Plasmapheresis as treatment for hyperlipidemic pancreatitis

Comparative analysis of therapeutic plasma exchange vs. standard management in hypertriglyceridemia-induced acute pancreatitis: triglyceride reduction and clinical outcomes

BACKGROUND AND AIM

The use of therapeutic plasma exchange (TPE) for treatment of hypertriglyceridemia-induced acute pancreatitis (HTGP) remains controversial in the literature. This study compared the clinical outcomes of TPE versus conventional therapy in patients with HTGP.

METHODS

Fifty-five patients with HTGP were included. Patients were retrospectively compared in pairs: those who received TPE treatment and those who did not, those whose triglyceride level fell below 500 mg/dL within 48 h, and those who did not, those with and without persistent organ failure. The primary outcome was the percentage of triglyceride reduction within 48 h. Secondary outcomes were the length of hospital stay, mortality, cost-effectiveness, and persistent organ failure.

RESULTS

Percentage decrease in triglyceride levels, medical hospitalization costs, and length of hospital stay were higher in the TPE group compared to the non-TPE group (p < 0.05, for each). However, there was no difference regarding persistent organ failure and mortality (p > 0.05, for each). The length of hospital stay, average cost, persistent organ failure, and mortality were similar in both groups whose triglyceride level fell below 500 mg/dL within 48 h and those who did not (p > 0.05, for each). Among patients with persistent organ failure, average cost was higher in the TPE group compared to the non-TPE group (p < 0.05). An independent relation was found between the average cost and persistent organ failure, TPE, length of hospital stay, albumin, and urea values in all patients (p < 0.05, for each).

CONCLUSIONS

The approach of using TPE for treatment of HTGP was not found to be superior to the conventional treatment. Randomized controlled studies with larger number of patients are needed to gain better understanding of this issue.

Therapeutic plasma exchange decreases serum triglyceride level rapidly and reduces early recurrence rate but no advantages in improving outcomes for patients with hyperlipidemic acute pancreatitis: a retrospective propensity score matching analysis based on twenty year's experience

BACKGROUND

Hyperlipidaemic acute pancreatitis (HLAP) has become the most common cause of acute pancreatitis (AP) not due to gallstones or alcohol (Mosztbacher et al, Pancreatology 20:608-616, 2020; Yin et al, Pancreas 46:504-509, 2017). Therapeutic plasma exchange (TPE) has been reported to be effective in reducing serum TG levels which is important in management of HLAP (World J Clin Cases 9:5794-803, 2021). However, studies on TPE are mostly focusing on cases reports, TPE remains poorly evaluated till date and need to be compared with conservative therapy with a well-designed study.

METHODS

A retrospectively cohort study on HLAP patients between January 2003 and July 2023 was conducted. Factors correlated with efficacy of TPE were included in a propensity model to balance the confounding factors and minimize selection bias. Patients with and without TPE were matched 1:2 based on the propensity score to generate the compared groups. Lipid profiles were detected on admission and consecutive 7 days. The triglyceride (TG) level decline rates, percentage of patients to reach the target TG levels, early recurrence rate, local complications and mortality were compared between groups.

RESULTS

A total of 504 HLAP patients were identified. Since TPE was scarcely performed on patients with TG < 11.3 mmol/L, 152 patients with TG level 5.65 to 11.3 mmol/L were excluded while 352 with TG ≧11.3 mmol/L were enrolled. After excluding 25 cases with incomplete data or pregnancy, 327 patients, of whom 109 treated without TPE while 218 treated with TPE, were included in data analysis. One-to-two propensity-score matching generated 78 pairs, 194 patients with well-balanced baseline characteristics. Of 194 patients enrolled after matching done, 78 were treated without while 116 with TPE. In the matched cohort (n = 194), patients treated with TPE had a higher TG decline rate in 48 h than those without TPE (70.00% vs 54.00%, P = 0.001); the early recurrence rates were 8.96% vs 1.83%, p = 0.055. If only SAP patients were analyzed, the early recurrence rates were 14.81% vs 0.00% (p = 0.026) respectively. For patients with CT severity index (CTSI) rechecked within 14 days, early CTSI improment rate were 40.90% vs 31.91%. Local complications checked 6 months after discharge were 44.12% vs 38.30%. Mortality was 1.28% vs 1.72%. No differences were found in early stage CTSI improment rate (P = .589), local complications (P = .451) or motality between two groups.

CONCLUSIONS

TPE reduces TG levels more quickly in 48 h compared with those with conservative treatment, but no difference in the consecutive days. TPE tends to reduce the early recurrence rate comparing with conventional therapy, but TPE has no advantages in improving CTSI in early stage, and no improvement for outcomes including local complications and mortalty.

Plasmapheresis in the ICU

Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient's plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. This paper provides a brief review of the principles, current applications, and potential future directions of TPE in critical care settings.

Evaluating the efficacy and timing of blood purification modalities in early-stage hyperlipidemic acute pancreatitis treatment

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is characterized by a violent cytokine storm-driven inflammation and is associated with a predisposition to severe disease. The treatment strategy for HTG-AP consists mainly of conventional symptomatic and lipid-lowering treatments. For early-stage HTG-AP, blood purification (BP) can rapidly and effectively reduce serum triglyceride and inflammatory cytokine levels, block the development of systemic inflammatory response syndrome, and improve patient outcomes. Currently, the primary modalities for BP in patients with HTG-AP include plasma exchange, hemoperfusion, and hemofiltration. When using BP to treat patients with HTG-AP, a comprehensive analysis incorporating the elevated lipid levels and severity of the patient's condition contributes to the selection of different treatment modes. Moreover, the timing of the treatment is also imperative. Early intervention is associated with a better prognosis for patients with HTG-AP requiring lipid-lowering treatment.

