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Treatment of pruritus due to hepatobiliary diseases (HBP), represents a clinical challenge for a high number of patients: up to 70-80% of hepatobiliary disease patients are affected with untreatable HBP with deleterious consequences in quality of life, daily activities and sleep disturbances, often refractory to pharmacological pruritus treatment. Such hyperresponsiveness is explained by its physiopathology: Despite advances in identifying potential causative agents, such as bile salts and neurotransmitters, a comprehensive understanding and effective treatment of pruritus in cholestasis remain elusive. An alternative therapeutic strategy for such a severe entity is proposed by American Society for Apheresis (ASFA) although with a low evidence for recommendation (Category III, Grade 1C), with therapeutic plasma exchange (TPE) prescription of replacement of 1 to 1.5 plasma volume thrice a week with albumin, followed by 2 to 4 per month for maintenance. In our center, a liver transplant referral center, we used TPE in managing refractory HBP. Additionally, we compared the reduction in ItchyQuant scale scores throughout the specified period.
A retrospective observational study was conducted at Fundación Cardioinfantil in Bogotá Colombia, between October 2021 to October 2023. This study focused on ambulatory patients exclusively diagnosed with primary biliary cirrhosis and refractory HBP treated in a daycare TPE model. We objectivized pruritus severity with the ItchyQuant scale. The therapies were administered in accordance with the progression of symptoms, ensuring that each patient received at least one therapy per month. A Wilcoxon signed-rank test was performed to compare the change in ItchyQuant scale score after each therapy.
We performed 39 TPE sessions to 4 patients in a daycare TPE model. Vascular access was tunneled hemodialysis catheter in all of them. The age range of the patients was from 33 to 57 years. Before the intervention, the median ItchyQuant scale score was 7.5, and a notable reduction in pruritus severity was observed, with a post-intervention median score of 2.17 (p <0.001). There were no severe adverse events related to the therapy; there was one event of hypotension managed with fluid administration. No thrombocytopenia or bleeding complications were reported.
In our study, TPE was safely performed and demonstrated promising results in alleviating refractory pruritus among ambulatory patients with primary biliary cirrhosis. While the study suggests the potential for improvement in domains of quality of life, such as physical well-being, vitality, social function, and mental health, it is important to note that further research is needed to establish conclusive evidence in this regard. We share our experience in a daycare TPE center as an affordable initiative specially for in development countries with lack of access to TPE or multiorgan support therapies.
References: Padmanabhan, A., Connelly‐Smith, L., Aqui, N., Balogun, R. A., Klingel, R., Meyer, E., ... & Schwartz, G. E. J. (2019). Guidelines on the use of therapeutic apheresis in clinical practice–evidence‐based approach from the Writing Committee of the American Society for Apheresis: the eighth special issue. Journal of clinical apheresis, 34(3), 171-354.