Current knowledge of hypertriglyceridemic pancreatitis

Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification

The aim of the study was to determine whether extrapancreatic inflammation on computed tomography (EPIC) is helpful in predicting organ failure in the early phase of acute pancreatitis (AP) as defined by the 2012 revised Atlanta classification.Patients (n = 208) who underwent abdominal computed tomography (CT) within 24 hours after AP onset and admission were retrospectively identified. Each patient's EPIC score, Balthazar score, bedside index of severity in acute pancreatitis (BISAP), and systemic inflammatory response syndrome (SIRS) score were obtained. Primary endpoints were organ failure occurrence and death. Scores were evaluated by receiver operator characteristic (ROC) curve and area under the curve (AUC) analysis.Median age was 45 years (range: 18-83 years). Forty-seven patients (22.6%) developed organ failure, and 5 patients (2.4%) developed infection and underwent surgery. Two patients died. The median EPIC score was 2 (range: 0-7). EPIC score accuracy (AUC = 0.724) in predicting organ failure was similar to that of BISAP (0.773) and SIRS (0.801) scores, whereas Balthazar scoring was not significant (P = .293). An EPIC score of 3 or greater had a sensitivity and specificity of 80.65% and 63.16%, respectively. EPIC scores correlated moderately with organ failure severity (Spearman r = 0.321) and number of failed organs (r = 0.343).The EPIC scoring system can be useful in predicting the occurrence of organ failure, but it does not differentiate severity and number of failed organs in early phase AP.

Therapeutic plasmapheresis for hypertriglyceridemia-associated acute pancreatitis: case series and review of the literature

BACKGROUND

Severe hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (AP) in the United States. The current standard of care includes management of HTG using pharmacological therapy. More recently, plasmapheresis has been proposed as a therapeutic tool for decreasing triglyceride (TG) levels, especially in critically ill patients. Few studies are available to ascertain overall benefits of plasmapheresis over traditional management.

OBJECTIVE

To analyze the outcomes of patients treated with plasmapheresis for severe HTG-associated pancreatitis.

METHODS

We conducted a retrospective chart review of three patients with severe HTG- associated (TGs greater than 1000 mg/dl; 11.29 mmol/l) AP at the Methodist University Hospital. All the patients underwent plasmapheresis as part of their treatment.

RESULTS

The average TG level before plasmapheresis was 3532 mg/dl (range: 2524-4562 mg/dl; 39.9 mmol/l; range: 28.5-51.6 mmol/l). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 1.3 (range 1-2), and mean TG level after plasmapheresis was 1051 mg/dl (range: 509-1771 mg/dl; 11.9 mmol/l; range: 5.8-20 mmol/l). After the first session, the average reduction of TG level was 2481 mg/dl (range 753-3750 mg/dl; 28 mmol/l; range: 8.5-42.4 mmol/l) or approximately 70%. None of the patients developed complications related to plasmapheresis.

CONCLUSIONS

Plasmapheresis can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

A 1-month-old infant with chylomicronemia due to GPIHBP1 gene mutation treated by plasmapheresis

Chylomicronemia is a severe type of hypertriglyceridemia characterized by chylomicron accumulation that arises from a genetic defect in intravascular lipolysis. It requires urgent and proper management, because serious cases can be accompanied by pancreatic necrosis or persistent multiple organ failure. We present the case of a 1-month-old infant with chylomicronemia treated by plasmapheresis. His chylomicronemia was discovered incidentally when lactescent plasma was noticed during routine blood sampling during a hospital admission for fever and irritability. Laboratory investigation revealed marked triglyceridemia (>5,000 mg/dL) with high chylomicron levels. We therefore decided to perform a therapeutic plasmapheresis to prevent acute pancreatitis. Sequence analysis revealed a homozygous novel mutation in exon 4 of GPIHBP1: c.476delG (p.Gly159Alafs). Glycosylphosphatidylinositol-anchored high density lipoprotein-binding protein 1 (GPIHBP1) stabilizes the binding of chylomicrons near lipoprotein lipase and supports lipolysis. Mutations of GPIHBP1, the most recently discovered gene, can lead to severe hyperlipidemia and are known to make up only 2% of the monogenic mutations associated with chylomicronemia. The patient maintains mild hypertriglyceridemia without rebound after single plasmapheresis and maintenance fibrate medication so far. Here, we report an infant with chylomicronemia due to GPIHBP1 mutation, successfully treated by plasmapheresis.

Correlation of Body Mass Index and Waist-Hip Ratio with Severity and Complications of Hyperlipidemic Acute Pancreatitis in Chinese Patients

Hyperlipidemic acute pancreatitis (HLAP) is characterized by critical condition and high recurrence rate compared with non-HLAP. We conducted this study to investigate the value of body mass index and waist-hip ratio in predicting severity and local complications in HLAP. 96 patients with HLAP were categorized by body mass index and waist-hip ratio, respectively. According to the body mass index, they were divided into 3 groups, including normal weight, overweight, and obesity. According to the waist-hip ratio, they were divided into central obesity group and no central obesity group. The body mass index and waist-hip ratio were compared in severity, local complications, and systematic complications of HLAP, using chi-square test and Monte Carlo simulations. The body mass index and waist-hip ratio were correlated with the severity of acute pancreatitis (MAP, MSAP, and SAP), respiratory failure, and circulatory failure in HLAP (p < 0.05), but not correlated with the local complications (walled-off necrosis, pancreatic abscess, and pancreatic pseudocyst), renal failure, and gastrointestinal bleeding.The body mass index and waist-hip ratio are valuable in predicting severity and complication in HLAP. We demonstrated that obese patients had an increased risk of developing more serious condition and more complications in HLAP.

