Hypertriglyceridemia-induced acute pancreatitis: A prospective, multicenter, international cohort analysis of 716 acute pancreatitis cases

Design, synthesis, and investigation of lipid-lowering and hepatoprotective effects of clofibrate-vanillin derivative based on structural optimization

The study aimed to optimize the structure of clofibrate to create a lipid-lowering medication with reduced liver damage properties. A new compound, clofibrate-vanillin (CF-Vanillin), was synthesized and tested in hyperlipidemic mice. The results showed that CF-Vanillin significantly reduce triglycerides (TG) and total cholesterol (TC), which was stronger than that of CF. The molecular docking results suggested that CF-Vanillin exhibits a favorable affinity towards PPAR-α. The results of the liver damage evaluation showed that CF-Vanillin significantly reduced liver damage compared to CF. The liver weight and liver coefficient of the CF-Vanillin group mice were significantly reduced (P < 0.01). The levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were significantly reduced (P < 0.05). Pathological analysis of liver tissue revealed a notable decrease in nuclear deformation, dissolution, inflammatory cell infiltration, and necrosis among mice treated with CF-Vanillin. Investigation into the liver damage reduction mechanism revealed a significant upregulation of Nrf2 and HO-1 expression (P < 0.01) in the liver tissue of CF-Vanillin group mice. Furthermore, CF-Vanillin exhibited notable antioxidant and anti-inflammatory properties. The results imply that CF-Vanillin shows improved lipid-lowering effects and decreased liver damage possibly due to its antioxidant and anti-inflammatory actions by activating the Nrf2/HO-1 signaling pathway.

A systematic review of the epidemiology and risk factors for severity and recurrence of hypertriglyceridemia-induced acute pancreatitis

This systematic review aims to comprehensively assess the epidemiology and identify risk factors associated with the severity and recurrence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). A search of PubMed, Web of Science, and Cochrane databases was conducted to identify all relevant randomized controlled trials (RCTs), prospective, or retrospective cohort studies on HTG-AP. Data related to epidemiology and risk factors for severity and recurrence of HTG-AP were extracted and analyzed. Seventy-seven studies met the inclusion criteria, comprising 1 RCT, 21 prospective studies, and 55 retrospective studies. A total of 56,617 acute pancreatitis (AP) patients were included, of which 19.99% were diagnosed with HTG-AP (n = 11,315). Compared to non-HTG-AP patients, HTG-AP patients were more likely to be male (68.7% vs. 57.3%) and younger (mean age 41.47 ± 4.32 vs. 50.25 ± 7.70 years). HTG-AP patients exhibited higher mortality rates (up to 20% vs. 15.2%), increased severity (8.3% to 100% vs. 3.8% to 47.2%), and higher recurrence rates (up to 64.8% vs. 23.3%). Analysis of temporal trends from 2002 to 2023 showed a range of HTG-AP prevalence in overall AP patients from 1.6% to 47.6%, with a slight upward trend that was not statistically significant (P = 0.1081). Regional analysis indicated relatively stable prevalence in North America (P = 0.5787), Europe (P = 0.0881), other regions (P = 0.738), while prevalence in China showed a significant increase (P = 0.0119). Thirteen studies investigated risk factors affecting HTG-AP severity, with elevated serum triglyceride (TG) levels associated with increased risk of complications such as pancreatic necrosis, systemic inflammatory response syndrome (SIRS), shock, and multi-organ failure. Additional factors including high neutrophil-to-lymphocyte ratio (NLR), elevated levels of amylase and C-reactive protein (CRP), hypocalcemia, and hypoalbuminemia were also implicated in HTG-AP severity. Smoking history, poor lipid control (TG > 3.1 mmol/L), or recurrent hypertriglyceridemia during follow-up were identified as potential predictors of HTG-AP recurrence. Our findings indicate a stable global prevalence of HTG-AP within AP patients, but a notable increase in China, possibly attributed to socio-economic and dietary factors.

Exploring the link between fibrates therapy and diabetes mellitus following primary acute pancreatitis with hypertriglyceridemia

OBJECTIVE

Post-acute pancreatitis diabetes mellitus (PPDM-A) is a type of diabetes linked to pancreatic exocrine dysfunction, which increases the risk of pancreatic cancer and mortality. Hyperlipidemia, or high blood lipid levels, is the third leading cause of acute pancreatitis (AP) and is associated with a higher diabetes risk. However, the link between lipid-lowering treatments and PPDM-A is unclear. This study aims to explore this relationship.

METHODS

A cohort of 223 patients diagnosed with AP and hyperlipidemia was categorized into PPDM-A and non-PPDM-A groups. Binary logistic regression was utilized to analyze the correlation between fibrate therapy and PPDM-A incidence. Mendelian randomization (MR) was used to determine whether there was a causal relationship between triglyceride levels and diabetes.

RESULTS

Elevated blood glucose levels (GLU) (OR=1.360, p<0.001), female (OR=0.091, p=0.030), severity of AP [moderately severe AP (MASP) (OR=5.585, p=0.019)], recurrent acute pancreatitis (RAP) (OR=6.399, p=0.007), and fibrate use (OR=0.109, p=0.001) emerged as independent influencing factors of PPDM-A. MR evidence suggests a causal relationship between triglyceride levels and diabetes risk (OR=1.088, p<0.001), with a two-step MR showing that pancreatitis partially mediates this effect with a mediated proportion of 1.55% (p=0.048).

CONCLUSION

Fibrates demonstrate the potential to lower the risk of PPDM-A among individuals with AP and hypertriglyceridemia. Furthermore, the effect of triglyceride levels on diabetes risk was partly mediated by pancreatitis.

The role of TyG index as a predictor of all-cause mortality in hospitalized patients with acute pancreatitis: a retrospective study utilizing the MIMIC-IV database

BACKGROUND

The TyG index is widely recognized as a reliable indicator for cardiovascular disease risk and as a biomarker for assessing insulin resistance(IR). However, its significance in the context of patients with acute pancreatitis(AP) needs further exploration. This study aimed to investigate the association between the TyG index and the risk of all-cause mortality in critically ill patients with AP.

METHODS

Data for this retrospective study were obtained from the MIMIC IV2.2 database. The participants were divided into four groups based on the TyG index tertiles. The primary outcome measured was in-hospital all-cause mortality. We employed Cox proportional hazards regression analysis and restricted cubic splines to evaluate the correlation between the TyG index and clinical outcomes in patients with AP.

RESULTS

The study included 586 patients, of which 44.71% were male. The rates of mortality observed in the hospital stay and in the ICU stay were 19.28% and 12.97%. By conducting multivariable Cox proportional hazards, it was determined that the TyG index was independently associated with a heightened risk of in-hospital mortality [HR(95%CI) of 1.38(1.03-1.87, P=0.033)] and in ICU mortality [1.65(1.12-2.44), P=0.012]. The analysis using restricted cubic splines showed that there was a consistent and gradually increasing risk of all-cause mortality as the TyG index increased. This indicates that a higher TyG index is associated with a higher risk of mortality.

CONCLUSION

In critically ill patients with AP, the TyG index shows a notable correlation with all-cause death in both hospital and ICU. The TyG index can be useful in identifying insulin resistance at an early stage in patients with AP, thereby improving risk assessment and guiding subsequent interventions.

LESS IS MORE: classified management of hypertriglyceridemia-induced acute pancreatitis on the basis of a propensity score matching cohort study

BACKGROUND

Effective management of hypertriglyceridemia is crucial in the treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP). The prognosis of HTG-AP may vary with different serum triglyceride levels, suggesting the need for stratified treatment approaches. In this study, we investigated hypertriglyceridemia management in HTG-AP patients and the optimal strategy.

METHODS

Patients with HTG-AP from October 2020 to October 2022 were included in the study. Propensity score matching was used to balance the bias and confounding variables. A mixed-effects model was used to analyse the decreasing tendency of triglycerides.

RESULTS

A total of 171 patients who were diagnosed with HTG-AP were enrolled in this cohort. Patients with very severe serum triglycerides (> 22.6mmol/L) had a higher proportion of severe acute pancreatitis (p < 0.05) than patients with severe hypertriglyceridemia (11.3-22.6 mmol/L). For the very severe hypertriglyceridemia group, no significant differences in prognosis were noted between the insulin and heparin group and the plasma exchange group. The cost of the insulin and heparin group was significantly lower than that of the plasma exchange group (p < 0.01). In patients with severe hypertriglyceridemia, no significant differences in prognosis were noted between the nothing-by-mouth (NPO) group and the insulin and heparin group. Compared with the insulin and heparin group, the NPO group had lower hospital costs (p < 0.05).