Early Plasmapheresis Among Patients With Hypertriglyceridemia-Associated Acute Pancreatitis

Importance

The incidence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is increasing. Plasmapheresis is theoretically effective in removing triglyceride from plasma, but whether it confers clinical benefits is unclear.

Objective

To assess the association between plasmapheresis and the incidence and duration of organ failure among patients with HTG-AP.

Design, Setting, and Participants

This is an a priori analysis of data from a multicenter, prospective cohort study with patients enrolled from 28 sites across China. Patients with HTG-AP were admitted within 72 hours from the disease onset. The first patient was enrolled on November 7th, 2020, and the last on November 30th, 2021. The follow-up of the 300th patient was completed on January 30th, 2022. Data were analyzed from April to May 2022.

Exposures

Receiving plasmapheresis. The choice of triglyceride-lowering therapies was at the discretion of the treating physicians.

Main Outcomes and Measures

The primary outcome was organ failure-free days to 14 days of enrollment. Secondary outcomes included other measures for organ failure, intensive care unit (ICU) admission, duration of ICU and hospital stays, incidence of infected pancreatic necrosis, and 60-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses were used to control potential confounders.

Results

Overall, 267 patients with HTG-AP were enrolled (185 [69.3%] were male; median [IQR] age, 37 [31-43] years), among whom 211 underwent conventional medical treatment and 56 underwent plasmapheresis. PSM created 47 pairs of patients with balanced baseline characteristics. In the matched cohort, no difference was detected concerning organ failure-free days between patients undergoing plasmapheresis or not (median [IQR], 12.0 [8.0-14.0] vs 13.0 [8.0-14.0]; P = .94). Moreover, more patients in the plasmapheresis group required ICU admission (44 [93.6%] vs 24 [51.1%]; P < .001). The IPTW results conformed to the results from the PSM analysis.

Conclusions and Relevance

In this large multicenter cohort study of patients with HTG-AP, plasmapheresis was commonly used to lower plasma triglyceride. However, after adjusting for confounders, plasmapheresis was not associated with the incidence and duration of organ failure, but with increased ICU requirements.

Plasmapheresis compared with conventional treatment for hypertriglyceridemia-induced acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

The treatment of acute pancreatitis (AP) induced by hypertriglyceridemia (HTG) remains controversial with regard to plasmapheresis vs conventional treatment. We reviewed relevant articles to explore the efficacy of plasmapheresis in the management of HTG-induced AP.

METHODS

We systematically reviewed studies that compared plasmapheresis with conventional treatment for HTG-induced AP using three databases: PubMed, Embase, and Cochrane Library, as well as relevant references. The primary outcomes were 24 h triglyceride reduction rate and in-hospital mortality.

RESULTS

A total of 791 articles were retrieved. Finally, 15 observational studies (1080 participants) were included, most of which were historical cohort studies. Compared with conventional treatment, plasmapheresis assisted in the reduction of serum triglyceride (TG) levels in the first 24 h after hospital admission (standardized mean difference [SMD]: 0.58; 95% confidence interval [CI]: 0.17 to 0.99; P = 0.005). However, it resulted in increased hospitalization costs (thousand yuan) (weighted mean difference [WMD]: 24.32; 95% CI: 12.96 to 35.68; P < 0.001). With regard to in-hospital mortality, although the mortality rate in the plasmapheresis group was higher than that in the conventional treatment group (relative risk [RR]: 1.74; 95% CI: 1.03 to 2.94; P = 0.038), the result was disturbed by confounding factors as per the subgroup and sensitivity analysis, as well as trial sequential analysis (TSA). No significant differences were found in other outcomes, including systematic complications, local complications, the requirement for surgery, and hospitalization duration.

CONCLUSION

The effect of plasmapheresis in HTG-induced AP is not superior to that of conventional treatment, even resulting in a greater economic burden to patients and health care system. High quality randomized control trials are required to obtain a more a definitive understanding of this issue.

Guidelines for the management of patients with severe acute pancreatitis, 2021

OBJECTIVE

To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.

DESIGN

A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.

CONCLUSIONS

There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.

Continuous insulin therapy versus apheresis in patients with hypertriglyceridemia-associated pancreatitis

BACKGROUND

The optimal treatment modality for lowering the triglyceride level in patients with hypertriglyceridemia (HTG)-associated acute pancreatitis is unknown. We evaluated the efficacy of continuous insulin infusion and apheresis procedures as triglyceride-lowering therapy.

MATERIALS AND METHODS

Clinical, demographic, and laboratory data were retrospectively evaluated for patients with HTG-associated pancreatitis who received continuous insulin infusion or apheresis in a single tertiary center. The endpoints were modality effectiveness and clinical outcomes.