Risk Factors of Hyperglycemia in Patients After a First Episode of Acute Pancreatitis: A Retrospective Cohort

OBJECTIVES

The aim of this study was to evaluate the risk factors for hyperglycemia development after a first episode of acute pancreatitis (AP).

METHODS

Three hundred and ten patients treated for AP were retrospectively evaluated. Hyperglycemia was determined by fasting blood glucose. All data were collected from the medical records room database and a follow-up telephone call.

RESULTS

The incidence rate of hyperglycemia was obviously increased 5 years after the event. Hazard ratios (HRs) of developing hyperglycemia in patients with hyperlipidemia, fatty liver, and hypertension were 2.52 (P < 0.001), 1.87 (P = 0.01), and 1.78 (P = 0.017), respectively. Patients of biliary origin that underwent endoscopic retrograde cholangiopancreatography presented a 4.62-fold greater risk than those managed conservatively. Other risk factors were random blood glucose greater than 8.33 mmol/L (HR, 4.19; P < 0.001), lactate dehydrogenase greater than 350 U/L (HR, 1.99; P = 0.017), calcium less than 1.75 mmol/L (HR, 3.86; P = 0.004), and elevated creatine kinase (HR, 2.74; P = 0.001). Patients with AB blood type showed 2.92-fold greater risk compared with those with O blood type. Among them, hyperlipidemia and hyperglycemia on admission were the only independent risk factors (both P < 0.05).

CONCLUSIONS

Hyperlipidemia, fatty liver, hypertension, endoscopic retrograde cholangiopancreatography treatment, acute hyperglycemia, elevated lactate dehydrogenase and creatine kinase, decreased calcium, and AB blood type were risk factors for hyperglycemia development after AP.

Development of a novel model of hypertriglyceridemic acute pancreatitis in mice

The morbidity rate of hypertriglyceridemic acute pancreatitis (HTG-AP) increased rapidly over the last decade. However an appropriate animal model was lacking to recapitulate this complicated human disease. We established a novel mice model of HTG-AP by poloxamer 407 (P-407) combined with caerulein (Cae). In our study, serum triglyceride levels of P-407 induced mice were elevated in a dose-dependent manner, and the pancreatic and pulmonary injuries were much severer in HTG mice than normal mice when injected with conventional dose Cae (50 ug/kg), what's more, the severity of AP was positively correlative with duration and extent of HTG. In addition, we found that a low dose Cae (5 ug/kg) could induce pancreatic injury in HTG mice while there was no obvious pathological injury in normal mice. Finally, we observed that HTG leaded to the increased infiltrations of macrophages and neutrophils in mice pancreatic tissues. In conclusion, we have developed a novel animal model of HTG-AP that can mimic physiological, histological, clinical features of human HTG-AP and it could promote the development of therapeutic strategies and advance the mechanism research on HTG-AP.

Antithrombin III and D-dimer levels as indicators of disease severity in patients with hyperlipidaemic or biliary acute pancreatitis

Objective To assess changes in anticoagulation and fibrinolytic systems between biliary and hyperlipidaemic acute pancreatitis (AP). Methods Patients with biliary or hyperlipidaemic AP were enrolled. Demographic and clinical data were collected, and antithrombin III (ATIII), protein C, protein S, and D-dimer levels were investigated. Results A total of 45 patients with biliary AP and 50 patients with hyperlipidaemic AP were included (68 with mild AP and 27 with moderately-severe AP). ATIII and protein C levels in the mild AP group were significantly higher, but prothrombin time and D-dimer were significantly lower, versus the moderately-severe AP group. ATIII and D-dimer were found to be risk factors for moderately-severe AP. ATIII could predict AP severity, particularly in patients with biliary AP. D-dimer was a sensitive and specific predictor for disease severity in patients with AP, particularly in patients with hyperlipidaemic AP. Conclusion ATIII and protein C levels decreased as severity of AP increased, particularly in cases of biliary AP. D-dimer levels increased with severity of AP, particularly in hyperlipidaemic AP. ATIII and D-dimer may be useful biomarkers for assessing AP severity in patients with biliary and hyperlipidaemic AP, respectively.

Diagnostic algorithm for familial chylomicronemia syndrome

BACKGROUND

Familial chylomicronemia syndrome (FCS) is a rare genetic disease that leads to severe hypertriglyceridemia often associated with recurrent episodes of pancreatitis. The recognition and correct diagnosis of the disease is challenging due to its rarity, and to the lack of specificity of signs and symptoms. Lipid experts, endocrinologists, gastroenterologists, pancreatologists, and general practitioners may encounter patients who potentially have FCS. Therefore, cooperation between experts and improved knowledge of FCS is essential in improving the diagnosis. Currently, a consensus on best practice for the diagnosis of FCS is lacking.