CONCLUSION

HTG-AP patients with very severe hypertriglyceridemia may be treated safely and effectively with insulin and heparin, potentially offering a more cost-effective treatment approach. Similarly, patients with severe hypertriglyceridemia might benefit from treatment involving NPO, which may be associated with lower costs. Further studies are needed to validate these findings in diverse populations and through long-term follow-up.

Association between the triglyceride glucose index and the risk of acute respiratory failure in patients with acute pancreatitis

BACKGROUND

The triglyceride glucose (TyG) index serves as a dependable marker for insulin resistance and has shown a significant correlation with the severity of acute pancreatitis (AP). However, no research exists regarding the association between the TyG index and the development of acute respiratory failure (ARF) in AP. This study assesses the association between TyG index and ARF in patients with AP.

METHODS

Retrospective cohort analysis was conducted with the MIMIC-IV 2.2 critical care data. The endpoint focused on ARF during hospitalization. Statistical analysis encompassed univariate and multivariate logistic regressions, alongside restricted cubic spline (RCS) analysis to explore potential nonlinear associations. Receiver operating characteristic (ROC) curve analysis was employed to identify the optimal TyG index cutoff, leading to the classification of patients into Low TyG and High TyG groups. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were subsequently applied to minimize the influence of confounding factors, thereby further clarifying the relationship between the TyG index and ARF in patients with AP.

RESULTS

A total of 758 patients were involved in this study, the incidence of ARF was 21.64%. Logistic regression analyses demonstrated a significant association between the TyG index and the incidence of ARF in patients with AP. The RCS model illustrated a nonlinear relationship between a higher TyG index and an increased risk of ARF. The cutoff value of TyG index was 9.099 for ARF in patients with AP based on the ROC curve analysis. Furthermore, following PSM and IPTW, multivariate logistic regression analysis indicated that the High TyG group exhibited a significantly higher risk of ARF compared to the Low TyG group (P < 0.05).

CONCLUSIONS

The TyG index is associated with ARF risk in AP patients and may aid in early risk assessment.

Effect of plasmapheresis versus standard medical treatment in patients with hypertriglyceridemia-associated acute pancreatitis complicated by early organ failure (PERFORM-R): Study design and rationale of a multicenter, pragmatic, registry-based randomized controlled trial

BACKGROUND

The prevalence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is increasing. Studies have demonstrated the association between higher initial plasma triglyceride (TG) levels and worse clinical prognosis; therefore, lowering plasma TG has been the mainstay when managing HTG-AP. For TG-lowering therapy, plasmapheresis, which is costly and of potential complications, is currently widely used to clear TG from plasma, but whether it confers clinical benefits is unclear. In this trial, we aimed to evaluate the effect of plasmapheresis versus standard medical treatment on the duration of organ failure in HTG-AP patients with early organ failure.

METHODS

This is a multicenter, pragmatic, registry-based, randomized controlled trial. Based on previous studies, up to 236 HTG-AP patients with early organ failure are projected to be randomly assigned to either the plasmapheresis group or the standard medical treatment group (insulin plus low molecular weight heparin therapy). The PERFORM registry will be used as the platform for patient enrollment. The primary outcome is organ failure-free days to 14 days of enrollment. Organ failure in this trial is defined as an individual sequential organ failure assessment (SOFA) score of two or more for the respiratory, cardiovascular, or renal system. Patients who died before day 14 will be assigned zero organ failure-free days.

DISCUSSION

This trial will provide top-class evidence regarding the clinical impact of plasmapheresis in HTG-AP patients with early organ failure. The findings of this trial will have a direct influence on the current clinical practice concerning the management of HTG-AP.

The 12-Year Experience of the Hungarian Pancreatic Study Group

The Hungarian Pancreatic Study Group (HPSG) was established with the aim of advancing pancreatology. Our summary outlines the methodologies, key results, and future directions of the HPSG. Methodological elements included, the formation of strategic national and international collaborations, the establishment of patient registries and biobanks, and a strong focus on education and guideline development. Key results encompassed, pioneering research on pancreatic ductal function and the role of cystic fibrosis transmembrane conductance regulator (CFTR) in inflammation, significant advancements in understanding acute and chronic pancreatitis, and the execution of numerous clinical trials to explore new therapeutic approaches. Despite challenges, such as securing funding and translating research into clinical practice, the HPSG's commitment to patient care and scientific innovation has been unwavering. The group aims to deepen research into pancreatic cancer and chronic pancreatitis, conduct more randomized controlled trials (RCTs), and expand its efforts internationally by involving global staff and patients. The authors hope that this summary inspires others to undertake similar initiatives and contribute to the global advancement of medical research and patient care in pancreatology.

The effect of blood glucose levels on serum triglyceride clearance in patients with hyperlipidemic acute pancreatitis

Preventing moderately severe and severe acute pancreatitis (MSAP & SAP) is the primary goal of the management of hyperlipidemic acute pancreatitis (HLAP). The main aim of this study was to investigate the factors affecting serum triglyceride (TG) clearance, particularly blood glucose (GLU) levels, which could potentially help to prevent the development of MSAP & SAP. The clinical data from 177 patients with MSAP & SAP and 195 patients with mild acute pancreatitis (MAP) on days 1-6 after the onset were collected and analyzed by multivariate logistic regression to identify the factors that have an impact on the severity of HLAP, especially TG. The optimal TG threshold was obtained by receiver operating characteristic (ROC) analysis to differentiate TG fast-clearance patients from TG slow-clearance patients, as defined in this study. Metabolism-related factors that may interfere with TG clearance, such as GLU, diabetes mellitus (DM), obesity, and uric acid, were further analyzed. Day 2 TG was an independent risk factor for MSAP & SAP in patients with HLAP (OR: 3.718, 95% CI: 2.042-6.77; P < 0.001). And patients with TG slow-clearance (day 2 TG ≥ 7.335 mmol/L) were more likely to develop MSAP & SAP (sensitivity 0.932, specificity 0.898), severe pancreatic necrosis, and death. DM (OR: 3.574, 95% CI: 1.13-11.308, P < 0.001) and day 2 GLU (OR: 1.537, 95% CI: 1.292-1.675; P < 0.001) were independent risk factors for TG slow-clearance but not for HLAP severity (OR: 1.728, P = 0.253 and OR: 1.119, P = 0.059). Day 2 GLU decreased below 13.07 mmol/L and 6.575 mmol/L in patients with DM and non-diabetes mellitus (NDM), respectively, contributing to the reduction of day 2 TG to 7.335 mmol/L. Day 2 TG levels had the most impact on the severity of HLAP, which also accurately predicted the occurrence of MSAP & SAP. It is worth noting whether the GLU can reach the target value on day 2, as it can directly affect the TG clearance rate and indirectly affect the severity of HLAP.

Clinical Outcomes in a Multicenter Cohort Involving 919 Patients With Hypertriglyceridemia-Associated Acute Pancreatitis

INTRODUCTION

Hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is one of the most common etiologies of acute pancreatitis (AP) worldwide. Compared with other etiologies, patients with HTG-AP may develop more severe AP, but previous studies yielded controversial conclusion due to the lack of adequate adjustment for the confounders. Therefore, the aim of this study was to examine the possibility and risk factors of developing severe AP in HTG-AP.

METHODS

Data from patients with an established diagnosis of AP were collected from January 2013 to December 2023 using a predesigned data collection form and were gathered from 5 tertiary cross-regional centers of China. HTG-AP was defined as serum triglyceride levels >500 mg/dL and excluded other etiologies. The possibility and risk factors of severe AP were assessed by multivariable logistic regressions after adjusting potential confounders. A prediction model was established and validated.

RESULTS

Between 2013 and 2023, we identified a total of 6,996 patients with AP, of whom 4,378 were included in the final analysis. Compared with other etiologies, patients with HTG-AP had a higher risk of developing severe AP (odds ratio: 1.897; 95% confidence interval: 1.380-2.608; P < 0.001) and organ failure. HTG-AP patients showed higher possibility for developing respiratory and circulation failure but renal failure compared with other etiologies. In HTG-AP patients, risk factors of severe AP included age, fasting blood glucose, white blood cell counts, and presence of pleural effusion. TG level was found not significantly associated with severity in HTG-AP patients. A prediction model incorporating these risk factors demonstrated an area under the curve (AUC) of 0.837 in the training and 0.883 in the testing set, with adequate calibration.

DISCUSSION

Using a multicenter cross-regional cohort, we demonstrated that HTG-AP had a higher risk of developing severe AP and organ failure. A risk prediction model for predicting severe AP was developed and effectively stratified patients.

Triglycerides and metabolic syndrome: from basic to mechanism - A narrative review

CONTENT

The impact of triglyceride levels is important to understand the changes in metabolism and structure. With an increase in obesity and hyperlipidemia due to diet; cardiovascular and neuronal structural changes have been shown to be more distinct.

OBJECTIVE

This review aims to discuss the pathophysiology and mechanisms involved in increased levels of triglycerides leading to vascular impairment, metabolic syndrome and cognitive decline.

