Therapy of intractable pruritus with MARS.

INTRODUCTION: Pruritus is the most disabling symptom in patients with cholestatic liver diseases. Many drug therapies have been used for the treatment of these diseases, with different outcomes. The molecular adsorbent recirculating system (MARS) has been used in the treatment of intractable pruritus in cholestatic syndromes. We report our experience with MARS in 3 patients with intractable pruritus on the waiting list: 2 liver transplant recipients and a patient with primary biliary cirrhosis. PATIENTS AND RESULTS: Two middle-aged women and 1 middle-aged man, who were recipients of an orthotopic liver transplant for primary biliary cirrhosis, underwent three (n = 2) and two (n = 1) 6-hour sessions of MARS due to medically uncontrollable pruritus. All noted marked improvement of pruritus, with decreased bilirubin levels, but this improvement lasted only a few days in all cases. We observed no changes in transaminase or albumin levels, or prothrombin time. Complications included an episode of angina due to anemia caused by jugular catheter bleeding, and thrombocytopenia in all patients. CONCLUSIONS: MARS is an effective treatment for intractable pruritus in cholestatic liver diseases, although its beneficial effect is short. This extracorporeal liver device is safe, because most related adverse events are mild.

Adsorption in hemodialysis.

The use of sorbents in different blood purification techniques is reviewed. The sorbents used in these therapies are divided into two groups: (1) Adsorption occurs fundamentally because of the hydrophobic properties of the sorbents. In this group, the sorbents used in different dialysis techniques are charcoal and nonionic macroporous resins. (2) Adsorption occurs by chemical affinity, such as ion exchange resins and chemisorbents. Sorbents were initially used in hemoperfusion, which caused many adverse events; later, with the use of coated charcoal, these undesired effects decreased or disappeared, but the adsorptive properties, water control, and acid-base balance still created problems. For these reasons, the use of sorbents in the treatment of chronic renal failure was almost totally discontinued. Little by little, interest in these substances has reappeared, and at present, they have been used in combination with other blood purification techniques such as hemodialysis, hemofiltration, peritoneal dialysis, and finally, hemodiafiltration. Within the various hemodiafiltration techniques, paired filtration dialysis-charcoal is being used to regenerate the ultrafiltrate, which is used as the replacement fluid. Charcoal regenerates the ultrafiltrate and transforms it into a physiological solution with a normal electrolyte composition, calcium, bicarbonate, and glucose, having eliminated the majority of both middle and large molecule uremic toxins. If regeneration is done properly, this replacement fluid is bacteria and endotoxin free. Studies currently are underway on the adsorption of different inflammatory substances in the ultrafiltrate, which could lead to improvement in the biocompatibility of the system.

Visceral leishmaniasis (kala-azar) in solid organ transplantation: report of five cases and review.

Visceral leishmaniasis is an infectious disease that occurs only rarely in recipients of solid organ grafts but is associated with an elevated mortality rate despite proper treatment. We report five cases diagnosed in our hospital. All the patients were men aged 30 to 60 years who had undergone kidney transplantation (3 patients), heart transplantation (1), or liver transplantation (1). Three of the patients died, one had multiple recurrences, and one developed post-kala-azar cutaneous leishmaniasis. We review the clinical features, treatments, and outcomes of 26 previously reported cases, pointing out the lower cure rate associated with human immunodeficiency virus infection.

Hemodiafiltration in two chambers without replacement fluid: a clinical study.

Paired filtration dialysis (PFD) is the only hemodiafiltration (HDF) technique in which ultrafiltrate (Uf) is obtained continuously with a similar composition to plasma. It has been proved that Uf is regenerated when it passes through an uncoated adsorbent charcoal cartridge: this one removes medium-to-large solutes and small toxines (except for urea and phosphates), but not the electrolytes and bicarbonate. This regenerated Uf can be used like replacement fluid, using the same Uf pump as the infusion pump; this makes the HDF technique easier and more reliable. During 12 months (3 h/3 sessions/week), we treated 13 patients with this PFD-Charcoal technique. These patients were previously on conventional PFD for at least 6 months. The biochemical results were excellent with a stabilization of all parameters (urea, creatinine, uric acid, Na, K, Cl, Ca, phosphates, beta 2-microglobulin, beta 2M, etc.) and a better control of acidosis (statistically significative after 6 months). The clinical tolerance was also excellent, and the technique was greatly simplified. We conclude that PFD-Charcoal is a good HDF technique that avoids the use of exogenous replacement fluid by using the regenerated Uf itself as an endogenous substitution fluid with bicarbonate.

Multicentric study on paired filtration dialysis as a short, highly efficient dialysis technique.

Paired filtration dialysis (two-chamber haemodiafiltration) was evaluated as a short, highly efficient renal replacement therapy in 35 uraemic subjects belonging to three different dialysis centres. The study period was 1 year. Patients were divided into two groups according to their body-weight and drinking habits. The smaller patients underwent 150-min dialysis sessions three times weekly. The larger patients underwent 3-h treatments thrice weekly. The treatment was adequate in all patients according to the KT/V criteria of adequacy. The intradialytic symptomatology was remarkably low and the treatments were well tolerated in all patients. The study confirms the reliability of paired filtration dialysis as a short dialysis technique. In some patients 150 min may be insufficient to achieve an adequate dialysis efficiency and 180 min may be required for the majority of the population.

Paired filtration dialysis: optimizing depurative efficiency with separate convection and diffusion processes.

To overcome reciprocal interaction between convection and diffusion occurring in hemodiafiltration, we separated the two processes in a new dialysis technique called paired filtration dialysis (PFD). In this technique, convection and diffusion take place separately on two capillary membranes: a polysulfone hemofilter and a hemophan dialyzer. The depurative effectiveness of PFD with respect to small (blood urea nitrogen, creatinine, uric acid, phosphate) and large (beta 2-microglobulin) molecules was acutely assessed in 6 patients on maintenance acetate hemodialysis. Despite a 3-hour treatment time, a high mass removal of small and large solutes was found in PFD without high ultrafiltration rates or blood flows in excess of 300 ml/min. There was no significant difference in solute removal between the two different depurative sequences adopted in PFD, i.e., convection followed by diffusion or vice versa. A significant reduction in beta 2-microglobulin serum levels was observed in both PFD modes. Twenty patients, on a 12-month period of 3-hour PFD treatment, maintained an unaltered metabolic, clinical, and acid-base status, and cardiovascular stability was not affected. PFD thus provides excellent depurative results, along with simple technical features that are particularly useful in treating patients with high depurative needs and yet are unable to tolerate high-flux techniques.

The bone scan in patients with aluminium-associated bone disease.

The bone scans of 32 patients on regular dialysis who received desferrioxamine therapy for fracturing osteomalacia secondary to aluminium intoxication are reviewed. All scans show the same pattern, with lack of tracer deposition in bone and deposition in soft tissues. Therapy with desferrioxamine controlled the aluminium intoxication in all cases, and in 21 patients the bone scan reverted to normal or showed a pattern typical of hyperparathyroidism.