Pancreatitis, familial hypertriglyceridemia, and pregnancy

Physiological changes in pregnancy and their influence on the endocrine investigation

BACKGROUND

Physiological changes in pregnancy may result in significant alterations in endocrine hormone profiles, serum and urine electrolytes and endocrine gland morphology on imaging. Pregnancy-specific pathophysiological processes may also affect the results for endocrine tests. Investigation of endocrine disorders in pregnancy requires knowledge of these changes and awareness of the safety of dynamic hormone testing and imaging for the mother and foetus.

OBJECTIVE

This review seeks to outline the important physiological changes in pregnancy affecting reference intervals of basal and dynamic endocrine tests in pregnancy and the scenarios in which these changes are clinically significant, the pregnancy-specific disorders that may affect the investigation of endocrine disorders, and the safety of dynamic testing and imaging.

CONCLUSION

Awareness of the effect of physiological changes, and the potential impact of pregnancy-specific disorders of endocrine tests, and the safety of imaging is crucial to the management of endocrine disorders in pregnancy.

Changes in biochemical tests in pregnancy and their clinical significance

Interpretation of laboratory investigations relies on reference intervals. Physiological changes in pregnancy may result in significant changes in normal values for many biochemical assays, and as such results may be misinterpreted as abnormal or mask a pathological state. The aims of this review are as follows: 1. To review the major physiological changes in biochemical tests in normal pregnancy. 2. To outline where these physiological changes are important in interpreting laboratory investigations in pregnancy. 3. To document the most common causes of abnormalities in biochemical tests in pregnancy, as well as important pregnancy-specific causes.

Pregnancies Complicated by Familial Hypertriglyceridemia: A Case Report

Background  Although rare, familial hypertriglyceridemia can cause acute and life-threatening complications in pregnancy. Cases  The first patient's pregnancy was complicated by multiple admissions for pancreatitis due to hypertriglyceridemia and noncompliance with gemfibrozil. In her second pregnancy, she was compliant with gemfibrozil and only experienced pancreatitis episodes toward the end of pregnancy. The second patient had diabetes mellitus and familial hypertriglyceridemia. She required multiple hospitalizations for diabetic ketoacidosis secondary to insulin noncompliance. In both pregnancies, she was compliant with gemfibrozil and had no complications related to hypertriglyceridemia. Conclusion  Treatment with gemfibrozil in pregnancies complicated by hypertriglyceridemia may prevent complications without adverse maternal or fetal effects and could be considered in treating pregnant patients with severe hypertriglyceridemia. These cases also demonstrate the importance of medication compliance in the prevention of poor outcomes.

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.

Hypertriglyceridemia Induced Pancreatitis in a Non-Diabetic Pregnant Patient Requiring the Use of Total Parenteral Nutrition

Hypertriglyceridemia induced pancreatitis in pregnancy is established and has been widely reported. However there are very scanty reports of cases involving the use of total parenteral nutrition. We report the case of a 37-year-old gravida 3, para 2 woman at 34 weeks of gestation who presented with one day of severe epigastric pain radiating to the back, nausea and bilious vomiting caused by pancreatitis induced by hypertriglyceridemia. Her initial serum triglyceride, amylase and lipase concentration were 6,552 mg/dl, 314 U/L and 537 U/L respectively. She initially received intravenous fluids and insulin with reduction of serum triglyceride levels to 583 mg/dl on the fifth day of admission. However attempts to refeed the patient with solid food resulted in induction of hypertriglyceridemia and relapse of pancreatitis. Lipid free total parenteral nutrition was commenced in the third week of admission and lead to a better control of triglyciderides and resolution of pancreatitis until delivery of a full term healthy neonate.

The relationship between abdominal aortic intima-media thickness and lipid profile in neonates born to mothers with preeclampsia

Neonates born to mothers with preeclampsia are known to be associated with lipid alterations that might increase the risk for cardiovascular disease in adult life. The aim of this study was to investigate the effect of preeclampsia on lipid metabolism, aortic intimamedia thickness (aIMT) and subsequent atherogenic risk in newborn infants. Aortic intima-media thickness was measured in 60 neonates of mothers with preeclampsia (group I; 30 neonates of mothers with preeclampsia and group II; 30 neonates of mothers with severe preeclampsia) and 30 healthy neonates (group III). Maternal and cord serum lipid profiles were determined in all groups. Mean abdominal aIMT measurements were higher in the neonates born to mothers with preeclampsia (group I; 0.36 +/- 0.03 mm and group II; 0.36 +/- 0.04 mm) compared with the control group (group III; 0.33 +/- 0.03 mm, p = 0.006). Serum triglyceride levels were significantly higher in the neonates born to mothers with preeclampsia (group I; 39.2 +/- 42.0 mg/dl and group II; 39.5 +/- 56.5 mg/dl) compared with the control group (group III; 14.9 +/- 18.8 mg/dl, p = 0,039). Serum HDL cholesterol levels were significantly lower in the neonates born to mothers with preeclampsia (group I; 17.3 +/- 12.3 mg/dl and group II; 17.1 +/- 12.8 mg/dl) compared with the control group (group III; 27.6 +/- 13.0 mg/dl, p = 0.002). In conclusion; neonates of mothers with preeclampsia have significantly higher aIMT with lipid alterations. This may play a role in the pathogenesis of atherosclerosis in adult life.