METHODS

The literature search was performed using the PubMed, Google scholar and Scopus databases, among which 180 articles were shortlisted based on key words, abstract, materials and methods and results. Among these 74 articles have been cited for the review.

RESULTS AND DISCUSSION

The review discusses the impact of hypertriglyceridemia on metabolism, triglyceride storage, and neurovascular integrity, highlighting mechanisms contributing to vascular dysfunction, metabolic syndrome, and cognitive deterioration.

CONCLUSION

Elevated triglyceride levels are a key factor in altering metabolic pathways and structural integrity in cardiovascular and neuronal systems. This review provides insights into the mechanisms underlying metabolic disorders caused by elevated triglyceride levels, It highlights the need for further studies to provide more supportive evidence and address existing limitations in understanding these changes.

Prospective observational study and mechanistic evidence showing lipolysis of circulating triglycerides worsens hypertriglyceridemic acute pancreatitis

BACKGROUNDWhile most hypertriglyceridemia is asymptomatic, hypertriglyceridemia-associated acute pancreatitis (HTG-AP) can be more severe than AP of other etiologies. The reasons underlying this are unclear. We thus examined whether lipolytic generation of nonesterified fatty acids (NEFAs) from circulating triglycerides (TGs) could worsen clinical outcomes.METHODSAdmission serum TGs, NEFA composition, and concentrations were analyzed prospectively for 269 patients with AP. These parameters, demographics, and clinical outcomes were compared between HTG-AP (TGs >500 mg/dL; American Heart Association [AHA] 2018 guidelines) and AP of other etiologies. Serum NEFAs were correlated with serum TG fatty acids (TGFAs) alone and with the product of TGFA serum lipase (NEFAs - TGFAs × lipase). Studies in mice and rats were conducted to understand the role of HTG lipolysis in organ failure and to interpret the NEFA-TGFA correlations.RESULTSPatients with HTG-AP had higher serum NEFA and TG levels and more severe AP (19% vs. 7%; P < 0.03) than did individuals with AP of other etiologies. Correlations of long-chain unsaturated NEFAs with corresponding TGFAs increased with TG concentrations up to 500 mg/dL and declined thereafter. However, NEFA - TGFA × lipase correlations became stronger with TGs above 500 mg/dL. AP and intravenous lipase infusion in rodents caused lipolysis of circulating TGs to NEFAs. This led to multisystem organ failure, which was prevented by pancreatic TG lipase deletion or lipase inhibition.CONCLUSIONSHTG-AP is made severe by the NEFAs generated from intravascular lipolysis of circulating TGs. Strategies that prevent TG lipolysis may be effective in improving clinical outcomes for patients with HTG-AP.FUNDINGNational Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, NIH) (RO1DK092460 and R01DK119646); Department of Defense (PR191945 under W81XWH-20-1-0400); National Institute on Alcohol Abuse and Alcoholism (NIAAA), NIH (R01AA031257).

Development of a Nomogram to Predict the Risk for Acute Necrotizing Pancreatitis

Background/Aims

Necrotizing pancreatitis (NP) presents a more severe clinical trajectory and increased mortality compared to edematous pancreatitis. Prompt identification of NP is vital for patient prognosis. A risk prediction model for NP among Chinese patients has been developed and validated to aid in early detection.

Methods

A retrospective analysis was performed on 218 patients with acute pancreatitis (AP) to examine the association of various clinical variables with NP. The least absolute shrinkage and selection operator (LASSO) regression was utilized to refine variables and select predictors. Subsequently, a multivariate logistic regression was employed to construct a predictive nomogram. The model's accuracy was validated using bootstrap resampling (n=500) and its calibration assessed via a calibration curve. The model's clinical utility was evaluated through decision curve analysis.

Results

Of the 28 potential predictors analyzed in 218 AP patients, the incidence of NP was 25.2%. LASSO regression identified 14 variables, with procalcitonin, triglyceride, white blood cell count at 48 hours post-admission, calcium at 48 hours post-admission, and hematocrit at 48 hours post-admission emerging as independent risk factors for NP. The resulting nomogram accurately predicted NP risk with an area under the curve of 0.822, sensitivity of 82.8%, and specificity of 76.4%. The bootstrap-validated area under the curve remained at 0.822 (95% confidence interval, 0.737 to 0.892). This model exhibited excellent calibration and demonstrated greater predictive efficacy and clinical utility for NP than APACHE II, Ranson, and BISAP.

Conclusions

We have developed a prediction nomogram of NP that is of great value in guiding clinical decision.

Chronic liver disease is an important risk factor for worse outcomes in acute pancreatitis: a systematic review and meta-analysis

Chronic liver diseases (CLD) affect 1.5 billion patients worldwide, with dramatically increasing incidence in recent decades. It has been hypothesized that the chronic hyperinflammation associated with CLD may increase the risk of a more severe course of acute pancreatitis (AP). This study aims to investigate the underlying impact of CLD on the outcomes of AP. A systematic search was conducted in Embase, Medline, and Central databases until October 2022. Studies investigating patients with acute pancreatitis and CLD, were included in the meta-analysis. A total of 14,963 articles were screened, of which 36 were eligible to be included. CLD was a risk factor for increased mortality with an odds ratio (OR) of 2.53 (CI 1.30 to 4.93, p = 0.01). Furthermore, renal, cardiac, and respiratory failures were more common in the CLD group, with ORs of 1.92 (CI 1.3 to 2.83, p = 0.01), 2.11 (CI 0.93 to 4.77, p = 0.062) and 1.99 (CI 1.08 to 3.65, p = 0.033), respectively. Moreover, the likelihood of developing Systemic Inflammatory Response Syndrome (SIRS) was significantly higher, with an OR of 1.95 (CI 1.03 to 3.68, p = 0.042). CLD is an important risk factor for worse outcomes in AP pancreatitis, leading to higher mortality and increased rates of local and systemic complications.

The effect of serum triglyceride levels and different lipid-lowering methods on the prognosis of hypertriglyceridemic acute pancreatitis: a single-center 12-year retrospective study by propensity score matching

AIM

To investigate the impact of triglyceride on hypertriglyceridemic acute pancreatitis (HTG-AP) and different lipid-lowering methods on triglyceride-lowering efficiency and HTG-AP.

METHODS

The patients with HTG-AP from January 2012 to December 2023 in Civil Aviation General Hospital were analyzed, retrospectively. Patients were divided and compared according to whether their triglycerides were below 5.56 mmol/L at 48 and 72 h of admission. The patients were divided into control group, insulin group, and low molecular weight heparin (LMWH)+bezafibrate group based on the different methods of lipid-lowering. Propensity score matching (PSM) was employed to balance the baseline characteristics.

RESULTS

There was no correlation between the severity of HTG-AP and the triglyceride at admission. The incidence of severity, local complications, and persistent organ failure (POF) were significantly decreased in patients with 48-h and 72-h triglyceride attainment. Following PSM, the incidence of infectious pancreatic necrosis (IPN) (3.3% vs. 13.3%) was significantly reduced in insulin group compared with control group (p < .05). Compared with control group, LMWH + bezafibrate group had higher lipid reduction efficiency, and the incidence of IPN (0.9% vs. 10.1%) and POF (8.3% vs. 19.3%) was significantly decreased (p < .05). There was no significant difference in the efficiency of lipid-lowering, complications, and POF between LMWH + bezafibrate group and insulin group (p > .05).

CONCLUSION

The severity of HTG-AP is not associated with the triglyceride levels at admission. However, rapid reduction of triglyceride levels can lower the incidence of local complications and respiratory failure. Compared with conservative treatment, insulin and LMWH + bezafibrate can both reduce the incidence of IPN in patients with HTG-AP.

Two successful pregnancies -in patients taking Volanesorsen for familial chylomicronemia syndrome

Familial chylomicronemia syndrome (FCS) is a rare inherited disorder characterized by severe hypertriglyceridemia, posing a heightened risk of acute pancreatitis. Recently, Volanesorsen, an APOC3 antisense oligonucleotide, gained approval for FCS treatment in the UK. Caution is advised during pregnancy due to limited safety data, although animal studies show no toxicity/teratogenicity. Two case scenarios are presented: In the first case, a patient with FCS continued Volanesorsen injections without having thrombocytopenia during an unplanned pregnancy until third trimester, maintaining triglyceride control. Upon discovering the pregnancy at 38 weeks, Volanesorsen was ceased, and a low-fat diet reinstated. Despite a heightened risk of pancreatitis, no episodes of pancreatitis occurred during the pregnancy. In the second case, stopping Volanesorsen before conception led to elevated triglycerides, and an episode of acute pancreatitis at 22 weeks, despite strict very low-fat diet and fibrate therapy from 14 weeks. At 23 weeks, Volanesorsen was reintroduced concurrently with regular therapeutic plasma exchange. No further episodes of pancreatitis occurred. In both case, fetal health was maintained throughout pregnancy, fetal scans revealed no anomalies, and planned C-sections delivered healthy babies without congenital issues. Both babies are well and developing normally at 24 and 19 months.

