study and goal of treatment were explained to each patient, and their oral consent to participate was obtained.

Plasma p e r f u s i o n through bilirubin-adsorbing resin column Femoral vessel catheterization with a dual-lumen catheter (for example, Quinton) was considered for a temporary vascular access in each patient. The procedure was performed at the bedside, with the patient under local anesthesia by the Seldinger technique (10). Plasma was first separated by a plasma-separating filter (Plasmaflo OP-05 Asahi Medical, Japan), using a plasma exchange monitor (Plasauto 1000, Asahi Medical). The blood pump rate was adjusted so that 8&120ml/min of blood passed through the plasma separator, to yield 15-30 ml of plasma. Heparin was used as the standard anticoagulant in a bolus initial dose of 5000 units, followed by 1000 units every 60min. The dose was monitored at the bedside by checking the activated clotting time (ACT). The plasma was then perfused through an anion exchange resin column made of the resin styrenedivinylbenzene with trimethylbenzylammonium as the ligand (BR-350 (350 ml), Asahi Medical). The resin was carefully rinsed before perfusion with 2 I of normal saline solution, followed by another 2 I of saline containing 5000 units of heparin per liter. The complete system, including plasma separation and plasma perfusion through the resin, is shown in Fig. 1.

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A . A . Aluruhi e( ul.

‘l‘dbk I. Patients’ characteristics

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1tching.i.

Patient

Age (years)

Sex

Diagnosis

NS

41

F

ES

72

F

BB

55

F

RB

61

M

Liver cirrhosis acute alcoholic hepatitis with cholestasis Cholestatic jaundice Sclerosing cholangitis Drug-induced (penicillin) intrahepatic cholestasis

+

S-bilirubin (4-21 pmol/l*)

S-bile acids (