There may be a link between intrahepatic cholestasis of pregnancy and familial combined hyperlipidaemia: a case report

A 26-year-old gravida 3 para 1+1 was referred for antenatal care. In her last pregnancy she had a early spontaneous preterm delivery at 32 weeks and 2 days complicated by intra hepatic cholestasis of pregnancy. She had a strong family history of ischemic heart and combined hyperlipidaemia. In view of her past obstetric history a baseline liver function test and fasting bile acid assay was carried out. Upto 21 week her Bile acids were normal but at 22 weeks her fasting bile acid assay increased to the upper limit of normal (9 micromol/L).Ursodeoxycholic acid was started from 28 weeks gestation on a dosage of 500 mg b.i.d., which was subsequently increased to 500 mg t.d.s. at 32 weeks.At 34 weeks she gave a history of occasional right upper quadrant abdominal pain and her biochemistry revealed raised serum aspartate transaminase ,alanine transaminase, fasting serum triglyceride and cholesterol levels 58 IU,79 IU/L,18.37 mmol/L and 25.7 mmol/L respectively. The triglyceride level was too high to calculate the low density lipoprotein cholesterol. A diagnosis of severe intrahepatic cholestasis of pregnancy in a patient with background familial combined hyperlipidaemia was made. Ultrasound abdomen and cardiotocography was normal. She had normal delivery. In cases of early onset cholestasis of pregnancy we suggest that lipid profiles are checked in these patients to rule out hyperlipidaemia and its attendant short term and long-term risks. More research will be required to ascertain if there is a link between these 2 disorders.

There may be a link between intrahepatic cholestasis of pregnancy and familial combined hyperlipidaemia: a case report

A 26-year-old gravida 3 para 1+1 was referred for antenatal care. In her last pregnancy she had a early spontaneous preterm delivery at 32 weeks and 2 days complicated by intra hepatic cholestasis of pregnancy. She had a strong family history of ischemic heart and combined hyperlipidaemia. In view of her past obstetric history a baseline liver function test and fasting bile acid assay was carried out. Upto 21 week her Bile acids were normal but at 22 weeks her fasting bile acid assay increased to the upper limit of normal (9 µmol/L).

Ursodeoxycholic acid was started from 28 weeks gestation on a dosage of 500 mg b.i.d., which was subsequently increased to 500 mg t.d.s. at 32 weeks.

At 34 weeks she gave a history of occasional right upper quadrant abdominal pain and her biochemistry revealed raised serum aspartate transaminase ,alanine transaminase, fasting serum triglyceride and cholesterol levels 58 IU,79 IU/L,18.37 mmol/L and 25.7 mmol/L respectively. The triglyceride level was too high to calculate the low density lipoprotein cholesterol. A diagnosis of severe intrahepatic cholestasis of pregnancy in a patient with background familial combined hyperlipidaemia was made. Ultrasound abdomen and cardiotocography was normal. She had normal delivery. In cases of early onset cholestasis of pregnancy we suggest that lipid profiles are checked in these patients to rule out hyperlipidaemia and its attendant short term and long-term risks. More research will be required to ascertain if there is a link between these 2 disorders.

Dyslipidaemic pancreatitis clinical assessment and analysis of disease severity and outcomes

INTRODUCTION

The relationship between pancreatitis and dyslipidaemia is unclear.

PATIENTS AND METHODS

Admissions with acute pancreatitis were prospectively evaluated. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths was made in relationship to the lipid profiles.

RESULTS

From June 2001 to May 2005, there were 230 admissions. The pancreatitis was associated with alcohol (63%), gallstones (18%), idiopathic (9%) and isolated dyslipidaemia (10%). Dyslipidaemia was significantly different between the two predominant race groups: Indian 50.5% and African 17.9% (p < 0.000017). Seventy-eight (34%) had associated dyslipidaemia and 152 (66%) were normolipaemic at admission. The average body mass index was higher in the dyslipidaemic group (27 +/- 6) than in the normolipaemic group (24.5 +/- 6.20; p = 0.004). The mortality rate was similar between the dyslipidaemic and normolipaemic patients (10 and 8%, respectively) and unrelated to race (p = 0.58). The 9 deaths in the dyslipidaemic group occurred in those with persistent hypertriglyceridaemia irrespective of its level (p = 0.003).