METHODS

Aiming to define a diagnostic algorithm for FCS, a board of European experts was instituted. Such an algorithm for FCS is important to guide practitioners in the diagnosis of suspected FCS and to optimize therapeutic strategies.

RESULTS

The multidisciplinary views were merged, leading to a diagnostic algorithm, proposed here.

CONCLUSION

This diagnostic algorithm represents a potentially useful tool to support primary and secondary care practitioners in the recognition of signs and clinical manifestations in individuals potentially affected by FCS.

Nonfasting Mild-to-Moderate Hypertriglyceridemia and Risk of Acute Pancreatitis

IMPORTANCE

Severe hypertriglyceridemia is associated with increased risk of acute pancreatitis. However, the threshold above which triglycerides are associated with acute pancreatitis is unclear.

OBJECTIVE

To test the hypothesis that nonfasting mild-to-moderate hypertriglyceridemia (177-885 mg/dL; 2-10 mmol/L) is also associated with acute pancreatitis.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study examines individuals from the Copenhagen General Population Study in 2003 to 2015 and the Copenhagen City Heart Study initiated in 1976 to 1978 with follow-up examinations in 1981 to1983, 1991 to 1994, and in 2001 to 2003. Median follow-up was 6.7 years (interquartile range, 4.0-9.4 years); and includes 116 550 individuals with a triglyceride measurement from the Copenhagen General Population Study (n = 98 649) and the Copenhagen City Heart Study (n = 17 901). All individuals were followed until the occurrence of an event, death, emigration, or end of follow-up (November 2014), whichever came first.

EXPOSURES

Plasma levels of nonfasting triglycerides.

MAIN OUTCOMES AND MEASURES

Hazard ratios (HRs) for acute pancreatitis (n = 434) and myocardial infarction (n = 3942).

RESULTS

Overall, 116 550 individuals were included in this study (median [interquartile range] age, 57 [47-66] years). Compared with individuals with plasma triglyceride levels less than 89 mg/dL (<1 mmol/L), the multivariable adjusted HRs for acute pancreatitis were 1.6 (95% CI, 1.0-2.6; 4.3 events/10 000 person-years) for individuals with triglyceride levels of 89 mg/dL to 176 mg/dL (1.00 mmol/L-1.99 mmol/L), 2.3 (95% CI, 1.3-4.0; 5.5 events/10 000 person-years) for 177 mg/dL to 265 mg/dL (2.00 mmol/L-2.99 mmol/L), 2.9 (95% CI, 1.4-5.9; 6.3 events/10 000 person-years) for 366 mg/dL to 353 mg/dL (3.00 mmol/L-3.99 mmol/L), 3.9 (95% CI, 1.5-10.0; 7.5 events/10 000 person-years) for 354 mg/dL-442 mg/dL (4.00 mmol/L-4.99 mmol/L), and 8.7 (95% CI, 3.7-20.0; 12 events/10 000 person-years) for individuals with triglyceride levels greater than or equal to 443 mg/dL (≥5.00 mmol/L) (trend, P = 6 × 10-8). Corresponding HRs for myocardial infarction were 1.6 (95% CI, 1.4-1.9; 41 events/10 000 person-years), 2.2 (95% CI, 1.9-2.7; 57 events/10 000 person-years), 3.2 (95% CI, 2.6-4.1; 72 events/10 000 person-years), 2.8 (95% CI, 2.0-3.9; 68 events/10 000 person-years), and 3.4 (95% CI, 2.4-4.7; 78 events/10 000 person-years) (trend, P = 6 × 10-31), respectively. The multivariable adjusted HR for acute pancreatitis was 1.17 (95% CI, 1.10-1.24) per 89 mg/dL (1 mmol/L) higher triglycerides. When stratified by sex, age, education, smoking, hypertension, statin use, study cohort, diabetes, body mass index (calculated as weight in kilograms divided by height in meters squared), alcohol intake, and gallstone disease, these results were similar with no statistical evidence of interaction.

CONCLUSIONS AND RELEVANCE

Nonfasting mild-to-moderate hypertriglyceridemia from 177 mg/dL (2 mmol/L) and above is associated with high risk of acute pancreatitis, with HR estimates higher than for myocardial infarction.

Comparison of BISAP, Ranson, MCTSI, and APACHE II in Predicting Severity and Prognoses of Hyperlipidemic Acute Pancreatitis in Chinese Patients

In recent years, with the developing of living standard, hyperlipidemia becomes the second major reason of acute pancreatitis. It is important to predict the severity and prognosis at early stage of hyperlipidemic acute pancreatitis (HLAP). We compared the BISAP, Ranson, MCTSI, and APACHE II scoring system in predicting MSAP and SAP, local complications, and mortality of HLAP. A total of 326 diagnosed hyperlipidemic acute pancreatitis patients from August 2006 to July 2015 were studied retrospectively. Our result showed that all four scoring systems can be used to predict the severity, local complications, and mortality of HLAP. Ranson did not have significant advantage in predicting severity and prognosis of HLAP compared to other three scoring systems. APACHE II was the best in predicting severity of HLAP, but it had shortcoming in predicting local complications. MCTSI had outstanding performance in predicting local complications, but it was poor in predicting severity and mortality. BISAP score had high accuracy in assessment of severity, local complications, and mortality of HLAP, but the accuracy still needs to be improved in the future.