Triglycerides: A Sensitizer but Not a Trigger for Hypertriglyceridemic Acute Pancreatitis

BACKGROUND

The incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) is increasing. Although the guideline defines the diagnostic criteria as triglyceride (TG) greater than 11.3 mmol/L, there is actually no specific threshold. Many people with hypertriglyceridemia (HTG) or obvious chyloid blood do not develop acute pancreatitis (AP).

AIMS

To explore the role of HTG in the pathogenesis of AP.

METHODS

Thirty-six male SD rats were randomly assigned into normal control, AP, HTG, HTG-AP, low-dose fenofibrate and high-dose fenofibrate groups. Serum indices and cytokine levels in serum, and pathological changes in pancreatic tissues were observed. The expression levels of TLR4 and NF-κBp65 in pancreatic tissues were detected by immunohistochemistry and Western blot.

RESULTS

In normal rats, HTG alone did not induce AP. However, after establishing the HTG-AP model with Poloxam 407 and L-arginine, serum-free fatty acid and TG levels were positively correlated with the levels of lipase, amylase, IL-1β, IL-6, pancreatic inflammation scores, and the expressions of TLR4 and NF-κBp65 (all P < 0.001). Expressions of TLR4 and NF-κBp65 were significantly increased in the pancreatic tissues of HTG-AP rats. Fenofibrate effectively decreased TG levels in HTG-AP rats and reduced the expression of TLR4 and NF-κBp65 (all P < 0.001).

CONCLUSIONS

HTG does not directly cause AP, but rather increases the susceptibility to AP or aggravates the inflammatory response. It is more like a sensitizer of inflammation rather than an activator.

Hypertriglyceridemia-Induced Acute Pancreatitis-The Milky Way Constellation-The Seven-Year Experience of a Large Tertiary Centre

(1) Background: Hypertriglyceridemia (HTG) is a well-known metabolic condition associated with an increased risk of acute pancreatitis. In this study, we tried to establish whether there are any significant disparities concerning recurrence rate, intensive care unit (ICU) admission, hospital (ICU and total) length of stay (LoS), morphology, severity and age between HTG-induced acute pancreatitis and any other known cause of pancreatitis (OAP). (2) Methods: The research was a retrospective unicentric cohort study, using information from the Bucharest Acute Pancreatitis Index (BUC-API) registry, a database of 1855 consecutive cases of acute pancreatitis. (3) Results: We found a weak association between HTG-AP and recurrence. The HTG-AP patients were younger, with a median of 44.5 years, and had a longer ICU stay than the OAP patients. In addition, we identified that the HTG-AP patients were more likely to develop acute peripancreatic fluid collection (APFC), to be admitted in ICU, to have a more severe course of disease and to be cared for in a gastroenterology ward. (4) Conclusions: Hypertriglyceridemia-induced APs have a more severe course. The typical patient with HTG-AP is a middle-aged male, with previous episodes of AP, admitted in the gastroenterology ward, with a longer ICU stay and longer length of hospitalization, more likely to evolve in a severe acute pancreatitis (SAP) and with a higher probability of developing APFC.

Association of admission serum triglyceride levels with intensive care unit hospitalization rates in acute pancreatitis patients: A retrospective study

Acute pancreatitis (AP) is a complex and unpredictable condition, of which hypertriglyceridemia (HTG) is the third most prevalent cause. This study aimed to conduct a retrospective analysis of clinical data from hospitalized AP patients to uncover a potential correlation between triglyceride (TG) levels and the necessity for intensive care unit (ICU) admission. This retrospective cohort study utilized the Medical Information Mart for Intensive Care IV 2.2 (MIMIC-IV) critical care dataset, incorporating data from 698 patients with hypertriglyceridemic acute pancreatitis (HTG-AP). The analysis employed the RCS model along with univariate and multivariate logistic regression methods to affirm the association between triglyceride levels and ICU admission. Subgroup analysis was performed to investigate specific populations. The study included 698 patients with AP, 42.41% of whom experienced HTG during hospitalization. RCS analysis revealed a linear association between TG levels and risk of ICU admission (p for nonlinear = .219, p for overall = .009). Multivariate logistic regression analysis indicated an increased risk of ICU admission in the TG range of 1.7-5.65 mmol/L (aOR = 1.83, 95% CI 1.12-2.99, P = .015) and TG >11.3 mmol/L (aOR = 5.69, 95% CI 2.36-13.74, P < .001) compared to the normal group. Similar results were observed across the various subgroups. As triglyceride levels increased, there was a corresponding increase in ICU admissions. Patients within the 1.7 to 5.65 mmol/L and > 11.3 mmol/L triglyceride groups exhibited higher rates of ICU admissions. Moreover, we observed a higher risk of ICU hospitalization even with mild TG elevation.

Association between serum triglyceride level and severity of acute biliary pancreatitis

BACKGROUND

Acute biliary pancreatitis (ABP) is the most common type of acute pancreatitis. However, the effect of serum triglyceride (TG) levels on the severity of ABP remains unclear. The aim of this study was to assess the correlation between serum TG levels and the severity of ABP.

METHODS

Data from 526 ABP patients was analyzed in this study. The patients were divided into normal and elevated groups according to the TG level measured within 24 h after admission, and the elevated group was further divided into mild, moderate, and severe elevated groups. The demographic data and clinical outcomes of each group were compared.

RESULTS

Of the 526 ABP patients, 394 were in the normal TG group and 132 were in the elevated TG group (36 mild, 57 moderate, and 39 severe). The elevated group was younger (51.5 ± 12.9 vs. 58.9 ± 13.9), predominantly male (66.7% vs. 45.2%), had more history of diabetes (22.7% vs. 12.4%) and hyperlipidemia (19.7% vs. 0.8%), and developed systemic inflammatory response syndrome (SIRS) (25.8% vs. 15.5%), persistent organ failure (POF) (11.4% vs. 2.8%), and local complications (62.9% vs. 42.1%) more frequently compared to the normal group (P < 0.05). The incidence of SIRS, POF, acute peripancreatic fluid collection (APFC), and acute necrotic collection (ANC) increased with increasing TG levels (Ptrend < 0.05). In multivariate analysis, TG was independently associated with POF, APFC, and ANC in increments of 100 mg/dl (P < 0.05), and there was a linear relationship between TG levels and POF, APFC, and ANC (non-linear P > 0.05, P overall <0.05). In addition, nonalcoholic fatty liver disease is not a risk factor for POF, ANC, and APFC in ABP patients.

CONCLUSIONS

Elevated serum TG levels were independently associated with more severe ABP. The incidence of POF, APFC, and ANC in ABP patients increased with the increase of TG levels, with a linear relationship.

Assessment of triglyceride clearance of haemoperfusion from three cases of hypertriglyceridaemia-induced acute pancreatitis: a case series

Rapid reduction of plasma triglycerides (TG) is believed to improve the outcome of pancreatitis in the context of hypertriglyceridaemia (HTG)-induced acute pancreatitis (HTG-AP). Previous studies have suggested that haemoperfusion (HP) with the Jafron cartridge series could be effective for reducing TG concentrations in patients with HTG-AP. However, the clearance capacity (CC) for TG removal has not been reported. This case series reports on data from three patients with HTG-AP who underwent HP with HA230 or HA330 cartridges. Blood samples were collected from both before and after the cartridge circuit every 30 min and the CC was calculated. Twelve pairs of blood samples were collected for each type of HP cartridge. The mean ± SD CC of the HA230 cartridge for TG removal in this case series was 0.009781 ± 1.117235 ml/min (95% confidence interval [CI], -0.7000762, 0.7196384 ml). The mean ± SD CC of the HA330 cartridge for TG removal in this case series was 0.344914 ± 1.412183 ml/min (95% CI, -0.5523448, 1.2421721 ml). Based on the findings of this small case series, special caution is advised when considering the use of the HA230 and HA330 cartridges for reducing blood TG concentration pending further conclusive evidence from larger studies.