CONCLUSION

Dyslipidaemic pancreatitis was more common in the Indian ethnic group. Adverse outcomes in those with dyslipidaemia were predominantly associated with hypertriglyceridaemia.

Pregnancy-induced hyperlipoproteinemia: review of the literature

It is well known that with the effect of hormonal changes during pregnancy, plasma lipid levels increase. Expected elevations for triglyceride and cholesterol levels during a normal gestational period usually do not exceed 332 mg/dL and 337 mg/dL, respectively (corresponding 95th percentile values). However, elevations over the 95th percentile values can be observed during pregnancy, and patients with levels over these expected adaptation levels can be divided into 2 groups: (1) supraphysiologic hyperlipoproteinemia during pregnancy and (2) extreme hyperlipoproteinemia limited to gestational period (triglyceride level >1000 mg/dL). Regarding the first group, some of these patients may develop hyperlipoproteinemia in their future life. What percentage of these women will translate into hyperlipoproteinemia later in life and how efficiently these women can be screened during pregnancy is an enigma. The underlying disorders in the second group of patients at least include dysbetalipoproteinemia, partial lipoprotein lipase deficiency, and apoprotein E3/3 genotype. Pregnancy had been reported to induce severe hyperlipoproteinemia that is limited to gestational period in these disorders. Dysbetalipoproteinemia, partial lipoprotein lipase deficiency, and apoprotein E3/3 genotype probably bring risks and implications to the future life of the carrying individuals although the true extent of the risks is yet to be defined. When disorders unique to gestational period such as gestational diabetes are considered, pregnancy may be accepted as an opportunity to identify women under risk of cardiovascular morbidity and mortality.

Acute hyperlipidemic pancreatitis in pregnancy

BACKGROUND

Pancreatitis in pregnancy remains a rare event and is most often associated with gallstone disease. Hyperlipidemic gestational pancreatitis usually occurs in women with a preexisting abnormality of the lipid metabolism and poses particular problems in diagnosis and clinical management.

CASES

We describe 5 patients with acute episodes of pancreatitis during pregnancy caused by hyperlipidemia.

CONCLUSION

Acute pancreatitis in pregnancy causes significant morbidity. Even though it is often associated with gallstones, we describe 5 cases in which the etiology of the pancreatitis was maternal hyperlipidemia. Etiology, diagnosis, and management will be discussed.

[Severe gestational hypertriglyceridemia: related complications and management]

We present two cases of severe hypertriglyceridemia (HTG>10g/l) in pregnancy. The first reports the case of a primigravida with mild HTG before conception. Triglycerides (TG) increased thereafter (20.9g/l) during pregnancy causing pancreatitis and in utero fetal death at 24 weeks' gestation (WG). The second deals with the de novo occurrence of a severe HTG (19g/l) diagnosed incidentally at 34 WG and complicated by acute renal failure. Severe HTG in pregnancy threatens maternal and fetal prognosis. We have summarized the curative and preventive management of gravidic HTG.

[Hypertriglyceridemia-induced pancreatitis in pregnancy. A case report]

We report the case of a 31-year-old pregnant patient in the 33rd week of gestation, with no history of dyslipidaemia, admitted for sub-acute epigastric pain. The milky aspect of blood samples was remarkable. Blood analysis showed a moderate increase in pancreatic enzymes but a major hyperlipaemia: triglyceridaemia 113 g/l and total cholesterolaemia 25 g/l. We suspected a hypertriglyceridemia-induced pancreatitis in pregnancy. The diagnosis was confirmed by CT-scan. Abdominal echography showed no abnormalities in biliary duct. After few hours, a caesarean was performed for acute fetal distress. The patient was admitted to the intensive care unit where a decrease of hypertriglyceridemia was already observed. Only one plasmapheresis was performed. Heparin was introduced. Rapid clinical improvement allowed discharge from intensive care at day 3. This case report illustrates lipid decrease with undertaken treatments. We discuss the management of hypertriglyceridemia-induced pancreatitis in pregnancy.

Total Parenteral Nutrition in Management of Hyperlipidemic Pancreatitis During Pregnancy

OBJECTIVE

To describe a case of severe gestational hyperlipidemic pancreatitis successfully managed with minimal-lipid-containing parenteral nutrition (PN) followed by a minimal-fat diet, which resulted in delivery of a healthy full-term neonate.

METHODS

We present the case of a young woman with gestational hyperlipidemic pancreatitis whose management included the use of PN during pregnancy. In addition, we review the literature pertaining to the management of hyperlipidemic pancreatitis during pregnancy and discuss the role for PN.