RESULTS

The study included 48 patients (mean age, 40.4 ± 9.9 years). Apheresis and insulin infusion were performed in 19 and 29 patients, respectively, in the first 24 h of hospital admission. Apheresis procedures included therapeutic plasma exchange in 10 patients and double filtration plasmapheresis in nine patients. Baseline mean triglyceride level was higher in the apheresis group. The two groups were similar in terms of other baseline clinical and demographic characteristics. Seventeen patients (58.6%) in the insulin group and nine patients (47.4%) in the apheresis group exhibited Balthazar grades D-E. There was a rapid reduction (78.5%) in triglyceride level after the first session of apheresis. Insulin infusion resulted in a 44.4% reduction in mean triglyceride level in the first 24 h. The durations of fasting and hospital stay, and the rates of respiratory failure and hypotension, were similar between groups. More patients in the apheresis group experienced acute renal failure or altered mental status. Prognosis did not significantly differ between groups.

CONCLUSION

Although apheresis treatments are safe and effective, they provided no clear benefit over insulin infusion for HTG-associated pancreatitis.

Rapid reduction in triglyceride levels by therapeutic plasma exchange in patients with hypertriglyceridemic pancreatitis

Objective

To investigate the effect of therapeutic plasma exchange (TPE) on lowering triglyceride (TG) levels in patients with hypertriglyceridemic pancreatitis (HLAP).

Methods

The TG‐lowering in patients with HLAP was compared between the TPE group and conservative treatment group (non‐TPE). The primary outcome was TG reduction to less than 500 mg/dL within 48 hours.

Results

The primary outcome was significantly correlated with TPE (univariate analysis odds ratio [OR] 2.74; 95% confidence interval [CI] 1.30‐5.79, P = .008; multivariate analysis OR 3.03; 95% CI 1.28‐7.19, P = .012). At 24 and 48 hours, conservative treatment resulted in a 48.24% and 70.44% reduction in TG, while TPE resulted in a 70.91% and 76.39% reduction in TG, respectively. A more rapid decrease of in TGs in a short period was clearly associated with TPE (P < .001 for interaction). After 72 hours, the TGs decreased by approximately 77% in both groups, with no significant difference (P = .563). There was no difference between groups in clinical outcomes over the acute time period or over the longer term.

Conclusions

In patients with HLAP, TPE resulted in a short‐term and rapid reduction in plasma TG concentrations, with no significant advantage over non‐TPE after 72 hours.

Clinical analysis of the therapeutic effect of plasma exchange on hypertriglyceridemic acute pancreatitis: A retrospective study

BACKGROUND

The therapeutic effect of plasma exchange (PE) on hypertriglyceridemic acute pancreatitis (HTGAP) is unclear. Therefore, we aimed to explore this therapeutic effect.

STUDY DESIGN AND METHODS

This study included 204 patients with HTGAP who underwent treatment at two provincial tertiary grade A hospitals in Fujian Province from October 2012 to May 2021. Patients were divided into a conventional group and a PE group. The Student's t-test and chi-square test were used for data analysis.

RESULTS

Among 204 patients, 56 and 148 were included in the PE and conventional groups, respectively. After propensity score matching (PSM), the PE and conventional groups each had 42 patients. There was no significant difference in age; sex; pregnancy; comorbidities; laboratory findings; incidences of complications, and multiple organ dysfunction syndrome (MODS); organ support treatment; surgical rate; mortality; and hospital stay between the groups (p > 0.05). The total expenses were significantly higher in the PE group than in the conventional group (p < 0.05). There was no statistically significant difference in the times of PE; total volume of PE; incidences of complications, and MODS; organ support treatment; surgical rate; mortality; and hospital stay between the early PE and delayed PE groups (p > 0.05). All patients in the PE group and conventional group with acute renal failure had significantly higher D-dimer levels than those without acute renal failure (p < 0.05).

DISCUSSION

Compared with conventional treatment, PE does not have a better therapeutic effect on HTGAP. The D-dimer level can predict whether patients with HTGAP will have acute renal failure.

Clinical review on triglycerides

Hypertriglyceridaemia is a common clinical problem. Epidemiologic and genetic studies have established that triglyceride-rich lipoproteins (TRL) and their remnants as important contributors to ASCVD while severe hypertriglyceridaemia raises risk of pancreatitis. While low-density lipoprotein is the primary treatment target for lipid lowering therapy, secondary targets that reflect the contribution of TRL such as apoB and non-HDL-C are recommended in the current guidelines. Reduction of severely elevated triglycerides is important to avert or reduce the risk of pancreatitis. Here we discuss interventions for hypertriglyceridaemia, including diet and lifestyle, established treatments such as fibrates and omega-3 fatty acid preparations and emerging therapies, including various biological agents.

Treatment of chylomicronemia

Fasting chylomicronaemia appears in type V (multifactorial chylomicronaemia syndrome, MCS), and in type I (familial chylomicronaemia syndrome, FCS). MCS needs to be treated as in any general hypertriglyceridaemia: low-calorie diet, avoid sugar and alcohol, reduce body weight, control of diabetes and, in some cases, common lipid lowering-drugs, such as fibrates or omega-3 fatty acids. For type I HLP, FCS, patients should adhere to a strict very low fat diet, usually less than 15-20 g per day. In spite of this, many patients with FCS suffer from recurrent abdominal pain and/or acute pancreatitis. Volanesorsen, an antisense oligonucleotide against apolipoprotein C-III, is the only drug approved to control the disease. As shown in the APPROACH study, the administration of volanesorsen at a weekly dose of 285 mg induced at three month a reduction of triglycerides of 77% (primary end-point) and a reduction of 1712 mg/dL from the baseline. Among patient receiving volanesorsen, 77% reached a fasting triglyceride value below 750 mg/dL. The most frequent side effects were a skin reaction at injection site and low platelet levels, which should be monitored.