Prediction of severe hypertriglyceridemia-associated acute pancreatitis using a nomogram based on CT findings and blood biomarkers

Hypertriglyceridemia is a common cause of acute pancreatitis (AP). Fatty liver, a manifestation of metabolic syndrome, is related to the severity of AP. The present study aimed to construct an accurate predictive model for severe AP (SAP) by combining the fatty liver infiltration on a computerized tomography (CT) scan with a series of blood biomarkers in patients with hypertriglyceridemia-associated AP (HTG-AP). A total of 213 patients diagnosed with HTG-AP were included in the present retrospective study. Clinical information and imageological findings were retrospectively analyzed. The model was constructed from independent risk factors using univariate analysis, the least absolute shrinkage and selection operator method. Subsequently, the data from the training group of 111 patients with HTG-AP was analyzed using logistic regression analysis. The efficacy of the model was verified using an external validation group of 102 patients through the receiver operating characteristic curve (ROC). Independent predictors, including serum calcium, C-reactive protein, lactate dehydrogenase and liver-to-spleen CT attenuation ratio (L/S ratio), were incorporated into the nomogram model for SAP in HTG-AP. The model achieved a sensitivity of 91.3% and a specificity of 88.6% in the training group. Compared with the Ranson model, the established nomogram model exhibited a better discriminative ability in the training group [area under the curve (AUC): 0.957] and external validation group (AUC: 0.930), as well as better calibration and clinical benefits. The present study demonstrates that the constructed nomogram based on CT findings and blood biomarkers is useful for the accurate prediction of SAP in HTG-AP.

Impact of therapeutic plasmapheresis on the duration of organ failure in patients with hypertriglyceridemia-associated acute pancreatitis

BACKGROUND

Plasmapheresis is widely used for severe hypertriglyceridemia-associated acute pancreatitis (HTG-AP) to remove excessive triglycerides from plasma. This study aimed to evaluate whether plasmapheresis could improve the duration of organ failure in HTG-AP patients.

METHODS

We analyzed a cohort of patients from a multicenter, prospective, long-running registry (the PERFORM) collecting HTG-AP patients admitted to the study sites within 72 h from the onset of symptoms. This study was based on data collected from November 2020 to March 2023. Patients who had organ failure at enrollment were involved in the analyses. The primary outcome was time to organ failure resolution within 14 days. Multivariable Cox regression model was used to evaluate the association between plasmapheresis and time to organ failure resolution. Directed acyclic graph (DAG) was used to identify potential confounders.

RESULTS

A total of 122 HTG-AP patients were included (median [IQR] sequential organ failure assessment (SOFA) score at enrollment, 3.00 [2.00-4.00]). Among the study patients, 46 underwent plasmapheresis, and 76 received medical treatment. The DAG revealed that baseline serum triglyceride, APACHE II score, respiratory failure, cardiovascular failure, and renal failure were potential confounders. After adjusting for the selected confounders, there was no significant difference in time to organ failure resolution between patients undergoing plasmapheresis and those receiving exclusive medical treatment (HR = 1.07; 95%CI 0.68-1.68; P = 0.777). Moreover, the use of plasmapheresis was associated with higher ICU requirements (97.8% [45/46] vs. 65.8% [50/76]; OR, 19.33; 95%CI 2.20 to 169.81; P = 0.008).

CONCLUSIONS

In HTG-AP patients with early organ failure, plasmapheresis was not associated with accelerated organ failure resolution compared to medical treatment but may be associated with more ICU admissions.

TRIAL REGISTRATION

The PERFORM study was registered in the Chinese Clinical Trial Registry (ChiCTR2000039541). Registered 30 October 2020.

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.

Risk factors for diabetes mellitus after acute pancreatitis: a systematic review and meta-analysis

Introduction

Within 5 years of having acute pancreatitis (AP), approximately 20% of patients develop diabetes mellitus (DM), which later increases to approximately 40%. Some studies suggest that the prevalence of prediabetes (PD) and/or DM can grow as high as 59% over time. However, information on risk factors is limited. We aimed to identify risk factors for developing PD or DM following AP.

Methods

We systematically searched three databases up to 4 September 2023 extracting direct, within-study comparisons of risk factors on the rate of new-onset PD and DM in AP patients. When PD and DM event rates could not be separated, we reported results for this composite outcome as PD/DM. Meta-analysis was performed using the random-effects model to calculate pooled odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 61 studies identified, 50 were included in the meta-analysis, covering 76,797 participants. The studies reported on 79 risk factors, and meta-analysis was feasible for 34 risk factor and outcome pairs. The odds of developing PD/DM was significantly higher after severe and moderately severe AP (OR: 4.32; CI: 1.76-10.60) than mild AP. Hypertriglyceridemic AP etiology (OR: 3.27; CI: 0.17-63.91) and pancreatic necrosis (OR: 5.53; CI: 1.59-19.21) were associated with a higher risk of developing PD/DM. Alcoholic AP etiology (OR: 1.82; CI: 1.09-3.04), organ failure (OR: 3.19; CI: 0.55-18.64), recurrent AP (OR: 1.89; CI: 0.95-3.77), obesity (OR: 1.85; CI: 1.43-2.38), chronic kidney disease (OR: 2.10; CI: 1.85-2.38), liver cirrhosis (OR: 2.48; CI: 0.18-34.25), and dyslipidemia (OR: 1.82; CI: 0.68-4.84) were associated with a higher risk of developing DM.

Discussion

Severe and moderately severe AP, alcoholic and hypertriglyceridemic etiologies, pancreatic necrosis, organ failure, recurrent acute pancreatitis and comorbidities of obesity, chronic kidney disease liver disease, and dyslipidemia are associated with a higher risk of developing PD or DM.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021281983.

Nonlinear Relationship Between Serum Total Cholesterol Levels and the Severity of Hypertriglyceridemic Acute Pancreatitis: A Cohort Study in China

BACKGROUND

The relationship between total cholesterol (TC) levels and the severity of hypertriglyceridemic acute pancreatitis (HTGAP) remains unclear.

AIMS

The aim of this study was to investigate the relationship between the levels of TC at admission with the severity of HTGAP, in order to apply it as a reliable predictor at early stage in clinical practice.

METHODS

We performed a cohort study including 249 patients with AHTGP between November 2012 and April 2022 in XuanWu Hospital. Fasting TC was assayed within 24 h of admission, age, gender, body mass index, hypertension, diabetes mellitus, drinking, smoking, neutrophil-lymphocyte ratio, C-reactive protein and glucose were recorded as confounding factors. To evaluate the relationship of TC and the severity of HTGAP, we used smooth curve fitting and a segmented regression model with adjustment of confounding factors to analyze the threshold effect between TC and SAP occurrence risk.

RESULTS

249 Patients were enrolled. The incidence of SAP was 25.3% (63/249). A nonlinear relationship between TC level and the severity of HTGAP. 6.09 mmol/L was the optimal TC value associated with the lowest risk of SAP occurrence. Moreover, TC level was negatively correlated with risk of severe HTGAP occurrence for TC < 6.09 mmol/L (OR 0.45, 95% CI 0.23-0.85, P = 0.014) and positively correlated for TC > 6.09 mmol/L in HTGAP patients (OR 1.14, 95% CI 1.04-1.26, P = 0.006).

CONCLUSIONS

We found that serum TC level is nonlinearly associated with the severity of HTGAP, and it can be a reliable predictor for early intervention and intensive care.

Treatment and diagnosis of hyperlipidemia acute pancreatitis in pregnancy associated with pre‑pregnancy obesity and diabetes: A case report

Hyperlipidemia acute pancreatitis (HLAP) is a specific type of pancreatitis mainly caused by elevated serum triglyceride (TG) levels. Therefore, knowledge of patients' medical history is crucial to the identification of those at high risk of HLAP. Diabetes and obesity are associated with high levels of triglycerides, a risk factor for the development of HLAP, which should be controlled before pregnancy. Moreover, HLAP is associated with additional diagnostic and management challenges related to hyperlipidemia (HL) and pregnancy. HLAP during pregnancy has a rapid onset and rapid progression, and complications are more likely to damage the function of multiple organs. HLAP is more common after 28 weeks of pregnancy, the cause is mostly high TG and the serum TG of the patient is often >1,000 mg/d1. Clinicians should be alert to the occurrence of server acute pancreatitis (AP). Therefore, clinicians need to identify and implement effective treatment in a timely manner to control the progression of HLAP during pregnancy and improve pregnancy outcomes. The present study reported the case of a 26-year-old pregnant patient who was hospitalized for epigastric pain at 35 weeks and 2 days of gestation. Medical and family history reported previous diagnoses of diabetes and obesity (weight before pregnancy, 103 kg; BMI, 36.40 kg/m2). Laboratory tests demonstrated high levels of lipase and amylase, a notable systemic inflammatory response, HL, coagulopathy, hypoproteinemia and hyperglycemia. Abdominal ultrasonography demonstrated a hypoechoic pancreatic head. A clinical diagnosis of AP was confirmed using CT scanning. Initial interventions for HLAP included aggressive intravenous hydration, bowel rest, pain control and a combination of heparin and insulin. Lipid-lowering agents were administered to reduce serum lipid levels. Hemoperfusion and continuous renal replacement therapy were also used to rapidly counteract the elevated lipid levels. Antibiotics were administered in the present case because inflammatory markers such as leukocytes, neutrophils and C-reactive protein were elevated. The patient and newborn were discharged 11 days after hospitalization, with an improvement in maternal clinical health and the infant was healthy. When evaluating pregnant patients with pre-obesity and diabetes presenting with abdominal pain, obstetricians should consider HLAP. Timely diagnosis and multi-team precision treatment are effective for good outcomes for mother and baby.