RESULTS

A 32-year-old gravida 2, para 1 woman at 27 weeks 3 days of gestation presented with 1 day of nausea, bilious emesis, and severe abdominal pain caused by pancreatitis attributable to hypertriglyceridemia. Her initial serum triglyceride concentration was 9,450 mg/dL. She received fluids intravenously and minimal-lipid PN until resolution of her symptoms. The serum triglyceride level remained less than 850 mg/dL during administration of PN. She subsequently tolerated a minimal-fat diet, while the serum triglyceride level was maintained at less than 1,400 mg/dL, until delivery of a full-term, healthy neonate.

CONCLUSION

In severe gestational hyperlipidemic pancreatitis, PN offers a safe and flexible treatment option by providing pancreatic rest and controlling serum triglyceride concentrations while maintaining fetal and maternal nutritional support.

Severe hypertriglyceridemia and acute pancreatitis during pregnancy: treatment with gemfibrozil

OBJECTIVE

To describe the effect of gemfibrozil therapy during pregnancy in a woman with severe hypertriglyceridemia.

METHODS

We present a case report, with details of lipid levels throughout several attempted pregnancies, and discuss other similar published studies.

RESULTS

In a 22-year-old woman, severe acute pancreatitis due to hypertriglyceridemia developed during her first pregnancy. After a prolonged hospital course, the outcome was fetal demise. The patient was subsequently treated with gemfibrozil, which controlled the hypertriglyceridemia. A second pregnancy ended with a therapeutic abortion at 1 month because of the possible risk of pancreatitis. Gemfibrozil therapy was instituted but subsequently discontinued when she was discovered to be pregnant again, at approximately 10 weeks of gestation; the potential risks involved with the use of this drug during pregnancy were unknown. Because of the patient's strong desire to maintain the pregnancy, gemfibrozil treatment was resumed 1 week later in order to help prevent recurrent pancreatitis. The patient ultimately delivered a fullterm healthy boy, and she had no recurrence of pancreatitis or other complications.

CONCLUSION

In selected patients at high risk for pancreatitis, the potential risk of gemfibrozil use during pregnancy may be offset by its benefits in the management of severe hypertriglyceridemia.

An observational study of severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens are given to women with and without familial hypertriglyceridemia

BACKGROUND

We assessed severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens were given to 56 women with and without familial hypertriglyceridemia. The 56 women had been consecutively referred to our center over a 3-year period because of triglycerides >400 mg/dl despite diet-drug treatment and/or a history of hypertriglyceridemic acute pancreatitis (AP). Of the 56 women, 17 had received estrogen replacement therapy (ERT), hormone replacement (HRT, n=6), or selective estrogen receptor modulators (SERM, n=1).

METHODS

After study at entry, in 56 women (median age, 52 years), 36 with familial hypertriglyceridemia, to lower triglycerides, estrogens and SERMs (hormone treatment, HT) were stopped; a very low fat diet (<15% of calories), gemfibrozil (1.2-1.5 mg/day), and omega-3-fatty acid (4-12 g/day) were started, with restudy 2-4 weeks later.

RESULTS

Of the 56 women, 24 (43%) were taking HT at entry, with median fasting triglycerides 1270 mg/dl in the HT group and 1087 mg/dl in the no-HT group. Seventeen women (30%) had a history of AP, nine of whom (53%) were/had been on HT at the development of AP. Significant positive correlates of triglycerides at entry in a stepwise regression model were hemoglobin A(1C) (partial r(2)=10.7%, p<0.05) and an interaction between estrogen use and familial hypertriglyceridemia (partial r(2)=15%, p=0.017). After 2-4 weeks on therapy, median triglycerides in the previous-HT group fell from 1270 to 284 mg/dl (p<0.0001) and in the no-HT group from 1087 to 326 mg/dl (p<0.0001).

CONCLUSIONS

Before starting HT, to avoid HT induced hypertriglyceridemic AP and exacerbation of overt or covert familial hypertriglyceridemia, triglycerides must be measured. HT is contraindicated in women with preexisting hypertriglyceridemia (triglycerides> or =500 mg/dl). Triglyceride-lowering diets and drugs often fail in the presence of HT and/or poorly controlled diabetes mellitus, but commonly succeed when HT is stopped and diabetes mellitus is tightly controlled.

Issues in hyperlipidemic pancreatitis

Hypertriglyceridemia (HTG) is a rare cause of pancreatitis. Pancreatitis secondary to HTG, presents typically as an episode of acute pancreatitis (AP) or recurrent AP, rarely as chronic pancreatitis. A serum triglyceride (TG) level of more than 1,000 to 2,000 mg/dL in patients with type I, IV, or V hyperlipidemia (Fredrickson's classification) is an identifiable risk factor. The typical clinical profile of hyperlipidemic pancreatitis (HLP) is a patient with a preexisting lipid abnormality along with the presence of a secondary factor (e.g., poorly controlled diabetes, alcohol use, or a medication) that can induce HTG. Less commonly, a patient with isolated hyperlipidemia (type V or I) without a precipitating factor presents with pancreatitis. Interestingly, serum pancreatic enzymes may be normal or only minimally elevated, even in the presence of severe pancreatitis diagnosed by imaging studies. The clinical course in HLP is not different from that of pancreatitis of other causes. Routine management of AP caused by hyperlipidemia should be similar to that of other causes. A thorough family history of lipid abnormalities should be obtained, and an attempt to identify secondary causes should be made. Reduction of TG levels to well below 1,000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment includes dietary restriction of fat and lipid-lowering medications (mainly fibric acid derivatives). Experiences with plasmapheresis, lipid pheresis, and extracorporeal lipid elimination are limited.