Prospective, Multicentre, Nationwide Clinical Data from 600 Cases of Acute Pancreatitis

OBJECTIVE

The aim of this study was to analyse the clinical characteristics of acute pancreatitis (AP) in a prospectively collected, large, multicentre cohort and to validate the major recommendations in the IAP/APA evidence-based guidelines for the management of AP.

DESIGN

Eighty-six different clinical parameters were collected using an electronic clinical research form designed by the Hungarian Pancreatic Study Group.

PATIENTS

600 adult patients diagnosed with AP were prospectively enrolled from 17 Hungarian centres over a two-year period from 1 January 2013.

MAIN RESULTS

With respect to aetiology, biliary and alcoholic pancreatitis represented the two most common forms of AP. The prevalence of biliary AP was higher in women, whereas alcoholic AP was more common in men. Hyperlipidaemia was a risk factor for severity, lack of serum enzyme elevation posed a risk for severe AP, and lack of abdominal pain at admission demonstrated a risk for mortality. Abdominal tenderness developed in all the patients with severe AP, while lack of abdominal tenderness was a favourable sign for mortality. Importantly, lung injury at admission was associated with mortality. With regard to laboratory parameters, white blood cell count and CRP were the two most sensitive indicators for severe AP. The most common local complication was peripancreatic fluid, whereas the most common distant organ failure in severe AP was lung injury. Deviation from the recommendations in the IAP/APA evidence-based guidelines on fluid replacement, enteral nutrition and timing of interventions increased severity and mortality.

CONCLUSIONS

Analysis of a large, nationwide, prospective cohort of AP cases allowed for the identification of important determinants of severity and mortality. Evidence-based guidelines should be observed rigorously to improve outcomes in AP.

Acute pancreatitis associated with everolimus after kidney transplantation: a case report

Background

Acute pancreatitis (AP) following KT is a rare and often fatal complication of the early post-transplant period. Common causative factors for AP are rare after KT; anti-rejection drugs as CyA, prednisone and MMF have been implicated, although evidence is not strong and we found no reports on possible causative role for mTOR inhibitors.

Case presentation

A 55-year-old Caucasian man with end-stage renal disease due to idiopathic membrano-prolipherative glomerulonephritis underwent single kidney transplantation (KT) from cadaveric donor. Anti-rejection protocol was based on Basiliximab induction followed by prednisone and mycophenolate mophetil (MMF) and Cyclosporine; Everolimus (Eve) was scheduled to substitute MMF at week 3. At day 1 he had an asymptomatic elevation of pancreatic enzymes, spontaneously resolved. The further course was unremarkable and on day 19 he started Eve, with following asymptomatic rise in pancreatic enzymes. At day 33 the patient presented with abdominal pain and a marked elevation in serum amylase (1383 U/l) and lipase (1015 U/l), normal liver enzymes and bilirubin, no hypercalcemia, mild elevation in triglycerids; RT-PCRs for Cytomegalovirus or Epstein-Barr virus were negative. The patient had no history of alcohol abuse; ultrasound, CT and MRI found no evidence of biliary lithiasis. CT scans showed a patchy fluid collection in the pancreatic head area, consistent with idiopathic necrotizing pancreatitis. The patient was treated medically and Eve was withdrawn 1 week after. Patient underwent guided drainage of the fluid collection, but developed bacterial sepsis; surgical intervention was required with debridement of necrotic tissue, lavage and drainage; immunosuppression was totally withdrawn. Following course was complicated with multiple systemic infection. Transplantectomy for acute rejection was performed, and patient entered hemodialysis.

Conclusions

Our patient had a presentation that is consistent for a causative role of Eve. A predisposing condition (acute pancreatic insult during transplant surgery) spontaneously resolved, relapsed and evolved rapidly in AP after the initiation of treatment with Eve with a consistent time latency. None of the well-known common causative factors for AP was present. We discourage the use of Eve in patients with recent episodes of sub-clinical pancreatitis, since it may represent a precipitating factor or interfere with resolution.

Protective Effect of Pretreatment with Acenocoumarol in Cerulein-Induced Acute Pancreatitis

Coagulation is recognized as a key player in inflammatory and autoimmune diseases. The aim of the current research was to examine the effect of pretreatment with acenocoumarol on the development of acute pancreatitis (AP) evoked by cerulein. Methods: AP was induced in rats by cerulein administered intraperitoneally. Acenocoumarol (50, 100 or 150 µg/kg/dose/day) or saline were given once daily for seven days before AP induction. Results: In rats with AP, pretreatment with acenocoumarol administered at the dose of 50 or 100 µg/kg/dose/day improved pancreatic histology, reducing the degree of edema and inflammatory infiltration, and vacuolization of acinar cells. Moreover, pretreatment with acenocoumarol given at the dose of 50 or 100 µg/kg/dose/day reduced the AP-evoked increase in pancreatic weight, serum activity of amylase and lipase, and serum concentration of pro-inflammatory interleukin-1β, as well as ameliorated pancreatic DNA synthesis and pancreatic blood flow. In contrast, acenocoumarol given at the dose of 150 μg/kg/dose did not exhibit any protective effect against cerulein-induced pancreatitis. Conclusion: Low doses of acenocoumarol, given before induction of AP by cerulein, inhibit the development of that inflammation.