Study on the Mechanism of Probucol Nanosuspension on Hyperlipidemic Pancreatitis and Regulation of Blood Lipid Function

High-fat pancreatitis and hyperlipidemia refer to disorders of blood lipid metabolism caused by abnormally elevated blood lipids, and are risk factors for high-risk diseases such as atherosclerosis, coronary heart disease, and cerebral infarction. Hyperlipidemia is also a common disease that is common in modern people, and has a tendency to become younger. In this paper, probucol is made into a self-assembled probucol loaded nanosuspensions (SPN) using molecular selfassembly technology for research on improving its oral absorption. The main research contents include: preparation, prescription screening and characterization of physicochemical properties of SPN nanosuspensions; study of SPN intestinal cell uptake and in vivo dynamic behavior; research on the mechanism of SPN improving oral absorption of probucol and its gastrointestinal Preliminary Evaluation of Physiological Safety. And by using the method of intraperitoneal injection of SPN to interfere with the retrograde bile duct injection of SPN in the hyperlipidemia model, to make hyperlipidemia combined with severe acute pancreatitis to observe the severity of pancreatitis and lung injury; discuss the protective effect of SPN on hyperlipidemia combined with severe acute pancreatitis with lung injury and its mechanism.

Retrospective analysis of outcomes in patients with acute hypertriglyceridemic pancreatitis treated without therapeutic plasma exchange

BACKGROUND

Therapeutic plasma exchange (TPE) is often used to decrease serum triglyceride levels in hypertriglyceridemic pancreatitis (HTGP), although there is a lack of high-quality data directly attributing improved clinical outcomes to TPE. There are currently no large studies evaluating the treatment of HTGP without TPE.

STUDY DESIGN AND METHODS

This study retrospectively analyzes clinical and laboratory outcomes of 115 encounters at Massachusetts General Hospital (MGH) wherein a HTGP patient was treated without TPE and compares these outcomes to those of HTGP patients in the literature treated with TPE.

RESULTS

After management without TPE, the median reduction in serum triglycerides was 48% (IQR 29%-63%) on day one and 74% (IQR 60%-84%) on day two in 115 episodes of acute HTGP. The reductions were comparable to those reported in several large published case series after a course of TPE (65.8% to 81% reduction). In 25 episodes among 24 patients, treatment included admission to an intensive care unit. There was no significant difference in mortality or rates of local complication, mechanical ventilation, or use of vasoactive medication or renal replacement therapy between this ICU subset and published cohorts (all P > .05).

CONCLUSIONS

HTGP patients who do not receive TPE do not experience inferior outcomes compared to patients in the literature treated with TPE. The added value of TPE in HTGP, if any exists, needs to be demonstrated in controlled trials.

Plasmapheresis in Hypertriglyceride-induced Pancreatitis: A Series of Four Cases

Hypertriglyceride-induced Acute Pancreatitis is a devasting condition. The rapid reduction of serum triglyceride is a key factor in its management. Beside the reduction in Triglyceride level plasmapheresis has other added advantage. Early initiation of plasmapheresis within 48 hrs has a better outcome. Plasmapheresis should be performed until triglyceride levels have been lowered to 500mg/dl. Here, we present a series of four cases of hypertriglyceride induced pancreatitis who underwent plasmapheresis. All the patients were diabetics. All cases showed the rapid reduction of triglyceride levels after plasmapheresis. Three patients were discharge from hospital, where as one patient died due to Sepsis. Out of four patients only one required Renal Replacement therapy.

Effect of type 2 diabetes mellitus on efficacy and safety of therapeutic apheresis for severe hypertriglyceridemia

The efficacy and safety of triglyceride (TG) apheresis in patients with type 2 diabetes mellitus (DM) is unclear. Diabetic complications may predispose patients to adverse events (AEs) associated with the apheresis procedure, and diabetic dyslipidemia may negatively affect the efficacy of therapeutic apheresis (TA). We investigated the effect of DM on the efficacy and complications of TA. Patients with severe hypertriglyceridemia who underwent apheresis for treatment or for the prevention of acute pancreatitis were included in this retrospective study. Epidemiological data, lipid parameters, and AEs were recorded before and after each therapeutic session. A total of 166 procedures were performed in 27 patients. Group 1 included 17 patients with type 2 DM, and Group 2 included 10 patients without DM. The mean percentage decrease in TG levels (TG%) was higher in Group 1 (71.9% vs 60.6%, P < .001). The TG% was negatively correlated with the duration of DM in Group 1 (r = -.49, P < .001). The total number of TA sessions was 142 in patients who underwent double filtration plasmapheresis and 24 in patients who underwent therapeutic plasma exchange. We observed 9 (5.4%) mild-to-moderate AEs. No intergroup difference was observed in the total number of AEs (P = .06). TA is safe and effective in patients with type 2 DM with severe hypertriglyceridemia.

