HRF Resolved Refractory Itch

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Received: 25 May 2020Revised: 20 August 2020Accepted: 24 August 2020
DOI: 10.1111/aor.13811
LETTER S T O TH E EDIT OR
Switching to HFR Supra resolved refractory itch and quality of

life in a chronic dialysis with liver transplant patient
Chronic itch (CI) is one of the most distressing conditions

1
that impair the quality of life (QOL). CI is associated with cirrhosis-hepatocarcinoma due to hepatitis C virus (HCV). The
many diseases of hepatic, renal, or hematological origin. OTLx was complicated by primary graft dysfunction and 3
Several pruritogens including bile salts have been hypothe- days later he underwent to a second OTLx with good graft
sized to be involved in the pathogenesis of CI, however, the function; renal function was normal. From March to August
underlying mechanism is still to be clarified and currently 2015 he was treated with sofosfubir leading HCV negativity,
available medications are ineffective. good liver function but he developed stage II chronic kidney
We report a case of severe refractory itch in a 52-year-old disease (CKD).
man with orthotopic liver transplant (OLTx) and end-stage In December 2016, the patient developed graft rejection
renal disease under chronic hemodialysis with highly treated with corticosteroids; posttransplant bile duct anasto-
impaired QOL, successfully resolved by switching from motic stenosis was diagnosed, with the increase of bile salts,
standard bi- carbonatedialysis to hemodiafiltration where cholestasis indexes, and the appearance of occasional itch;
the replacement fluid consists of endogenous ultrafiltrate cholestyramine and ursodeoxycholic acid were introduced.
from the patient, re- generated through a cartridge CKD worsened to stage IIIb.
containing hydrophobic styrene resin (HFR Supra, In March 2017, the occlusion of the right renal artery
2,3
Bellco/Medtronic, Mirandola, Italy). contributed to CKD progression to stage IV; itch became
In April 2018, the patient was referred to our unit for more intense. In the following months CKD worsened and
starting dialysis. Five years before he underwent OTLx after a the patient started bicarbonate-dialysis. Liver function
history of remained stable; bile salts and cholestasis indexes
increased, and CI became
TABLE 1 Liver and renal function trends from June 2013 to November 2018. EQ-5D-5L and VAS scale based on renal replacement
technique
June 2013 August 2015 December 2016 March

2017 April 2018 September 2018 November
2018
Albumin, g/L 40 44 40 40 42 45 46
AST, U/L 22 20 24 50 17 25 32
ALT, U/L 70 23 37 30 26 31 37
γGT, U/L 189 23 282 186 176 167 175
Total bilirubin, μmol/L 16.3 13.2 12.3 6.1 9.1 8.7 9.4
Bile salts, μmol/L 3.5 3.7 19.2 23 50 34 11
a b c
Creatinine, mg/dL 0.94 1.30 2.09 2.43 HD HFR HFR Supra
eGFR, mL/min 94 62 34 29 KT/V 1.37 KT/V 1.43 KT/V 1.48
Proteinuria, g/day 0.07 0.77 3.00 3.44 – – –
Phosphorus, mmol/L 0.87 0.85 0.94 1.12 1.43 1.52 1.56
PTH, ng/L 47 50 54 65 64 106 97
EQ-5D-5L – – – – 11 342 11 241 11 121
VAS – – – – 41 51 73
a © 2020 International Center for Artificial
HD: Bicarbonate dialysis 240 min/three times a week high flux dialyzer PAES/PVP, KT/V 1.37.
b Organs and Transplantation and Wiley
HFR: 240 min/three times a week HFR dialyzer, KT/V 1.43. Periodicals LLC.
c
HFR Supra: 240 min/three times a week HFR Supra dialyzer KT/V 1.48.
–, not available. Artificial Organs. 2020;00:1–2.
The bold text underlines the critical data as provided by the comparison of different type of dialysis as considered in the text.
wileyonlinelibrary.com/journal/aor |1
2 | LETTERS TO THE EDITOR
refractory and very distressing with heavily compromised Nephrology, Dialysis and Transplantation
QOL. Due to continuous scratching the patient could not Unit, Department of Medicine, University of
work, practice simple daily activities, and people stood away Padova,
from him thinking he was infectious. Padova, Italy
QOL, evaluated by EuroQol-5 Dimensions-5 level (EQ-
4
5D-5L), was low. Plasma phosphorus was well controlled Correspondence
by hemodialysis and sevelamer (Table 1). Lorenzo A. Calò, Nephrology, Dialysis and
In September 2018, the patient was switched from bicar- Transplantation Unit, Department of Medicine, University
bonate-dialysis to HFR, which led to a slight improvement of Padova, Via
of CI. EQ-5D-5L score slightly improved. Giustiniani, 2, Padova 35128, Italy.
In November 2018, after obtaining patient’s signed in- Email: renzcalo@unipd.it
formed consent, the patient was switched to HFR Supra,
which significantly reduced CI and plasma levels of bile Giuseppe Scaparrotta and Laura Gobbi contributed equally
salts (−67%), β2-microglobulin (−42%), serum amyloid-A to this work.
(−64%), and interleukin-6 (−9%), with consequent clear im-
provement of QOL. The continuous scratching ended, the ORCID
patient was able to work, focus on his activities, and have Lorenzo A. Calò https://orcid.org/0000-0002-7534-0128
normal life with other people.
Although in the case of our patient itch could have a REFERENCES
multi- factorial origin and the identification of the main 1. Huesmann M, Huesmann T, Osada N, Phan NQ, Kremer AE,
pruritogens could be difficult, HFR Supra has demonstrated Ständer S. Cholestatic pruritus: a retrospective analysis on clini-
a clear effect in resolving CI with its very distressing-related cal characteristics and treatment response. J Dtsch Dermatol Ges.
QOL and by reducing the inflammatory state. This 2013;11:158–69.
2. Ursino M, Colí L, Magosso E, Capriotti P, Fiorenzi A, Baroni P,
treatment, therefore, should be continued in such patients
et al. A mathematical model for the prediction of solute kinetics,
and HFR Supra may definitely represent a valid therapeutic osmolarity and fluid volume changes during hemodiafiltration
approach in case of CI in dialysis patients, offering a good with on-line regeneration of ultrafiltrate (HFR). Int J Artif Organs.
compromise between optimization of toxin removal and 2006;29:1031–41.
possible loss of beneficial physiological substances. 3. Riccio E, Cataldi M, Minco M, Argentino G, Russo R, Brancaccio
S, et al. Evidence that p-cresol and IL-6 are adsorbed by the HFR
Giuseppe Scaparrotta cartridge: towards a new strategy to decrease systemic
inflammation in dialyzed patients? PLoS ONE 2014;9:e95811.
Laura Gobbi
4. Pickard AS, Kohlmann T, Janssen MF, Bonsel GJ, Rosenbloom S,
Lorenzo A. Calò Cella D. Evaluating equivalency between response systems:
applica- tion of the Rasch model to a 3-level and 5-level EQ-5D.
Med Care. 2007;45:812–9.

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Received: 25 May 2020Revised: 20 August 2020Accepted: 24 August 2020

Switching to HFR Supra resolved refractory itch and quality of

Chronic itch (CI) is one of the most distressing conditions

June 2013 August 2015 December 2016 March

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