Plasma Exchange With Corticosteroids as a Rescue Therapy for Severe Prolonged Cholestasis in Acute Viral Hepatitis

Background and aims

Prolonged cholestasis after acute viral hepatitis (AVH) complicates <1% of patients. The treatment includes the use of anti-pruritic medications in a stepwise manner. This study assessed the role of Plasma exchange (PLEX) with corticosteroids on severe prolonged cholestasis.

Methods

Retrospective analysis of patients with AVH and prolonged cholestasis was conducted. Prolonged cholestasis was defined as jaundice for >6 weeks with peak serum bilirubin >10 mg/dL, in the absence of haemolysis and renal failure with alanine transferase level below 500U/L. A combination of centrifugal PLEX with corticosteroids was offered if there was no response to anti-pruritic medications. A control group, which received only anti-pruritic medications, was included for comparison.

Results

Fifty-nine patients, predominantly males (90%; n = 53) were included. Most common etiology was HAV (n = 56; 94.9%) followed by HEV (n = 3; 5.1%). Despite more severe disease, (higher Visual Analogue Scale (VAS) - 9 [9-9] vs 8 [7–8], P < 0.001 and higher bilirubin - 30.6 ± 4.1 vs 27.3 ± 7.1 mg/dL, P = 0.03), bilirubin reduction was faster in combination group. Percentage reduction in bilirubin at week 1 and week 4 was 43.6% ± 7.9% and 93.8% ± 1.6% in the combination group vs 37.9% ± 12.9% and 89.4% ± 4.4% in the conservative group (P = 0.04 and < 0.001, respectively). Median time to symptom improvement was less in the combination group (25 [22–27] days vs 42 [38–48] days; P < 0.001 in conservative group).

Conclusion

PLEX combined with low-dose oral steroids results in significant improvement in prolonged cholestasis and can be considered as an effective rescue therapy in patients who do not respond to standard anti-pruritic medications.