Relationship between Plasma Triglyceride Level and Severity of Hypertriglyceridemic Pancreatitis

Background

Hypertriglyceridemia is the third most common cause of acute pancreatitis, but whether the level of triglyceride (TG) is related to severity of pancreatitis is unclear.

Aim

To evaluate the effect of TG level on the severity of hypertriglyceridemic pancreatitis (HTGP).

Design

Retrospective cohort study.

Methods

We reviewed the records of 144 patients with HTGP from 1999 to 2013 at Tri-Service General Hospital. Patients with possible etiology of pancreatitis, such as gallstones, those consuming alcohol or drugs, or those with infections were excluded. The classification of severity of pancreatitis was based on the revised Atlanta classification. We allocated the patients into high-TG and low-TG groups based on the optimal cut-off value (2648 mg/dL), which was derived from the receiver operating characteristic (ROC) curve between TG level and severity of HTGP. We then compared the clinical characteristics, pancreatitis severity, and mortality rates of the groups.

Results

There were 66 patients in the low-TG group and 78 patients in the high-TG group. There was no significant difference in the age, sex ratio, body mass index, and comorbidity between the 2 groups. The high-TG group had significantly higher levels of glucose (P = 0.022), total cholesterol (P = 0.002), and blood urea nitrogen (P = 0.037), and lower levels of sodium (P = 0.003) and bicarbonate (P = 0.002) than the low-TG group. The incidences of local complication (P = 0.002) and severe and moderate form of pancreatitis (P = 0.004) were significantly higher in the high-TG group than in the low-TG group. The mortality rate was higher in the high-TG group than in the low-TG group (P = 0.07).

Conclusions

Higher TG level in patients with HTGP may be associated with adverse prognosis, but randomized and prospective studies are needed in the future verify this relationship.

Palmitic acid aggravates inflammation of pancreatic acinar cells by enhancing unfolded protein response induced CCAAT-enhancer-binding protein β-CCAAT-enhancer-binding protein α activation

Hypertriglyceridemia is an independent risk factor for acute pancreatitis, in which the pathological mechanisms are not fully illustrated. Intracellular inflammatory response is a key pathological response in acute pancreatitis and endoplasmic reticulum stress has been suggested to induce inflammation and CCAAT-enhancer-binding protein expression. Therefore, the current study aims to elucidate the possible relationship between endoplasmic reticulum stress and inflammation in hypertriglyceridemia associated pancreatitis and the possible involvement of CCAAT-enhancer-binding protein. In cholecystokinin-8 stimulated rat primary acinar cells, incubation with palmitic acid caused the activation of endoplasmic reticulum stress and inflammatory responses. Pre-incubation with the chemical chaperone 4-phenylbutyric acid inhibited inflammatory responses induced by palmitic acid, whereas stimulation with the endoplasmic reticulum stress inducer thapsigargin alone induced inflammatory responses. Meanwhile we found that the transcription factors CCAAT-enhancer-binding protein α and CCAAT-enhancer-binding protein β were also induced in the palmitic acid-stimulated pancreatic acinar cells, and were similarly inhibited by 4-phenylbutyric acid pre-incubation and induced by thapsigargin stimulation alone, indicating that endoplasmic reticulum stress was responsible for CCAAT-enhancer-binding protein α and CCAAT-enhancer-binding protein β induction in the pancreatic acinar cells. Knockdown of CCAAT-enhancer-binding protein β by siRNA transfection inhibited inflammatory responses and CCAAT-enhancer-binding protein α induction but did not affect endoplasmic reticulum stress. Our study provides strong evidence that in response to palmitic acid stimulation, endoplasmic reticulum stress induces inflammatory responses in pancreatic acinar cells through induction of the CCAAT-enhancer-binding protein family, wherein CCAAT-enhancer-binding protein β activation is responsible for CCAAT-enhancer-binding protein α activation.

Fasting and nonfasting triglycerides in cardiovascular and other diseases

Moderately elevated plasma/serum triglycerides (2-10 mmol/l) signalize increased risk for cardiovascular disease or presence of non-alcoholic steatohepatitis. Extremely elevated triglycerides (more than 10 mmol/l) signalize increased risk for pancreatitis and lipemia retinalis. The concentration of triglycerides is regulated by many genetic and nongenetic factors. Extremely elevated triglycerides not provoked by nutritional factors, especially inappropriate alcohol intake are more likely to have a monogenic cause. On the contrary, mildly to moderately elevated triglycerides are often caused by polygenic disorders; these could be also associated with central obesity, insulin resistance, and diabetes mellitus. Concentration of triglycerides is also closely interconnected with presence of atherogenic remnant lipoproteins, impaired reverse cholesterol transport and more atherogenic small LDL particles. In general, there is tight association between triglycerides and many other metabolic factors including intermediate products of lipoprotein metabolism which are frequently atherogenic. Therefore, reliable evaluation of the independent role of triglycerides especially in atherosclerosis and cardiovascular disease is difficult. In individual cases values of HDL cholesterol, non-HDL cholesterol (total minus HDL cholesterol), non-HDL/nonLDL cholesterol (total minus HDL minus LDL cholesterol, especially in nonfasting status), atherogenic index of plasma and/or apolipoprotein B could help in decisions regarding aggressiveness of treatment.