Severe hyperlipemia-induced pseudoerythrocytosis - Implication for misdiagnosis and blood transfusion: A case report and literature review

BACKGROUND

Severe hyperlipemia (SHLE) has an impact on the results of many kinds of laboratory tests. Complete blood count (CBC) examination by automated blood cell counter (ABCC) is a quick and convenient measurement for screening abnormalities of blood cells that are triggered by various pathogenic insults in disease diagnosis and for monitoring changes in the treatment of existing hematological conditions. However, CBC results are frequently affected by many intrinsic and extrinsic factors from blood samples, such as in the setting of hypergammaglobulinemia and certain anticoagulants. SHLE could also affect CBC results.

CASE SUMMARY

A 33-year-old Chinese male presented with painful foot numbness and abdominal pain. He was initially misdiagnosed as having a myeloproliferative neoplasm (MPN) because of the marked abnormalities in CBC examination by the ABCC. Morphological evaluation of the bone marrow smears and biopsy showed no evidence of MPN. Gene mutations in Breakpoint cluster regions-Abelson murine leukemia viral oncogene homologue 1 (BCR-ABL1), Janus kinase 2 (JAK2), calreticulin (CALR), myeloproliferative leukemia virus (MPL), and colony-stimulating factor 3 receptor (CSF3R) were negative. Having noticed the thick chylomicron layer on blood samples and the dramatically fluctuating CBC results, we speculated that the fat droplets formed by shaking the blood samples in the setting of SHLE were mistakenly identified as blood cells due to the limited parameters of ABCC. Therefore, we removed a large part of the chylomicron layer and then reexamined the CBC, and the CBC results, as we expected, differed significantly from that of the sample before the chylomicron layer was removed. These significant differences had been validated by the subsequently repeated laboratory tests by measuring dual blood samples that the chylomicron layer was removed in one sample and was not in another, and comparing the CBC results. Computerized tomography reexamination of the upper abdomen revealed an exudative lesion surrounding his pancreas. After intensive consultation, definitive diagnosis was made as recurrent pancreatitis, hyperlipemia and pseudoerythrocytosis.

CONCLUSION

SHLE may become a potential cause of misdiagnosis of hyperlipemia-related diseases as MPNs and the resultant mistreatment. It may also lead to the misinterpretation of transfusion indications in patients with hematological disorders who critically need blood transfusion for supportive treatment.

Anti-lipid therapy and risk factor management for triglyceridaemia-induced acute pancreatitis

BACKGROUND

Pancreatitis secondary to hypertriglyceridaemia is rare, accounting for less than 5% of pancreatitis presentations. We reviewed our institutional experience with triglyceridaemia induced acute pancreatitis to report the clinical presentation, patient demographics and clinical management.

METHODS

The Acute Surgical Unit database at a high-volume general surgical referral centre was queried to identify cases of acute pancreatitis secondary to hypertriglyceridaemia between 2016 and 2019. Patient demographics, clinical manifestations, biochemical derangements and treatment regimens were analysed. Current related literature was reviewed.

RESULTS

There were 496 presentations for acute pancreatitis of which 14 presentations (2.8%), amongst 12 patients were due to hypertriglyceridaemia. The mean triglyceride level at presentation was 92.46 (standard deviation 46.9) mmol/L. Ten patients (83%) had poorly controlled type 2 diabetes. All patients were managed using conservative therapy combined with a restricted fat diet and commenced on long-term anti-lipid therapy to manage associated risk factors. In addition, 10 patients received an insulin infusion and one patient received insulin infusion, plasmapheresis and heparin infusion in combination. The median length of hospital stay was 5.5 (range 3-13) days. Two patients (16%) developed a recurrent episode related to non-compliance to medical therapy.

CONCLUSION

Hypertriglyceridaemia is a rare cause of acute pancreatitis. Successful management involves the treatment of acute pancreatitis in conjunction with long-term anti-lipid therapy and optimisation of associated risk factors.

Effects of different triglyceride-lowering therapies in patients with hypertriglyceridemia-induced acute pancreatitis

The aim of the present study was to investigate the effects of various triglyceride (TG)-lowering therapies on hypertriglyceridemia-induced acute pancreatitis (HTGAP). A total of 132 patients with HTGAP were retrospectively divided into an insulin intensive therapy (IIT), a plasma exchange (PE) and a non-intensive insulin therapy (NIIT) group according to the TG-lowering therapies they had received. The clinical and biochemical data of the subjects were analyzed. The baseline data, including sex, age, TG, amylase, severe acute pancreatitis and systemic inflammatory response syndrome were not significantly different among the three groups (P>0.05). The 24-h TG clearance rate (χ²=7.74, P=0.021), onset to treatment time (χ²=14.50, P<0.001) and the time required to reach the target TG level (χ²=6.12, P=0.047) were different in these three groups, but no significant differences were observed between the IIT and NIIT groups (P>0.05). The incidence of therapy-associated complications in the PE group (30.23%) was higher than that in the IIT (2.17%) and NIIT (4.65%) groups. The difference in the incidence of therapy-associated complications was significant among the three groups (P<0.001), but no significant difference was present between the IIT and NIIT groups (P>0.05). In the PE group, the length of stay was increased compared with that in the IIT and NIIT groups (χ²=7.05, P<0.05), while there was no significant difference between the IIT and NIIT groups (P>0.05). The present study suggested that NIIT at presentation had a similar therapeutic efficacy to that of IIT to improve the prognosis of HTGAP, and NIIT and IIT were associated with fewer complications than PE treatment. NIIT may favorably perform in patients presenting early after symptom onset and may be considered for clinical application.