Pancreatic pseudocysts in pregnancy: a case report and review of the literature

BACKGROUND

Pancreatic pseudocyst in pregnancy is a rare condition whose management is not standardized.

STUDY DESIGN

We combine one case report with nine others published in the literature since 1980. The cases are compiled to provide a descriptive review of this condition.

RESULTS

The natural history of pancreatic pseudocysts in pregnancy appears similar to that in nongravid patients. Hyperlipidemia is overrepresented as a cause of pancreatic pseudocysts in pregnancy, causing more cases than alcoholic and biliary pancreatitis combined. Seventy-five percent of cases of known parity was primaparous. While in some cases percutaneous or endoscopic drainage was performed antepartum, most patients were conservatively managed until delivery. Despite two cases of successful vaginal delivery, cesarian section may be preferable for large pseudocysts to avert rupture.

Structure-function analysis of D9N and N291S mutations in human lipoprotein lipase using molecular modelling

Lipoprotein lipase (LPL) plays a central role in lipid metabolism. The D9N and N291S mutations in the LPL gene are associated with elevated triglyceride and decreased HDL-cholesterol levels. Published in vitro expression studies suggest that these two mutations are associated with reduced LPL enzymatic activity. We sought to gain further insight on the impact of these two mutations on the LPL structure and function by molecular modelling techniques. Homology modelling was used to develop a three-dimensional (3D) structure of LPL from human pancreatic lipase. Two separate LPL models for the D9N and N291S substitutions were constructed and compared with the wild type LPL for differences in hydrophobicity, atomic burial, hydrogen bond pattern, and atomic mobility. In comparison to the wild type model, the 9N model was associated with significantly increased atomic mobility of its neighboring residues, but the catalytic site was not affected. The region near residue 9 in the upper part of the N-domain was considered a candidate site for protein-protein interaction. In the N291S model, alterations in H-bonds and constrained atomic mobility were among conformational changes in the region where the substitution had occurred. These are hypothesized to cause an increase in the rate of dissociation in LPL dimerization, subsequently affecting the LPL enzymatic activity. We also modelled the C-domain of apoCII, the obligatory cofactor of LPL, from 2D NMR data and docked the model with LPL to explore their interaction site. These docking experiments suggest that the C-domain of apoCII interacts with the interface of N- and C-domains of LPL and part of the lid structure that covers the catalytic site. In summary, we provide molecular modelling data on two well-known mutations in the LPL gene to help explain the published in vitro expression findings and propose a possible LPL-apoCII interaction site. Our data indicate that molecular modelling of LPL mutations could provide a valuable tool to understand the effects of a mutation on the structure-function of this important enzyme.

Successful pregnancy outcome in a patient with severe chylomicronemia due to compound heterozygosity for mutant lipoprotein lipase

OBJECTIVES

Familial chylomicronemia syndrome is characterized by massive accumulation of plasma chylomicrons, which typically results from an absolute deficiency of lipoprotein lipase (LPL). Chylomicronemia in pregnancy is a rare, but serious clinical problem and can be found in patients with underlying molecular defects in the LPL gene. We report the course and treatment of an 18 yr-old primigravida who had LPL deficiency and hypertriglyceridemia since birth. We also analyzed the molecular basis of her LPL deficiency.

DESIGN AND METHODS

The patient's antenatal course was complicated by extreme elevations of plasma triglycerides. Her management included a very low fat diet, pharmacotherapy with gemfibrozil in the third trimester, and intermittent hospitalization with periods of fasting supplemented by IV glucose feeding. We used DNA sequencing to determine whether mutations in LPL were present.

RESULTS

At 38 weeks of gestation, labor was induced, and the patient delivered a healthy 2.77 kilogram male. Postnatal triglycerides fell to prenatal levels. DNA sequencing showed that she was a compound heterozygote for mutant LPL: I > T194 and R > H243.

CONCLUSIONS

This experience indicates that vigilance is required during pregnancy in patients with familial chylomicronemia due to mutant LPL. Gemfibrozil was used in this patient without apparent adverse effects. Compound heterozygosity for LPL mutations is an important underlying mechanism for LPL deficiency.