Management of acute pancreatitis in Japan: Analysis of nationwide epidemiological survey

Acute pancreatitis (AP) is an acute inflammatory disease of the exocrine pancreas. In Japan, nationwide epidemiological surveys have been conducted every 4 to 5 years by the Research Committee of Intractable Pancreatic Diseases, under the support of the Ministry of Health, Labour, and Welfare of Japan. We reviewed the results of the nationwide surveys focusing on the severity assessment and changes in the therapeutic strategy for walled-off necrosis. The severity assessment system currently used in Japan consists of 9 prognostic factors and the imaging grade on contrast-enhanced computed tomography. By univariate analysis, all of the 9 prognostic factors were associated with AP-related death. A multivariate analysis identified 4 out of the 9 prognostic factors (base excess or shock, renal failure, systemic inflammatory response syndrome criteria, and age) that were associated with AP-related death. Receiver-operating characteristics curve analysis showed that the area under the curve was 0.82 for these 4 prognostic factors and 0.84 for the 9 prognostic factors, suggesting the comparable utility of these 4 factors in the severity assessment. We also examined the temporal changes in treatment strategy for walled-off necrosis in Japan according to the 2003, 2007, and 2011 surveys. Step-up approaches and less-invasive endoscopic therapies were uncommon in 2003 and 2007, but became popular in 2011. Mortality has been decreasing in patients who require intervention for walled-off necrosis. In conclusion, the nationwide survey revealed the comparable utility of 4 prognostic factors in the severity assessment and the increased use of less-invasive, step-up approaches with improved clinical outcomes in the management of walled-off necrosis.

Therapeutic effects of quercetin on early inflammation in hypertriglyceridemia-related acute pancreatitis and its mechanism

OBJECTIVE

To investigate the therapeutic effects of quercetin on early-stage inflammation in hypertriglyceridemia (HTG)-related acute pancreatitis (AP) both in vivo and in vitro, and its possible mechanism.

METHODS

In vivo, rats were fed a high-fat diet to induce HTG, and AP was induced by intraperitoneal injection of cerulein (50 μg/kg × 2). Quercetin (100, 150 and 200 mg/kg) was administered by intraperitoneal injection after AP induction. In vitro, rat exocrine acinar cells were preincubated with palmitic acid (PA, 0.1 mmol/L, 6 h) with quercetin (5, 10, 20 and 40 μM) prior to a cholecystokinin analog CCK-8 (20pM). Injury of the pancreas was assessed by amylase secretion and pancreatic histological evaluation. Inflammation was estimated by measuring IL-1β, IL-6, TNFα and NF-kB expression. Dynamic expression of IRE1α, sXBP1, C/EBPα and C/EBPβ was monitored by real-time PCR, immunofluorescence (IF) and western blot (WB).

RESULTS

Quercetin intervention reduced plasma amylase level (P < 0.001) in a dose-dependent manner, attenuated pancreatic histopathological damage (P < 0.05), and reduced the mRNA and protein expression of NF-kB, IL-1β, IL-6, TNFα (P < 0.05) more significantly in HTG-related AP rats than in normal-lipid AP rats. Quercetin also down-regulated gene and protein expression levels of IRE1α, sXBP1, C/EBPα and C/EBPβ in a dose-dependent manner.

CONCLUSIONS

Quercetin attenuates early-stage inflammation in HTG-related AP, probably by reducing IRE1α, sXBP1, C/EBPα and C/EBPβ expression.

Chylomicrons: Advances in biology, pathology, laboratory testing, and therapeutics

The adequate absorption of lipids is essential for all mammalian species due to their inability to synthesize some essential fatty acids and fat-soluble vitamins. Chylomicrons (CMs) are large, triglyceride-rich lipoproteins that are produced in intestinal enterocytes in response to fat ingestion, which function to transport the ingested lipids to different tissues. In addition to the contribution of CMs to postprandial lipemia, their remnants, the degradation products following lipolysis by lipoprotein lipase, are linked to cardiovascular disease. In this review, we will focus on the structure-function and metabolism of CMs. Second, we will analyze the impact of gene defects reported to affect CM metabolism and, also, the role of CMs in other pathologies, such as atherothrombotic cardiovascular disease and diabetes mellitus. Third, we will provide an overview of the laboratory tests currently used to study CM disorders, and, finally, we will highlight current treatments in diseases affecting CMs.

Influence of Fatty Liver on the Severity and Clinical Outcome in Acute Pancreatitis

Acute pancreatitis (AP) is a common disease in the department of gastroenterology with variable severity, from being mild and self-limited to severe and fatal. The early diagnosis and accurate prediction of AP severity are of great importance. Our primary observation showed that fatty liver (FL) was frequently detected in patients with AP. In this retrospective study, we aimed to evaluate the relation between FL and the severity and outcomes of AP. The medical records of 2671 patients with AP were reviewed retrospectively, and characteristics of AP patients were recorded. FL was assessed by abdominal CT scan, and AP patients were categorized by the occurrence of FL for the analysis. The variation of mortality, clinical severity and the appearance of CT were analyzed between the non-FL group and FL groups. Compared with patients without FL, an obviously higher rate of death and higher frequency of severe AP (SAP) and necrotizing AP (ANP) were observed in patients with FL, as well as the incidence of local complications and systemic complications. Taking obesity into consideration, a higher rate of death and more severe AP were found in patients with FL, no matter whether they were obese or not. Alcoholic fatty liver (AFL) and non-alcoholic fatty liver (NAFL) were also separated for comparison in this study; the incidence of ANP and the clinical severity had no significant difference between the AFL and NAFL groups. In conclusion, FL could influence the severity and clinical outcome and may play a prognostic role in AP. This study is of clinical significance, because few reports have been previously issued on FL and AP.