Saikosaponin a attenuates hyperlipidemic pancreatitis in rats via the PPAR-γ/NF-κB signaling pathway

The therapeutic effect of saikosaponin a (SSa) on hyperlipidemic pancreatitis (HP) is not completely understood. The aim of the present study was to investigate the therapeutic effect and the underlying mechanism of SSa using a rat model of HP. Following successful establishment of the HP rat model, different doses of SSa (low dose group, 10 mg/kg or high dose group, 20 mg/kg) were administrated. Histopathological examination, the wet/dry (W/D) ratio and myeloperoxidase (MPO) activity of the pancreatic tissues were assessed. The lipid, amylase (AMY), lipase and proinflammatory cytokine profiles in serum, as well as the expression of peroxisome proliferator-activated receptor (PPAR)-γ and the NF-κB signaling pathway-related proteins in pancreatic tissues were evaluated. The results showed that SSa effectively attenuated pancreatic pathological injury and reduced both the W/D ratio and MPO activity compared to the HP model rats. SSa also improved lipid metabolism by significantly decreasing the serum levels of total cholesterol and triglycerides (P<0.05). Following the administration of SSa, the activity of AMY and lipase, as well as the levels of the proinflammatory cytokines tumor necrosis factor-α, interleukin (IL)-1β and IL-6 were reduced, particularly in the high dosage group (P<0.05). Furthermore, SSa activated PPAR-γ expression and suppressed the NF-κB signaling pathway in pancreatic tissues. The present study suggested that SSa attenuated HP in rats by increasing lipid metabolism and inhibiting the release of proinflammatory cytokines via the NF-κB inflammatory pathway. The results from the present study indicated that SSa might be a promising therapeutic agent for the treatment of HP.

Predictability and efficacy of therapeutic plasma exchange for hypertriglyceridemia induced acute pancreatitis

BACKGROUND

Hypertriglyceridemia induced acute pancreatitis is associated with more severe clinical course than acute pancreatitis caused by other etiologies. Therapeutic plasma exchange (TPE) is a potential treatment for patients with severe hypertriglyceridemia induced acute pancreatitis due to its rapid effect in lowering triglycerides (TG) levels and reducing inflammatory cytokines. However, clinical data regarding the effectiveness and safety of TPE is limited.

METHODS

We retrospectively reviewed eight cases of hypertriglyceridemia induced acute pancreatitis and treated with TPE. Patients' demographic data, personal history, clinical course, laboratory results, apheresis data and clinical outcome were collected and analyzed.

RESULTS

At initial presentation, the average TG levels for the eight patients was 3381.6 mg/dl (SD: 1491.6 mg/dl). Twelve procedures were performed on the eight patients in the study, and TG levels decreased by an average of 2673.2 mg/dl (SD: 2306.3 mg/dl) with a corresponding average reduction rate of 60.3 % (SD:21.1 %), ranging from 14.6%-84.9%. A 60 % or greater reduction was achieved in 66.7 % of all the procedures; however, the degree of reduction for each procedure was not predictable, even among repeat procedures on the same patient.

CONCLUSIONS

Our study indicates that TPE is an effective and safe treatment option for patients with hypertriglyceridemia induced acute pancreatitis. However, due to the unpredictability of TG removal, repeat procedures may be necessary for some patients.

Conservative management in hypertriglyceridemia-associated pancreatitis

BACKGROUND

Severe hypertriglyceridemia (serum triglyceride >10 mmol L^-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis.

OBJECTIVE

We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach.

METHODS

A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia.

RESULTS

Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L^-1 on presentation to 13.3 mmol L^-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups.

CONCLUSION

Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.

The role of plasma exchange in hypertriglyceridemia-induced acute pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG)-induced acute pancreatitis (AP) leads to higher morbidity and mortality compared with other etiologies. The role of plasma exchange (PE) in this context is still not well established. We aimed to assess the clinical outcomes of patients with HTG-induced AP who underwent PE and compare it with those who did not.

PATIENTS AND METHODS

We retrospectively evaluated the data of patients who were admitted with HTG-induced AP between January 2013 and May 2018. The endpoint of the study was to assess the clinical outcomes, which included complication rates, mortality, and pancreatitis recurrence rate.

RESULTS

Overall, 41 patients were included in the final analysis. Of these, 12 (29.2%) underwent PE. Patients undergoing PE had more severe pancreatitis on the basis of the Japanese Severity Score [10 (83.3%) vs. 14 (48.3%), P=0.03, respectively). Although mortality was higher in patients who underwent PE [three (25.0%) vs. zero, P<0.01, respectively], there was no difference in terms of complications and recurrence rates. Over a median 21 months of follow-up, 11 (26.8%) patients had recurrent AP.

CONCLUSION

Although PE effectively reduced plasma triglyceride levels, there was no decrease in mortality or recurrences.

Therapeutic plasma exchange for hypertriglyceridemia induced acut pancreatitis: the 33 cases experience from a tertiary reference center in Turkey

BACKGROUND/AIMS

Hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis. In patients with severe HTG (TG level>1000 mg/dL), it may be beneficial to immediately lower the levels of triglyceride (TG) and chylomicrons. In this study, we present one of the largest case series on the use of therapeutic plasma exchange (TPE) for hypertriglyceridemia-induced acute pancreatitis (HTG-AP).