Clomiphene-induced severe hypertriglyceridemia and pancreatitis

Clomiphene has been available for clinical use since 1960 and has been successfully used to aid fertility in women with certain anovulatory disorders. It is a synthetic estrogen analog, of the triphenylethylene derivative group, and its biochemical structure is similar to that of tamoxifen. Estrogen and tamoxifen lower total and low-density lipoprotein cholesterol and increase triglyceride and high-density lipoprotein cholesterol levels. In patients with baseline hypertriglyceridemia, these agents can induce severe hypertriglyceridemia and pancreatitis. The actions of clomiphene on lipid metabolism have not been studied, and to our knowledge, no cases of severe hypertriglyceridemia related to the use of clomiphene have been described. We report the case of a woman who developed 2 episodes of clomiphene-induced hypertriglyceridemia and pancreatitis while receiving this drug for treatment of infertility. Given the striking structural similarity between clomiphene and tamoxifen, it is likely that clomiphene is capable of inducing severe hypertriglyceridemia in patients with certain underlying lipid disorders by a mechanism similar to that of tamoxifen.

Prevention of hyperlipidemic acute pancreatitis during pregnancy with medium-chain triglyceride nutritional support

CONCLUSION

A combination of diet therapy, nutritional support with medium-chain triglycerides (MCT), and well-planned preterm Cesarean delivery on demand is an effective measure to prevent gestational hyperlipidemic pancreatitis and leads to successful childbirth.

BACKGROUND

Prevention and therapy of gestational hyperlipidemic pancreatitis are important, although difficult, because the condition carries a high maternal and fetal morbidity and mortality.

RESULTS

We describe a 32-yr-old female with lipoprotein lipase-deficient familial hypertriglyceridemia who had recurrent episodes of acute pancreatitis. The third episode occurred with worsened hyperlipidemia 7 yr earlier at 32 wk of her first pregnancy and resulted in fetal death. The fourth and fifth episodes were also accompanied by marked hyperlipidemia probably caused by drug discontinuance and dietary noncompliance. She became pregnant. Serum triglyceride levels were controlled below 2000 mg/dL by strict monitoring with low-fat, low-calorie diet and MCT nutritional support. A premature but healthy infant was born by Cesarean delivery at 36 wk of gestation when the mother presented with mild abdominal pain and was found to have uterine contractions. The ensuing clinical course has been uneventful.

Identification of homozygous lipoprotein lipase gene mutation in a woman with recurrent aggravation of hypertriglyceridaemia induced by pregnancy

We herein report a case of a 40-year-old Japanese woman (patient IT) with a history of recurrent aggravation of hypertriglyceridaemia, pancreatitis and miscarriages in three previous pregnancies. However, strict dietary intervention was applied during a fourth pregnancy. As a result, acute pancreatitis was avoided, and the patient gave birth to a healthy infant. In patient IT, the underlying etiology of the recurrent aggravation of hypertriglyceridaemia during pregnancy was a lipoprotein lipase (LPL) gene aberration. She was homozygous for LPL deficiency due to a nonsense mutation (TGG1401 --> TGA/Trp382 --> Stop) in exon 8 of the LPL gene, which resulted in the absence of LPL activity and immunoreactive LPL mass. Our findings indicate that, in LPL deficiency, pregnancy seriously exacerbates hypertriglyceridaemia and increases the risk of acute pancreatitis, which endangers both the mother and fetus. Early diagnosis of LPL deficiency and appropriate management thereof are essential for normal childbirth.

Estrogen induces glomerulosclerosis in analbuminemic rats

Progression of chronic renal disease is usually more rapid in males, both in humans and in experimental animals. Estrogen-replacement studies indicate that this may be related to the beneficial effects of estrogen on the lipoprotein profile. However, in hyperlipidemic analbuminemic rats (NAR), females are more prone to develop renal injury than males, and ovariectomy tends to decrease triglyceride levels and prevent renal disease. Therefore, we studied the effects of estrogen administration on lipoproteins, and the induction of renal injury in uninephrectomized female and male NAR. Ovariectomized and orchidectomized uninephrectomized NAR were treated with estradiol implants for 24 weeks. In an additional group of ovariectomized rats, the implant was removed after 12 weeks. Both in ovariectomized and orchidectomized NAR, estradiol caused severe hypercholesterolemia (9 to 12 mmol/liter) and hypertriglyceridemia (6 to 8 mmol/liter) after six weeks. Subsequently, these rats developed severe proteinuria, reaching 209 +/- 25 and 95 +/- 43 mg/day, respectively, after 24 weeks. At this point there was severe glomerular sclerosis, with a respective score of 107 +/- 21 and 61 +/- 33. In terminal blood samples the most pronounced increase in lipid levels were observed in very low density lipoproteins (VLDL), intermediate density lipoproteins (IDL) and low density lipoproteins (LDL). In contrast, ovariectomized NAR and orchidectomized NAR without exogenous estrogen had much lower lipid levels (cholesterol 5 to 7 mmol/liter and triglycerides 1 to 2 mmol/liter) after six weeks. These rats, or ovariectomized NAR where the estrogen treatment had been withdrawn, had practically no proteinuria (4 +/- 1, 19 +/- 11, and 13 +/- 4 mg/day, respectively) or renal damage (glomerulosclerosis score 1 +/- 0.4, 5 +/- 3 and 3 +/- 1, respectively) after 24 weeks. Thus, in hypertriglyceridemic analbuminemic rats, estrogen-treatment causes further increases in both triglycerides and cholesterol. Most probably these changes contribute to the development of renal injury by estrogen in this model. This effect of estrogen, which has also been observed in the Zucker rat, is unique for the hypertriglyceridemic state and deserves further study.