Clinical characteristics of three distinct types of pancreatitis with overlapping etiologies: A ten-year retrospective cohort study

BACKGROUND

Hypertriglyceridemia (HTG) is frequently observed in non-HTG-induced acute pancreatitis (AP), such as in the early stage of acute biliary pancreatitis (ABP). There is overlap in the etiologies of ABP, HTG-AP, and biliary-hypertriglyceridemia acute pancreatitis (BHAP), which may be perplexing for clinicians.

METHODS

We retrospectively analyzed 394 AP patients. The patients were divided into three groups based on etiology. We analyzed the differences among the three groups of patients in terms of general information, laboratory parameters, and prognosis.

RESULTS

The mean age of patients in the ABP group was significantly higher than that in the HTG-AP and BHAP groups (p < 0.001). Females made up a greater percentage of the ABP group, whereas males made up the majority in the HTG-AP and BHAP groups. The ABP group had the highest PCT, AMS, LPS, ALT, AST, GGT, TBIL, DBIL, APACHE II, and BISAP scores. TG and BMI were highest in the HTG-AP group. AST and GGT levels were substantially greater in BHAP patients than those in HTG-AP. The BHAP group had the greatest incidence of organ failure, systemic complications, and local complications.

CONCLUSION

ABP usually develops in people aged 50-59 years. HTG-AP primarily affects people aged 30-39 years. However, the peak incidence age of BHAP falls between the two aforementioned age groups (40-49 years). We also found that patients with BHAP seem to be in an intermediate state in terms of some biochemical markers and demographic characteristics. Furthermore, BHAP may have the worst clinical outcomes compared with HTG-AP and ABP.

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.

Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis

It is well known, that the inflammatory process that characterizes acute pancreatitis (AP) can lead to both pancreatic damage and systemic inflammatory response syndrome (SIRS). During the last 20 years, there has been a growing incidence of episodes of acute pancreatitis associated with hypertriglyceridaemia (HTAP). This review provides an overview of triglyceride metabolism and the potential mechanisms that may contribute to developing or exacerbating HTAP. The article comprehensively discusses the various pathological roles of free fatty acid, inflammatory response mechanisms, the involvement of microcirculation, serum calcium overload, oxidative stress and the endoplasmic reticulum, genetic polymorphism, and gut microbiota, which are known to trigger or escalate this condition. Future perspectives on HTAP appear promising, with ongoing research focused on developing more specific and effective treatment strategies.

The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review

Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.

Detailed Characteristics of Post-discharge Mortality in Acute Pancreatitis

BACKGROUND & AIMS

The in-hospital survival of patients suffering from acute pancreatitis (AP) is 95% to 98%. However, there is growing evidence that patients discharged after AP may be at risk of serious morbidity and mortality. Here, we aimed to investigate the risk, causes, and predictors of the most severe consequence of the post-AP period: mortality.

METHODS

A total of 2613 well-characterized patients from 25 centers were included and followed by the Hungarian Pancreatic Study Group between 2012 and 2021. A general and a hospital-based population was used as the control group.

RESULTS

After an AP episode, patients have an approximately threefold higher incidence rate of mortality than the general population (0.0404 vs 0.0130 person-years). First-year mortality after discharge was almost double than in-hospital mortality (5.5% vs 3.5%), with 3.0% occurring in the first 90-day period. Age, comorbidities, and severity were the most significant independent risk factors for death following AP. Furthermore, multivariate analysis identified creatinine, glucose, and pleural fluid on admission as independent risk factors associated with post-discharge mortality. In the first 90-day period, cardiac failure and AP-related sepsis were among the main causes of death following discharge, and cancer-related cachexia and non-AP-related infection were the key causes in the later phase.

CONCLUSION

Almost as many patients in our cohort died in the first 90-day period after discharge as during their hospital stay. Evaluation of cardiovascular status, follow-up of local complications, and cachexia-preventing oncological care should be an essential part of post-AP patient care. Future study protocols in AP must include at least a 90-day follow-up period after discharge.

Hypertriglyceridemia as a risk factor for complications of acute pancreatitis and the development of a severity prediction model

BACKGROUND

Hypertriglyceridemia (HTG) is a major cause of acute pancreatitis (AP). We aimed to determine whether HTG is an independent risk factor for AP complications and construct a prediction model for non-mild AP.

METHODS

We conducted a multi-center cohort study including 872 patients with AP and divided them into HTG-AP and non-HTG-AP groups. Multivariate logistic regression was performed, and a prediction model for non-mild HTG-AP was developed.

RESULTS

HTG-AP patients had a higher risk of systemic complications, including systemic inflammatory response syndrome [odds ratio (OR): 1.718; 95% confidence interval (CI): 1.286-2.295], shock (OR: 2.103; 95%CI: 1.236-3.578), acute respiratory distress syndrome (OR: 2.231; 95%CI: 1.555-3.200), acute renal failure (OR: 1.593; 95%CI: 1.036-2.450), and local complications such as acute peripancreatic fluid collection (OR: 2.072; 95%CI: 1.550-2.771), acute necrotic collection (OR: 1.996; 95%CI: 1.394-2.856), and walled-off necrosis (OR: 2.157; 95%CI: 1.202-3.870). The area under curve of our prediction model was 0.898 (95%CI: 0.857-0.940) and 0.875 (95%CI: 0.804-0.946) in the derivation and validation datasets respectively.

CONCLUSION

HTG is an independent risk factor for AP complications. We constructed a simple and accurate prediction model for progression of non-mild AP.

Efficacy and cost of double filtration plasmapheresis in severe hypertriglyceridemia-induced pancreatitis: A retrospective observational study

BACKGROUND

The value of double filtration plasmapheresis (DFPP) in severe hypertriglyceridemia-induced pancreatitis (sHTGP) is controversial. This study aimed to investigate the efficacy of DFPP on clinical outcomes in patients with sHTGP and the costs associated with the procedure.

METHODS

Patients who underwent DFPP after admission between January 2016 and December 2021 were recruited. Data on lipid profile, clinical parameters, and costs were retrospectively collected and analyzed.

RESULTS

Fifty sHTGP patients who received DFPP were enrolled. All of the lipid profile were significantly reduced and maintained a downward trend. The APACHE II score on admission was higher and the reduction after DFPP was more obvious (P < 0.05) in patients with higher triglyceride (TG) levels (≥33.9 mmol/L) than in patients with lower TG levels. More material fees were expended in the higher TG group due to more DFPP sessions (P < 0.05), but no significant differences existed in total hospital costs between the two groups.

CONCLUSION

DFPP could rapidly and effectively reduce TGs to a safe level. APACHE II score reduction was obvious in patients with TGs ≥33.9 mmol/L and was associated with lipid profile changes. DFPP may benefit sHTGP patients with a TG level higher than the current initiation threshold.

Acute Pancreatitis (AP) in Pregnancy and Its Complications From an Anesthesia Perspective: A Case Report

Acute pancreatitis (AP) is a rare event in pregnancy that is characterized by a sudden and severe inflammation of the pancreas. The clinical manifestation of AP during pregnancy is highly variable ranging from a mild form to a severe and potentially life-threatening presentation. We share a case of a 29-year-old female (gravida II, para I) who presented in her 33rd gestational week. The patient complained of upper abdominal pain and nausea. Her previous history revealed that she had four episodes of vomiting (food-containing, non-projectile) at home. Her uterine tone was normal, and her cervix was closed. Her white blood cell count was 13,000/mm3, and her C-reactive protein (CRP) level was 65 mg/L. She underwent an emergency laparotomy due to suspected acute appendicitis; however, no peritonitis was found intraoperatively. Further blood tests showed high levels of triglyceride at 87.5 mmol/L. The electrophoretic pattern of lipoprotein was consistent with type V hyperlipoproteinemia. An abdominal computed tomography (CT) confirmed the diagnosis of acute pancreatitis. During follow-up after one month, the patient showed triglyceride levels at 4.75 mmol/L and cholesterol at 6.07 mmol/L. Acute pancreatitis due to hypertriglyceridemia is a rare finding; nonetheless, it should be considered as a potential etiology in pregnant patients with nonobstructive abdominal pain.

Metabolic-associated fatty liver disease is associated with acute pancreatitis with more severe course: Post hoc analysis of a prospectively collected international registry

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is a proven risk factor for acute pancreatitis (AP). However, NAFLD has recently been redefined as metabolic-associated fatty liver disease (MAFLD). In this post hoc analysis, we quantified the effect of MAFLD on the outcomes of AP.