MATERIALS AND METHODS

Overall, 33 patients who were admitted to our clinic for HTG-AP and underwent TPE between January 2007 and July 2017 were included in the study. Clinical data and outcomes and the reduction of triglyceride levels were examined retrospectively.

RESULTS

The TG level decreased by 54.4%, and the total cholesterol level decreased by 52.1% after one TPE session. The TG decrease after the second TPE session was found to be 79.4%. There were 20 (60.6%) patients with mild acute pancreatitis, 10 (30.3%) patients with moderetaly severe acute pancreatitis, and 3 (9.1%) patients with severe acute pancreatitis based on the categorization according to the revised Atlanta criteria. Regarding local complications, the acute peripancreatic fluid collection was observed in 13 (39.4%) patients, acute necrotic collection was observed in 1 (3%) patient, walled-off necrosis was observed in 1 (3%) patient, and pancreatic pseudocyst was not observed in any patient. Mortality was not determined in patients with mild and moderately severe acute pancreatitis, and its rate was 33.3% in patients with severe acute pancreatitis. The overall mortality rate was 3%. No significant complications related to TPE were noted.

CONCLUSION

TPE is a safe and helpful therapeutic treatment method for patients with HTG-AP and may be considered particularly in patients with severe acute pancreatitis.

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

BACKGROUND & AIMS

The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies.

METHODS

The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included.

RESULTS

Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis.

CONCLUSION

The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Management of hypertriglyceridaemic pancreatitis in the acute setting and review of literature

Acute pancreatitis (AP) is a potentially life-threatening complication of severe hypertriglyceridaemia, which is the third most common cause of AP after gallstone disease and alcohol excess. Standard therapy involves the use of lipid-lowering agents, low-molecular-weight heparin and insulin infusion. In some cases, when standard medical therapies fail, non-pharmacological methods based on the removal of triglycerides with therapeutic plasma exchange can provide positive results in the acute phase. There are currently no guidelines covering management in the acute phase, however, these approaches should be considered in severe or very severe hypertriglyceridaemia. Here, we report the case of a 37-year-old man with recurrent AP due to hypertriglyceridaemia and review the literature.

Double filtration plasmapheresis in treatment of acute pancreatitis associated with severe hypertriglyceridemia: Three case reports

RATIONALE

Severe hypertriglyceridemia is the 3rd-leading cause of acute pancreatitis. Current treatment option for hypertriglyceridemia associated with acute pancreatitis is mainly supportive measures, including adequate fluid supply, pain management, and broad-spectrum antibiotics if necessary. Extracorporeal method by mean of plasmapheresis is effective in reducing serum level of triglyceride. It has been proposed to have therapeutic potential in limited small sample studies.

PATIENT CONCERNS

A retrospective review of therapeutic effect of double filtration plasmapheresis in treating hypertriglyceridemia associated with acute pancreatitis was conducted by enlisting 3 patients who meet the criteria for the present study.

DIAGNOSES

Three patients met the criteria for hypertriglyceridemia (serum level >800 mg/dL) associated with acute pancreatitis (either with elevated serum level of lipase and/or amylase and/or with computed tomography evidence of acute pancreatitis).

INTERVENTIONS

Patients received double filtration plasmapheresis.

OUTCOMES

We found that an effective reduction of triglyceride was achieved on an average of 84.7% as a result of a single session of plasmapheresis. All 3 of our patients survived, but needed extended hospitalization.

LESSONS

A substantial clinical trial is required to further assess the effectiveness of plasmapheresis in managing of acute pancreatitis in the setting of hypertriglyceridemia.

Management of Hypertriglyceridemia Induced Acute Pancreatitis

Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.

Plasmapheresis for recurrent acute pancreatitis from hypertriglyceridemia

Acute pancreatitis is a known complication of severe hypertriglyceridemia. Therapeutic experience with plasmapheresis is less well reported but has been highly successful in life-threatening presentations. We describe a 38-year-old obese Hispanic woman with a previous history of acute pancreatitis from diabetic hypertriglyceridemia who presented to the emergency department with a 2-day history of worsening abdominal pain. Plasmapheresis was initiated with one calculated plasma volume exchange using 5% albumin replacement within 24 hours of admission. Following this treatment, the triglyceride level fell 74%. Another session was performed the following day. The final triglyceride level represented a 93% reduction. This case is novel in that the patient presented twice within the same year with hypertriglyceridemic pancreatitis and responded well to prompt plasmapheresis therapy.

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.

Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology?

OBJECTIVE

We sought to define the severity and natural history of hypertriglyceridemia induced acute pancreatitis (HTG-AP), specifically whether HTG-AP causes more severe AP than that caused by other etiologies.

METHODS

Systematic review of the English literature.

RESULTS

Thirty-four studies (15 countries; 1972-2015) included 1340 HTG-AP patients (weighted mean prevalence of 9%). The median admission triglyceride concentration was 2622 mg/dl (range 1160-9769). Patients with HTG have a 14% weighted mean prevalence of AP. Plasmapheresis decreased circulating triglycerides, but did not conclusively affect AP mortality. Only 7 reports (n = 392 patients) compared severity of HTG-AP to that of AP from other etiologies. Of these, 2 studies found no difference in severity, while 5 suggested that HTG-AP patients may have increased severity compared to AP of other etiology.