Clinical update: management of acute pancreatitis

The management of acute pancreatitis commences with confirming the diagnosis and establishing the aetiology. Improved methods of assessing the biliary tree may reduce the number of patients regarded as having idiopathic pancreatitis. Detailed clinical and laboratory protocols, designed to assess severity, have no major advantage over clinical assessment. The contrast-enhanced computed tomography scan is important to assess the degree of pancreatic necrosis and to detect local complications. The treatment of pancreatitis continues to be largely supportive. However, controlled studies support the use of antibiotics in severe acute pancreatitis and indicate a possible role for the use of octreotide and antioxidants. The place of endoscopic and surgical intervention is becoming better defined. Once an attack has passed, further investigation is often required in a bid to prevent further episodes of inflammation.

Plasma exchange for dramatic gestational hyperlipidemic pancreatitis

We describe the response to plasma exchange in a woman with extreme gestational hyperlipidemia and severe pancreatitis. Her serum triglyceride reached an astounding level of 21,300 mg/dl-among the highest concentrations ever recorded. Two consecutive plasma exchanges led to a remarkable reduction in triglyceride levels of 73% and 82%, respectively. Plasma viscosity decreased by 50% after the first plasma exchange. This was associated with an equally dramatic and unexpectedly rapid resolution of severe pancreatitis. Plasma exchange can rapidly and safely resolve extreme hyperlipidemia and be associated with prompt resolution of pancreatitis in women with severe gestational hyperlipidemic pancreatitis.

Gestational diabetes complicated by severe hypertriglyceridemia and acute pancreatitis

We present a case of severe acute pancreatitis in pregnancy associated with hypertriglyceridemia, gestational diabetes, sepsis and Adult Respiratory Distress Syndrome. The patient was successfully treated by antibiotics, parenteral feeding, intravenous insulin and bezafibrate and gave birth to a healthy boy at 40 weeks gestation.

The surgical management of intra-abdominal inflammatory conditions during pregnancy

The timely diagnosis and treatment of intra-abdominal conditions during pregnancy can challenge the surgical consultant. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk by trimester. The general surgeon will be called upon to diagnose and treat appendicitis, biliary tract disease (including pancreatitis), and liver disease. Knowledge of how these conditions become manifest is essential. The surgical consultant should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process.

Gene-environment interaction in the conversion of a mild-to-severe phenotype in a patient homozygous for a Ser172-->Cys mutation in the lipoprotein lipase gene

Normal pregnancy is associated with a two- to threefold increase in plasma triglyceride levels, particularly in the third trimester, due both to the overproduction of VLDLs and to the possible suppression of lipoprotein lipase (LPL) activity. Numerous mutations in the human LPL gene causing complete LPL deficiency have been described, but naturally occurring mutations that result in defective LPL with partial activity have not yet been reported. Here we describe a 30-yr-old woman who was first diagnosed with LPL deficiency during pregnancy after she developed pancreatitis. Her plasma triglyceride levels remained mildly elevated at approximately 300 mg/dl (3.4 mmol/liter) after the first pregnancy but rose significantly after she became pregnant again (1800 to 2000 mg/dl) (20.2 to 22.5 mmol/liter). DNA sequence analysis of the LPL gene showed that the patient is homozygous for a Ser172-->Cys missense mutation in exon 5. In vitro mutagenesis revealed that the Ser172-->Cys mutation caused a mutant LPL protein that had residual activity higher than that seen in all eight other missense mutations in patients with LPL deficiency identified in our laboratory. We propose that some mutations in the LPL gene produce a defective LPL with partial activity, which usually leads to mild hypertriglyceridemia.

