ORIGINAL ARTICLE Charcoal hemoperfusion in the treatment of medically refractory pruritus in cholestatic liver disease Wonngarm Kittanamongkolchai 1 • Ziad M. El-Zoghby 1 • J. Eileen Hay 2 • Russell H. Wiesner 2 • Patrick S. Kamath 2 • Nicholas F. LaRusso 2 • Kymberly D. Watt 2 • Carl H. Cramer 1 • Nelson Leung 1 Received: 18 July 2016 / Accepted: 9 November 2016 Ó Asian Pacific Association for the Study of the Liver 2016 Abstract Background Pruritus is a distressing symptom in a con- siderable proportion of cholestatic patients and a few of them do not respond to conventional treatment. Charcoal hemoperfusion (CH) is an extracorporeal technique that is effective in eliminating protein-bound substances which may have accumulated during cholestasis. Several case reports have shown significant reduction of bilirubin in mechanical jaundice and neonatal hemolytic jaundice. However, the published data of CH for the treatment of refractory pruritus in cholestatic patients are scarce. Methods Procedure code ‘‘Charcoal hemoperfusion’’ (90997) was used to identify patients who received CH at Mayo Clinic, Rochester, from 1 January 2000 to 5 January 2015. Patients who received CH for refractory cholestatic pruritus were retrospectively reviewed. Results Thirteen patients were identified. A median of 5 (range 1–18) sessions for a total of 20 (1–72) h were per- formed. CH resulted in a significant decrease of pruritus in nine patients (69%). Two patients did not have significant relief and two patients did not pursue further treatments after having adverse reactions during the first session. Median pruritus numerical rating scale significantly decreased from 9/10 (9–10) to 4/10 (0–9) post-treatment (p = 0.004). Duration of symptom-free periods ranged from 8 to 90 days (median 18 days) in six patients who returned for follow-up. Most common adverse reactions were pain, bleeding from the catheter site and fever. Conclusion CH temporarily improves the severity of medically refractory cholestatic pruritus in some patients. However, the improvement is not sustained and the short duration of benefit should be balanced with the invasive nature of the therapy and the relatively common adverse reactions. Keywords Charcoal hemoperfusion Á Cholestasis liver disease Á Pruritus Introduction Pruritus is a common symptom in patients with cholestasis and can vary from mild to severe. It is usually reasonably controlled with medical therapy. However, about 5% of patients with cholestatic pruritus are refractory to medical therapy [1, 2]. This can be very disabling with poor quality of life, sleep deprivation and even suicidal ideation [3, 4]. In these patients, several therapeutic interventions including phototherapy [5], nasobiliary drainage [6] and ileal bypass [7] have been used to improve quality of life and as a bridge to liver transplant. In addition, because the pruritus is believed to be secondary to the accumulation in the blood of ‘‘prurito- genic’’ compounds (none proven at this point to be causative), extracorporeal therapies have been tried, including molecular adsorbent recirculating system (MARS), hemodialysis- and plasmapheresis-based system (Prometheus) and plasma- pheresis, with some promising results [8–12]. Charcoal hemoperfusion (CH) is another method of extracorporeal elimination in which blood circulates Electronic supplementary material The online version of this article (doi:10.1007/s12072-016-9775-9) contains supplementary material, which is available to authorized users. & Nelson Leung Leung.nelson@mayo.edu 1 Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 2 Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 123 Hepatol Int DOI 10.1007/s12072-016-9775-9