Elevated serum triglycerides are independently associated with persistent organ failure in acute pancreatitis

OBJECTIVES

Hypertriglyceridemia (HTG) represents a major health problem with prevalence exceeding 30% in the U.S. The present study aims to assess the effect of elevated serum triglyceride (TG) levels on the severity of acute pancreatitis (AP).

METHODS

Prospectively enrolled AP patients were categorized into normal, mild, moderate, and severe/very severe categories based on their TG levels and compared in respect to demographics, comorbidities, and clinical outcomes. Multivariate analysis determined whether elevated TG levels were independently associated with persistent organ failure.

RESULTS

Two hundred and one out of 400 AP patients had serum TGs measured within 72 h of presentation, of which 115 had normal TG levels and 86 HTG (20 mild, 41 moderate, and 25 severe/very severe). Patients with HTG were of younger age (44 vs. 52 years), predominantly male (65% vs. 45%), obese (57% vs. 34%), diabetic (38% vs. 17%), and developed more frequently persistent organ failure (40% vs. 17%) compared with those with normal TGs (P<0.02). The rate of persistent organ failure increased proportionally with HTG severity grades (17% when normal TGs, 30% in mild, 39% in moderate, and 48% in severe/very severe HTG, Ptrend<0.001). On multivariate analysis controlling for age, gender, body mass index, diabetes, and alcohol etiology, moderate HTG (odds ratio (OR), 2.6; P=0.04) and severe/very severe HTG (OR, 4.9; P=0.009) were independently associated with persistent organ failure.

CONCLUSIONS

Elevated serum TGs in AP patients are independently and proportionally correlated with persistent organ failure regardless of etiology. TG-mediated lipotoxicity may be an attractive target to design novel interventions for severe AP.

Novel mutations in the GPIHBP1 gene identified in 2 patients with recurrent acute pancreatitis

BACKGROUND

Glycosylphosphatidylinositol-anchored high-density lipoprotein-binding protein 1 (GPIHBP1) has been demonstrated to be essential for the in vivo function of lipoprotein lipase (LPL), the major triglyceride (TG)-hydrolyzing enzyme involved in the intravascular lipolysis of TG-rich lipoproteins. Recently, loss-of-function mutations of GPIHBP1 have been reported as the cause of type I hyperlipoproteinemia in several patients.

METHODS

Two unrelated patients were referred to our Lipid Units because of a severe hypertriglyceridemia and recurrent pancreatitis. We measured LPL activity in postheparin plasma and serum ApoCII and sequenced LPL, APOC2, and GPIHBP1.

RESULTS

The 2 patients exhibited very low LPL activity not associated with mutations in LPL gene or with ApoCII deficiency. The sequence of GPIHBP1 revealed 2 novel point mutations. One patient (proband 1) was found to be homozygous for a C>A transversion in exon 3 resulting in the conversion of threonine to lysine at position 80 (p.Thr80Lys). The other patient (proband 2) was found to be homozygous for a G>T transversion in the third base of the ATG translation initiation codon in exon 1, resulting in the conversion of methionine to isoleucine (p.Met1Ile).

CONCLUSION

In conclusion, we have identified 2 novel GPIHBP1 missense mutations in 2 unrelated patients as the cause of their severe hypertriglyceridemia.

Distinctive roles of unsaturated and saturated fatty acids in hyperlipidemic pancreatitis

AIM: To investigate how the saturated and unsaturated fatty acid composition influences the susceptibility of developing acute pancreatitis.

METHODS: Primary pancreatic acinar cells were treated with low and high concentrations of different saturated and unsaturated fatty acids, and changes in the cytosolic Ca²⁺ signal and the expression of protein kinase C (PKC) were measured after treatment.

RESULTS: Unsaturated fatty acids at high concentrations, including oleic acid, linoleic acid, palmitoleic acid, docosahexaenoic acid, and arachidonic acid, induced a persistent rise in cytosolic Ca²⁺ concentrations in acinar cells. Unsaturated fatty acids at low concentrations and saturated fatty acids, including palmitic acid, stearic acid, and triglycerides, at low and high concentrations were unable to induce a rise in Ca²⁺ concentrations in acinar cells. Unsaturated fatty acids at high concentrations but not saturated fatty acids induced intra-acinar cell trypsin activation and cell damage and increased PKC expression.

CONCLUSION: At sufficiently high concentrations, unsaturated fatty acids were able to induce acinar cells injury and promote the development of pancreatitis. Unsaturated fatty acids may play a distinctive role in the pathogenesis of pancreatitis through the activation of PKC family members.