METHODS

We identified our patients from the multicentric, prospective International Acute Pancreatitis Registry of the Hungarian Pancreatic Study Group. Next, we compared AP patients with and without MAFLD and the individual components of MAFLD regarding in-hospital mortality and AP severity based on the revised Atlanta classification. Lastly, we calculated odds ratios (ORs) with 95% confidence intervals (CIs) using multivariate logistic regression analysis.

RESULTS

MAFLD had a high prevalence in AP, 39% (801/2053). MAFLD increased the odds of moderate-to-severe AP (OR = 1.43, CI: 1.09-1.89). However, the odds of in-hospital mortality (OR = 0.89, CI: 0.42-1.89) and severe AP (OR = 1.70, CI: 0.97-3.01) were not higher in the MAFLD group. Out of the three diagnostic criteria of MAFLD, the highest odds of severe AP was in the group based on metabolic risk abnormalities (OR = 2.68, CI: 1.39-5.09). In addition, the presence of one, two, and three diagnostic criteria dose-dependently increased the odds of moderate-to-severe AP (OR = 1.23, CI: 0.88-1.70, OR = 1.38, CI: 0.93-2.04, and OR = 3.04, CI: 1.63-5.70, respectively) and severe AP (OR = 1.13, CI: 0.54-2.27, OR = 2.08, CI: 0.97-4.35, and OR = 4.76, CI: 1.50-15.4, respectively). Furthermore, in patients with alcohol abuse and aged ≥60 years, the effect of MAFLD became insignificant.

CONCLUSIONS

MAFLD is associated with AP severity, which varies based on the components of its diagnostic criteria. Furthermore, MAFLD shows a dose-dependent effect on the outcomes of AP.

Effect of Plasma Exchange Treatment in Patients with Hypertriglyceridemia-Induced Acute Pancreatitis

Background and Objectives: To describe the clinical and biological characteristics of patients with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) and to evaluate the effectiveness of therapeutic plasma exchange (TPE) in the management of HTG-AP. Materials and Methods: A cross-sectional study was conducted on 81 HTG-AP patients (30 treated with TPE and 51 treated conventionally). The main outcome was a decrease in serum triglyceride levels (<11.3 mmol/L) within 48 h of hospitalization. Results: The mean age of participants was 45.3 ± 8.7 years, and 82.7% were male. Abdominal pain was the most frequent clinical sign (100%), followed by dyspepsia (87.7%), nausea or vomiting (72.8%), and a bloated stomach (61.7%). The HTG-AP patients treated with TPE had significantly lower calcemia and creatinemia levels but higher triglyceride levels than those who received conservative treatment. They also had more severe diseases than those treated conservatively. All patients in the TPE group were admitted to the ICU, whereas the ICU admission rate in the non-TPE group was 5.9%. The TPE patients were more likely to experience a rapid decrease in triglyceride levels within 48 h of treatment than those treated conventionally (73.3% vs. 49.0%, p = 0.03, respectively). The decrease in triglyceride levels did not depend on the age, gender, or comorbidities of the HTG-AP patients or the severity of disease. However, TPE and early treatment in the first 12 h of disease onset were effective in rapidly reducing serum triglyceride levels (adjusted OR = 3.00, p = 0.04 and aOR = 7.98, p = 0.02, respectively). Conclusions: This report demonstrates the effectiveness of early TPE in reducing triglyceride levels among HTG-AP patients. More randomized clinical trials studies with a large sample size and post-discharge follow-up are needed to confirm the effectiveness of TPE methods in managing HTG-AP.

A Rare Case of Acute Necrotizing Pancreatitis Infected With Prevotella Species

Acute pancreatitis is one of the leading causes of gastrointestinal-related hospitalizations in the United States. One of the complications of acute pancreatitis is infected pancreatic necrosis. We present a rare case of acute necrotizing pancreatitis infected with Prevotella species in a young patient. We demonstrate the importance of early suspicion of complicated acute pancreatitis and the need for early intervention to prevent hospital re-admission and improve the morbidity and mortality associated with infected pancreatic necrosis.

High Triglyceride-Glucose Index Is Associated with Poor Prognosis in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common gastrointestinal disease worldwide. Severe acute pancreatitis (SAP) is characterized as persistent organ failure with a mortality rate as high as 20-30%. Early assessment of the severity and screening out possible SAP is of great significance. Given that there is still a lack of both convenient and practical tools for evaluating SAP, we conducted this study to explore the association between TyG index and acute pancreatitis prognosis.

METHODS

A total of 353 in-patients diagnosed with acute pancreatitis in the Second Hospital of Shandong University were retrospectively enrolled from January 2018 to November 2021 in this study. According to the Atlanta Classification, they were divided into two groups based on the AP severity. Demographic information and clinical materials were retrospectively collected. The TyG index calculation formula is as follows: ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2]. Statistical analyses were performed using SPSS software (IBM version 22.0) and Medcalc software. Multivariable logistic regression analyses were used to investigate independent predictors for SAP. ROC curve was plotted to assess the predictive ability and cutoffs of TyG index.

RESULTS

A total of 353 AP patients were respectively enrolled in this study, of which 47 suffered from SAP. Compared with the non-SAP group, TyG index was significantly higher in the SAP group (10.44 ± 1.55 vs 9.33 ± 1.44, P < 0.001). Multivariate logistic regression analysis showed that TyG index was an independent risk factor for SAP (OR 1.835, 95% CI 1.380-2.442 P < 0.001), with a cutoff of 8.76 for non-HTG/AAP and 11.81 for HTG/AAP by ROC curve. TyG index of patients who suffered from SIRS, OF, APFC, and ANC was higher than those without (P < 0.05).

CONCLUSIONS

The triglyceride-glucose index is an independent risk factor for SAP. High TyG index is closely related to SAP and AP-related complications.

Mechanisms linking hypertriglyceridemia to acute pancreatitis

Hypertriglyceridemia (HTG) is a metabolic disorder, defined when serum or plasma triglyceride concentration (seTG) is >1.7 mM. HTG can be categorized as mild to very severe groups based on the seTG value. The risk of acute pancreatitis (AP), a serious disease with high mortality and without specific therapy, increases with the degree of HTG. Furthermore, even mild or moderate HTG aggravates AP initiated by other important etiological factors, including alcohol or bile stone. This review briefly summarizes the pathophysiology of HTG, the epidemiology of HTG-induced AP and the clinically observed effects of HTG on the outcomes of AP. Our main focus is to discuss the pathophysiological mechanisms linking HTG to AP. HTG is accompanied by an increased serum fatty acid (FA) concentration, and experimental results have demonstrated that these FAs have the most prominent role in causing the consequences of HTG during AP. FAs inhibit mitochondrial complexes in pancreatic acinar cells, induce pathological elevation of intracellular Ca²⁺ concentration, cytokine release and tissue injury, and reduce the function of pancreatic ducts. Furthermore, high FA concentrations can induce respiratory, kidney, and cardiovascular failure in AP. All these effects may contribute to the observed increased AP severity and frequent organ failure in patients. Importantly, experimental results suggest that the reduction of FA production by lipase inhibitors can open up new therapeutic options of AP. Overall, investigating the pathophysiology of HTG-induced AP or AP in the presence of HTG and determining possible treatments are needed.

COVID-19, Hypertriglyceridemia, and Acute Pancreatitis: A Case Report and Clinical Considerations

Acute pancreatitis (AP) is a serious condition that can result in numerous negative outcomes including death. The underlying causes of AP are varied, with both COVID-19 and hypertriglyceridemia being documented in the medical literature. Here, we present the case of a young man with a pre-existing diagnosis of prediabetes and class 1 obesity who developed severe hypertriglyceridemia, AP, and mild diabetic ketoacidosis while concurrently infected with COVID-19. It is crucial for healthcare providers to be vigilant in recognizing the potential complications associated with COVID-19, regardless of whether the patient has received a vaccination.

Current and Emerging Therapies for Atherosclerotic Cardiovascular Disease Risk Reduction in Hypertriglyceridemia

Hypertriglyceridemia (HTG) is a prevalent medical condition in patients with cardiometabolic risk factors and is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD), if left undiagnosed and undertreated. Current guidelines identify HTG as a risk-enhancing factor and, as a result, recommend clinical evaluation and lifestyle-based interventions to address potential secondary causes of elevated triglyceride (TG) levels. For individuals with mild to moderate HTG at risk of ASCVD, statin therapy alone or in combination with other lipid-lowering medications known to decrease ASCVD risk are guideline-endorsed. In addition to lifestyle modifications, patients with severe HTG at risk of acute pancreatitis may benefit from fibrates, mixed formulation omega-3 fatty acids, and niacin; however, evidence does not support their use for ASCVD risk reduction in the contemporary statin era. Novel therapeutics including those that target apoC-III and ANGPTL3 have shown to be safe, well-tolerated, and effective for lowering TG levels. Given the growing burden of cardiometabolic disease and risk factors, public health and health policy strategies are urgently needed to enhance access to effective pharmacotherapies, affordable and nutritious food options, and timely health care services.

Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis

BACKGROUND

Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes.

PURPOSE

An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients.

METHODS

We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis.

RESULTS

NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs.

CONCLUSIONS

NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.

Acute Pancreatitis Severity Prediction: It Is Time to Use Artificial Intelligence

The clinical course of acute pancreatitis (AP) can be variable depending on the severity of the disease, and it is crucial to predict the probability of organ failure to initiate early adequate treatment and management. Therefore, possible high-risk patients should be admitted to a high-dependence unit. For risk assessment, we have three options: (1) There are univariate biochemical markers for predicting severe AP. One of their main characteristics is that the absence or excess of these factors affects the outcome of AP in a dose-dependent manner. Unfortunately, all of these parameters have low accuracy; therefore, they cannot be used in clinical settings. (2) Score systems have been developed to prognosticate severity by using 4-25 factors. They usually require multiple parameters that are not measured on a daily basis, and they often require more than 24 h for completion, resulting in the loss of valuable time. However, these scores can foresee specific organ failure or severity, but they only use dichotomous parameters, resulting in information loss. Therefore, their use in clinical settings is limited. (3) Artificial intelligence can detect the complex nonlinear relationships between multiple biochemical parameters and disease outcomes. We have recently developed the very first easy-to-use tool, EASY-APP, which uses multiple continuous variables that are available at the time of admission. The web-based application does not require all of the parameters for prediction, allowing early and easy use on admission. In the future, prognostic scores should be developed with the help of artificial intelligence to avoid information loss and to provide a more individualized risk assessment.

Circulating monocytes in acute pancreatitis

Acute pancreatitis is a common gastrointestinal disease characterized by inflammation of the exocrine pancreas and manifesting itself through acute onset of abdominal pain. It is frequently associated with organ failure, pancreatic necrosis, and death. Mounting evidence describes monocytes - phagocytic, antigen presenting, and regulatory cells of the innate immune system - as key contributors and regulators of the inflammatory response and subsequent organ failure in acute pancreatitis. This review highlights the recent advances of dynamic change of numbers, phenotypes, and functions of circulating monocytes as well as their underling regulatory mechanisms with a special focus on the role of lipid modulation during acute pancreatitis.

Insulin or blood purification treatment for hypertriglyceridaemia-associated acute pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hypertriglyceridaemia increases risks from acute pancreatitis (HTG-AP) over other aetiologies, but optimal management for HTG-AP remains undefined. We performed a systematic review and meta-analysis of studies of insulin-based treatment (IT) versus blood purification treatment (BPT) for HTG-AP.

METHODS

Searches were conducted to identify randomised trials and observational studies published between 1946 and 2022 that compared IT and BPT for HTG-AP reporting baseline and post-treatment serum triglyceride (TG) levels with clinical outcomes. The primary outcome was serum TG reduction (Δ-TG) from baseline while secondary outcomes included complications, length of stay, adverse events, and cost.

RESULTS

Fifteen (1 randomised, 2 prospective case-controlled, and 12 retrospective cohort) studies were analysed comprising 909 cases with HTG-AP. Pooled results demonstrated IT was significantly less efficient than BPT in Δ-TG at 24 h (WMD -666.06, 95% CI -1130.18 to -201.94, P = 0.005; 12 studies), at 48 h (WMD -672.60, 95% CI -1233.44 to -111.77; 8 studies), and overall Δ-TG by day 7 (WMD -385.81, 95% CI -711.07 to -60.54; 8 studies) (both P = 0.02). IT, however, was associated with significantly fewer adverse events (OR 0.09, 95% CI 0.03 to 0.27, P < 0.0001; 7 studies) and significantly reduced cost (WMD -2.50, 95% CI -3.61 to -1.39, P < 0.00001; 3 studies). Other secondary outcomes were not significantly different between the two regimens (all P ≥ 0.11). In subgroup analysis Δ-TG at 24 h and overall Δ-TG became insignificant, while other results were unaffected.

CONCLUSION

Our findings support the general use of IT for inpatient management of HTG-AP, restricting BPT to those predicted or found to respond poorly to IT.

Plasma Exchange for the Treatment of Severe Hypertriglyceridemic Pancreatitis With Diabetic Ketoacidosis: A Case Report From Sub-Saharan Africa

The triad of acute pancreatitis, diabetic ketoacidosis, and hyperlipidemia is exceedingly rare. Case reports describing this uncommon triad have successfully been managed with insulin infusions only. Herein, we highlight the challenges in making this diagnosis and present Sub-Saharan Africa's first experience with therapeutic plasma exchange in the management of hypertriglyceridemic pancreatitis associated with diabetic ketoacidosis, which was initially refractory to insulin infusion alone.

Evaluating the Clinical Characteristics and Outcomes of Idiopathic Acute Pancreatitis: Comparison With Nonidiopathic Acute Pancreatitis Over a 10-Year Period

OBJECTIVE

Up to 30% of acute pancreatitis (AP) cases do not have an established etiology (idiopathic AP [IAP]). We evaluated the characteristics and outcomes of hospitalized IAP patients compared with those with established AP cause (non-IAP).

METHODS

A retrospective study of AP patients admitted to a single center from 2008 to 2018 was performed. Patients were divided into IAP and non-IAP groups. Outcomes included mortality, 30-day and 1-year readmission, length of stay (LOS), intensive care unit admissions, and complications.

RESULTS

Of 878 AP patients, 338 had IAP and 540 non-IAP (234 gallstone, 178 alcohol). Groups had similar demographics, Charlson Comorbidity Index, and pancreatitis severity. The IAP patients had more 1-year readmissions (0.64 vs 0.55, P = 0.006) but similar 30-day readmissions and mortality. Patients with IAP had shorter LOS (4.98 vs 5.99 days, P = 0.01), and fewer intensive care unit admissions (3.25% vs 6.85%, P = 0.03) and extrapancreatic complications (15.4% vs 25.2%, P = 0.001). There was no difference in pain level between groups.

CONCLUSIONS

The IAP patients tend to have more readmissions in 1 year, but less severe presentations, shorter LOS, and fewer complications. Readmission rates may be related to lack of defined etiology and treatment to prevent recurrence.

Development and validation of a risk prediction score for the severity of acute hypertriglyceridemic pancreatitis in Chinese patients

BACKGROUND

The frequency of acute hypertriglyceridemic pancreatitis (AHTGP) is increasing worldwide. AHTGP may be associated with a more severe clinical course and greater mortality than pancreatitis caused by other causes. Early identification of patients with severe inclination is essential for clinical decision-making and improving prognosis. Therefore, we first developed and validated a risk prediction score for the severity of AHTGP in Chinese patients.

AIM

To develop and validate a risk prediction score for the severity of AHTGP in Chinese patients.

METHODS

We performed a retrospective study including 243 patients with AHTGP. Patients were randomly divided into a development cohort (n = 170) and a validation cohort (n = 73). Least absolute shrinkage and selection operator and logistic regression were used to screen 42 potential predictive variables to construct a risk score for the severity of AHTGP. We evaluated the performance of the nomogram and compared it with existing scoring systems. Last, we used the best cutoff value (88.16) for severe acute pancreatitis (SAP) to determine the risk stratification classification.

RESULTS

Age, the reduction in apolipoprotein A1 and the presence of pleural effusion were independent risk factors for SAP and were used to construct the nomogram (risk prediction score referred to as AAP). The concordance index of the nomogram in the development and validation groups was 0.930 and 0.928, respectively. Calibration plots demonstrate excellent agreement between the predicted and actual probabilities in SAP patients. The area under the curve of the nomogram (0.929) was better than those of the Bedside Index of Severity in AP (BISAP), Ranson, Acute Physiology and Chronic Health Evaluation (APACHE II), modified computed tomography severity index (MCTSI), and early achievable severity index scores (0.852, 0.825, 0.807, 0.831 and 0.807, respectively). In comparison with these scores, the integrated discrimination improvement and decision curve analysis showed improved accuracy in predicting SAP and better net benefits for clinical decisions. Receiver operating characteristic curve analysis was used to determine risk stratification classification for AHTGP by dividing patients into high-risk and low-risk groups according to the best cutoff value (88.16). The high-risk group (> 88.16) was closely related to the appearance of local and systemic complications, Ranson score ≥ 3, BISAP score ≥ 3, MCTSI score ≥ 4, APACHE II score ≥ 8, C-reactive protein level ≥ 190, and length of hospital stay.

CONCLUSION

The nomogram could help identify AHTGP patients who are likely to develop SAP at an early stage, which is of great value in guiding clinical decisions.