CONCLUSIONS

1) hypertriglyceridemia is a relatively uncommon (9%) cause of acute pancreatitis; however, patients with hypertriglyceridemia have a high (14%) incidence of acute pancreatitis; 2) plasmapheresis may offer specific therapy unique to this patient population; and 3) data specifically comparing the severity of HTG-AP with AP caused by other etiologies are heterogeneous and scarce.

Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach

OBJECTIVES

Acute hypertriglyceridemia induced pancreatitis (HTP) presents with a more severe clinical course compared to other etiologies of pancreatitis. Therapeutic plasma exchange (TPE) is a potential treatment option for lowering plasma triglycerides and possibly decreasing morbidity and mortality. However, clinical data regarding its effectiveness are limited.

METHODS

We retrospectively examined the clinical data and outcomes of 13 consecutive episodes of HTP in which TPE was employed to reduce plasma triglycerides during a 15-month period.

RESULTS

The TPE was initiated at a median of 19 hours from the time of presentation. We performed 1.2-1.5 volume TPEs with 5% albumin as the replacement fluid. After only one TPE procedure, the mean plasma triglycerides values decreased from 2993 mg/dl to 487 mg/dl with a reduction of 84%. All 13 patients survived with a mean length of hospital stay of 9.5 days. There were no complications related to TPE.

CONCLUSIONS

One TPE procedure is an effective method for reducing plasma triglycerides and possibly decreases the length of hospital stay in patients admitted with HTP.

Successful Plasma Exchange for Acute Pancreatitis Complicated With Hypertriglyceridemia: A Case Report

A 33-year-old male with acute pancreatitis induced by hypertriglyceridemia had problems during treatment with plasma exchange. The hypercoagulable state was prevented by introducing innovative methods for cleaning and warming of the circuit and dialyzer. This enabled successful therapy, and the patient fully recovered from life-threatening acute pancreatitis.

Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis

Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.

Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis

Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.

Severe/Extreme Hypertriglyceridemia and LDL Apheretic Treatment: Review of the Literature, Original Findings

Hypertriglyceridemia (HTG) is a feature of numerous metabolic disorders including dyslipidemias, metabolic syndrome, and diabetes mellitus type 2 and can increase the risk of premature coronary artery disease. HTG may also be due to genetic factors (called primary HTG) and particularly the severe/extreme HTG (SEHTG), which is a usually rare genetic disorder. Even rarer are secondary cases of SEHTG caused by autoimmune disease. This review considers the causes of SEHTG, and their management including treatment with low density lipoprotein apheresis and analyzes the original findings.

Diabetic Ketoacidosis-induced Hypertriglyceridemic Acute Pancreatitis Treated with Plasmapheresis-Recipe for Biochemical Disaster Management

Diabetic ketoacidosis (DKA)-induced hypertriglyceridemia causing pancreatitis is an interesting phenomenon that has rarely been reported in literature. Plasmapharesis is a well known treatment modality for hypertriglyceridemia-induced pancreatitis. We report a patient with DKA-induced hypertriglyceridemic acute pancreatitis treated successfully with plasmapharesis.

Current knowledge of hypertriglyceridemic pancreatitis

Severe hypertriglyceridemia (HTG) is a well established and the most common cause of acute pancreatitis (AP) after alcohol and gall stone disease. It is alleged to account for up to 10% of all pancreatitis episodes. Studies suggest that in patients with triglyceride (TG) levels>1000 mg/dL (>11.3 mmol/L), hypertriglyceridemia-induced acute pancreatitis (HTGP-AP) occurs in approximately 15-20% of all subjects referred to Lipid Clinics. Until now, there is no clear evidence which patients with severe HTG will develop pancreatitis and which will not. Underlying pathophysiological concepts include hydrolysis of TG by pancreatic lipase and excessive formation of free fatty acids with inflammatory changes and capillary injury. Additionally hyperviscosity and ischemia may play a decisive role. The clinical features of HTG-AP patients are supposed to be no different from patients with AP of other etiologies. Yet, there are well-conducted studies suggesting that HTG-AP is associated with a higher severity and complication rate. Therapeutic measurements in HTG-AP include dietary modifications, different antihyperlipidemic agents, insulin and/or heparin treatment. The beneficial use of plasmapheresis is repeatedly reported and suggested in many studies. Yet, due to the lack of randomized and controlled trials, it is currently unknown if plasmapheresis may improve morbidity and mortality in the clinical setting of HTG-AP. Since there are no commonly accepted clinical guidelines in the management of HTG-AP, there is a definite need for an international, multicenter approach to this important subject.

Extreme hypertriglyceridemia managed with insulin

Extreme hypertriglyceridemia can lead to acute pancreatitis and rapid lowering of serum triglycerides (TG) is necessary for preventing such life-threatening complications. However, there is no established consensus on the acute management of extreme hypertriglyceridemia. We retrospectively reviewed 10 cases of extreme hypertriglyceridemia with mean serum TG on presentation of 101.5 ± 23.4 mmol/L (8982 ± 2070 mg/dL) managed with insulin. Serum TG decreased by 87 ± 4% in 24 hours in those patients managed with intravenous insulin and fasting and 40 ± 8.4% in those managed with intravenous insulin alone (P = .0003). The clinical course was uncomplicated in all except 1 patient who subsequently developed a pancreatic pseudocyst. Thus, combination of intravenous insulin with fasting appears to be an effective, simple, and safe treatment strategy in immediate management of extreme hypertriglyceridemia.