Clinical Study of 224 Patients with Hypertriglyceridemia Pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG) is the most common etiology of acute pancreatitis (AP) after alcohol and gallstone-induced disease. Elevation of serum triglyceride (TG) levels to ≥ 1000 mg/dl in a patient with AP strongly indicates HTG as the cause. The absolute risk of pancreatitis based on serum TG ≤ 1000 mg/dl has not been clearly defined. The aims of this study were to address the role of elevated TG levels between 500 and 1000 mg/dl in the clinical course of HTG pancreatitis (HTGP); and assess the relationship between the level of serum TG and disease severity.

METHODS

A total of 224 HTGP patients between 2007 and 2011 were divided into two subgroups. Totally, 122 patients in Group A had serum TG >1000 mg/dl; 102 patients in Group B had maximal TG levels between 500 and 1000 mg/dl accompanied by lactescent serum; 100 patients with biliary AP and 99 patients with alcoholic AP hospitalized during the study period were enrolled as controls. The clinical and biochemical data were analyzed.

RESULTS

The clinical presentation of HTG-induced pancreatitis was similar to other causes. Severe form of AP in Group A was higher than Group B (χ2 = 4.002, P = 0.045). The severity with HTGP was significantly higher as compared to biliary AP (χ2 = 33.533, P = 0.000) and alcoholic AP (χ2 = 7.179, P = 0.007). Systemic complications with HTGP were significantly higher than biliary AP (χ2 = 58.763, P = 0.000).

CONCLUSIONS

The study demonstrated that TG level ≥ 500 mg/dl should raise a high degree of suspicion, especially if no other etiology of AP is apparent. The severity of HTGP seems to correlate directly with TG level. HTGP seems be more severe than other causes of AP.

Double filtration plasmapheresis in the treatment of pancreatitis due to severe hypertriglyceridemia

BACKGROUND

Severe hypertriglyceridemia (HTG) leads to major complications such as acute pancreatitis. Lipoprotein apheresis has been proposed as a therapeutic tool for decreasing triglyceride levels, although experience is limited.

OBJECTIVE

To describe our experience with double filtration plasmapheresis (DFPP) in patients with severe HTG and pancreatitis in the plasmapheresis unit of a tertiary hospital in Spain.

METHODS

We recruited 4 patients with severe HTG (triglycerides [TGs] >1000 mg/dL) and acute pancreatitis. All the patients underwent DFPP as part of their treatment. Epidemiologic and laboratory data were collected before and after each plasmapheresis session.

RESULTS

The average TG level before plasmapheresis was 3136 mg/dL (35.44 mmol/L; range, 1306-6693 mg/dL, 14.76-75.63 mmol/L), and the average Acute Physiology And Chronic Health Evaluation (APACHE) II level before the first session was 6 (range, 3-8). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 2.1 (range, 1-3), and mean TG level after plasmapheresis was 428 mg/dL (4.84 mmol/L; range, 169-515 mg/dL; 1.91-5.82 mmol/L). After the first session, the mean decrease in TG levels was 69.16% (2169 mg/dL, range, 945-5925 mg/dL; 24.51 mmol/L, range, 10.78-66.95 mmol/L), and after the last session, TG levels fell by 89.09% (2794 mg/dL, range, 945-6198 mg/dL; 31.57 mmol/L, range, 10.68-70.04 mmol/L). None of the patients developed complications related to plasmapheresis.

CONCLUSIONS

According to available evidence and our own experience, DFPP can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.

Chylomicronaemia--current diagnosis and future therapies

This Review discusses new developments in understanding the basis of chylomicronaemia--a challenging metabolic disorder for which there is an unmet clinical need. Chylomicronaemia presents in two distinct primary forms. The first form is very rare monogenic early-onset chylomicronaemia, which presents in childhood or adolescence and is often caused by homozygous mutations in the gene encoding lipoprotein lipase (LPL), its cofactors apolipoprotein C-II or apolipoprotein A-V, the LPL chaperone lipase maturation factor 1 or glycosylphosphatidylinositol-anchored high density lipoprotein-binding protein 1. The second form, polygenic late-onset chylomicronaemia, which is caused by an accumulation of several genetic variants, can be exacerbated by secondary factors, such as poor diet, obesity, alcohol intake and uncontrolled type 1 or type 2 diabetes mellitus, and is more common than early-onset chylomicronaemia. Both forms of chylomicronaemia are associated with an increased risk of life-threatening pancreatitis; the polygenic form might also be associated with an increased risk of cardiovascular disease. Treatment of chylomicronaemia focuses on restriction of dietary fat and control of secondary factors, as available pharmacological therapies are only minimally effective. Emerging therapies that might prove more effective than existing agents include LPL gene therapy, inhibition of microsomal triglyceride transfer protein and diacylglycerol O-acyltransferase 1, and interference with the production and secretion of apoC-III and angiopoietin-like protein 3.

Hypertriglyceridemia induced pancreatitis (chylomicronemia syndrome) treated with supportive care

Hypertriglyceridemia is a rare cause of pancreatitis. In treatment pancreatic rest, lifestyle changes, medications (fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid) are essential. Many experimental treatment modalities have been reported as insulin and heparin infusion and plasmapheresis. In this study we present the hypertriglyceridemia-induced pancreatitis treated with supportive care.