Extracorporeal lipid elimination for treatment of gestational hyperlipidemic pancreatitis

Gestational hyperlipidemia complicated by pancreatitis during the 24th week of gestation has been successfully managed by long-term extracorporeal elimination of triglyceride-rich lipoproteins. Three modes of treatment (plasma exchange, immunospecific apheresis, and a combination of both treatments) were compared for efficacy as therapy for metabolic derangements, altered blood rheology, and the loss of immunoglobulins. Treatments were performed by means of a peripheral venovenous approach. A combination plasma exchange/apheresis technique was highly effective; the loss of immunoglobulins remained acceptable. Clinical symptoms of pancreatitis subsided within 24 hours of the first treatment. A relapse during the 32nd week of gestation necessitated treatments more frequently than once a week. At the 36th week of gestation, after confirming lung maturity as indicated by a lecithin-sphingomyelin ratio of > 2.0, a cesarean section was performed. A healthy boy was delivered (2470 g; Apgar score, 9/10). This is the first report to show that long-term extracorporeal elimination of lipoproteins is a highly effective treatment of hyperlipidemic gestational pancreatitis.

Eruptive xanthomas during pregnancy

A case of eruptive xanthomas during two successive pregnancies is reported. These xanthomas developed in association with marked hypertriglyceridemia; complications included severe pancreatitis and acute respiratory distress syndrome. This patient most likely had combined familial hyperlipidemia which usually causes only a modest elevation in plasma lipid levels. However, with the added stimulus of estrogens during pregnancy, hypertriglyceridemia and secondary complications developed.

Lipoprotein lipase deficiency due to long-term heparinization presenting as severe hypertriglyceridaemia in pregnancy

A case of severe hypertriglyceridaemia presenting in the third trimester of pregnancy in a woman on long-term heparin prophylaxis is described. The hypertriglyceridaemia was attributed to impaired clearance of triglyceride-rich lipoprotein particles secondary to heparin-induced reduction in the activity of the lipolytic enzyme, lipoprotein lipase.

Initial diagnosis of lipoprotein lipase deficiency in a 75-year-old man

Lipoprotein lipase deficiency, characterized by recurrent pancreatitis, profound hypertriglyceridemia, and delayed clearance of chylomicrons, is generally first diagnosed in childhood. Although patients with this condition have died during episodes of acute pancreatitis in the fourth and fifth decades, no patient older than 50 years has been previously reported. The de novo diagnosis of lipoprotein lipase deficiency in a 75-year-old man illustrates important points about this disease. This inborn error in metabolism may have a relatively benign clinical course resulting in normal life span, particularly if there is strict adherence to a low-fat diet and abstinence from alcohol. Moreover, measurement of lipoprotein lipase activity in persons with severe hypertriglyceridemia and recurrent abdominal pain, even in elderly patients, should lead to the correct diagnosis and treatment of this condition.

Chylomicronemia syndrome. Interaction of genetic and acquired hypertriglyceridemia

Chylomicrons accumulating in plasma obtained after an overnight fast are always abnormal and can be detected in association with triglyceride levels above 1000 mg per dl. The chylomicronemia syndrome is associated with marked hypertriglyceridemia (plasma triglyceride level above 2000 mg per dl), abdominal pain or pancreatitis, eruptive xanthomata, lipemia retinalis, dyspnea, mental aberrations, and other minor findings. The marked hypertriglyceridemia is usually due to the interaction of a common familial form of hypertriglyceridemia and a common acquired form of hypertriglyceridemia secondary to another disease, drug, or alcohol. Rarely, genetic abnormalities in lipoprotein lipase are the cause of the marked hypertriglyceridemia. Therapy that successfully lowers plasma triglyceride levels is associated with clearing of the symptoms and signs of the chylomicronemia syndrome and prevention of its recurrence.

Cholesterol-free diet and the physiologic hyperlipidemia of pregnancy in familial hypercholesterolemia

Longitudinal studies of the effects of a cholesterol-free diet and a less rigid 300 mg/day low cholesterol diet, both with a polyunsaturated to saturated fatty acid ratio of 1.8/1, were carried out preconception, during gestation, and postpartum in a women heterozygous for familial hypercholesterolemia. On the cholesterol-free diet, during weeks 8-14 of gestation, plasma cholesterol was lowered 25% (from 310 to 230mg/dl), and plasma low density lipoprotein cholesterol (C-LDL) (from 240 to 160 mg/dl), 33%. The 25% reduction in plasma cholesterol was slightly more than previously reported decrements of 19% in 14 normal women during pregnancy, also receiving a cholesterol-free diet. The 300 mg cholesterol diet was not as hypocholesterolemic as the cholesterol-free diet. Its maintenance throughout gestation limited the within-pregnancy increments of total plasma cholesterol and C-LDL to 21% (352-426 mg/dl) and 14% (286-326 mg/dl) respectively. Both the cholesterol-free and the 300 mg cholesterol diet were well tolerated, and should be nutritionally adequate for pregnant women, since they contain more than the recommended amounts of high quality protein, vitamins, minerals, and calories for pregnant women. Cholesterol restricted diets during pregnancy in familial hypercholesterolemics should reduce the physiologic hypercholesterolemia of pregnancy, and potentially reduce the increased risk of coronary heart disease relative to the degree and duration of elevations of total and LDL cholesterol.