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Gligorijevic N, Stefanovic-Racic M, Kershaw EE. Medical management of hypertriglyceridemia in pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00085. [PMID: 37421386 DOI: 10.1097/mog.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) should be considered in all cases of acute pancreatitis and triglyceride levels measured early, so that appropriate early and long-term treatment can be initiated. RECENT FINDINGS In most cases of HTG-AP, conservative management (nothing by mouth, intravenous fluid resuscitation and analgesia) is sufficient to achieve triglyceride levels less than 500 mg/dl. Intravenous insulin and plasmapheresis are sometimes used, although prospective studies showing clinical benefits are lacking. Pharmacological management of hypertriglyceridemia (HTG) should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk or recurrent acute pancreatitis. In addition to currently used fenofibrate and omega-3 fatty acids, several novel agents are being studied for long-term treatment of HTG. These emerging therapies focus mainly on modifying the action of lipoprotein lipase (LPL) through inhibition of apolipoprotein CIII and angiopoietin-like protein 3. Dietary modifications and avoidance of secondary factors that worsen triglyceride levels should also be pursued. In some cases of HTG-AP, genetic testing may help personalize management and improve outcomes. SUMMARY Patients with HTG-AP require acute and long-term management of HTG with the goal of reducing and maintaining triglyceride levels to less than 500 mg/dl.
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Affiliation(s)
- Nikola Gligorijevic
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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2
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Zhang M, Pang M. Early prediction of acute respiratory distress syndrome complicated by acute pancreatitis based on four machine learning models. Clinics (Sao Paulo) 2023; 78:100215. [PMID: 37196588 DOI: 10.1016/j.clinsp.2023.100215] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Acute Respiratory Distress syndrome (ARDS) is a common complication of Acute Pancreatitis (AP) and is associated with high mortality. This study used Machine Learning (ML) to predict ARDS in patients with AP at admission. METHODS The authors retrospectively analyzed the data from patients with AP from January 2017 to August 2022. Clinical and laboratory parameters with significant differences between patients with and without ARDS were screened by univariate analysis. Then, Support Vector Machine (SVM), Ensembles of Decision Trees (EDTs), Bayesian Classifier (BC), and nomogram models were constructed and optimized after feature screening based on these parameters. Five-fold cross-validation was used to train each model. A test set was used to evaluate the predictive performance of the four models. RESULTS A total of 83 (18.04%) of 460 patients with AP developed ARDS. Thirty-one features with significant differences between the groups with and without ARDS in the training set were used for modeling. The Partial Pressure of Oxygen (PaO2), C-reactive protein, procalcitonin, lactic acid, Ca2+, the neutrophil:lymphocyte ratio, white blood cell count, and amylase were identified as the optimal subset of features. The BC algorithm had the best predictive performance with the highest AUC value (0.891) than SVM (0.870), EDTs (0.813), and the nomogram (0.874) in the test set. The EDT algorithm achieved the highest accuracy (0.891), precision (0.800), and F1 score (0.615), but the lowest FDR (0.200) and the second-highest NPV (0.902). CONCLUSIONS A predictive model of ARDS complicated by AP was successfully developed based on ML. Predictive performance was evaluated by a test set, for which BC showed superior predictive performance and EDTs could be a more promising prediction tool for larger samples.
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Affiliation(s)
- Mengran Zhang
- Gastroenterology Department, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Mingge Pang
- Internal Medicine Department, Beijing Puren Hospital, Beijing, China.
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3
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Kiss L, Fűr G, Pisipati S, Rajalingamgari P, Ewald N, Singh V, Rakonczay Z. Mechanisms linking hypertriglyceridemia to acute pancreatitis. Acta Physiol (Oxf) 2023; 237:e13916. [PMID: 36599412 DOI: 10.1111/apha.13916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/25/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Lóránd Kiss
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Gabriella Fűr
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Sailaja Pisipati
- Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Prasad Rajalingamgari
- Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Nils Ewald
- Institute for Endocrinology, Diabetology and Metabolism, University Hospital Minden, Minden, Germany.,Justus-Liebig-Universität Giessen, Giessen, Germany
| | - Vijay Singh
- Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.,Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
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Prevalence, Severity and Management of Hypertriglyceridemia-Associated Pancreatitis; A 7-Year Retrospective Cohort Study at Canadian Quaternary Care Hospitals. J Clin Lipidol 2022; 16:455-462. [DOI: 10.1016/j.jacl.2022.05.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 12/12/2022]
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5
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Nomogram for the prediction of in-hospital incidence of acute respiratory distress syndrome in patients with acute pancreatitis. Am J Med Sci 2021; 363:322-332. [PMID: 34619145 DOI: 10.1016/j.amjms.2021.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 05/09/2021] [Accepted: 08/09/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) associated with high mortality is the common complication in acute pancreatitis (AP). The aim of this study was to formulate and validate an individualized predictive nomogram for in-hospital incidence of ARDS in Patients with AP. METHOD From January 2017 to December 2018, 779 individuals with AP were involved in this study. They were randomly distributed into primary cohort (n=560) and validation cohort (n=219). Based on the primary cohort, risk factors were identified by logistic regression model and a nomogram was performed. The nomogram was validated in the primary and validation cohort by the bootstrap validation method. The calibration curve was applied to evaluate the consistency between the nomogram and the ideal observation. RESULTS There were 728 patients in the non-ARDS group and 51 in the ARDS group, with an incidence of about 6.55%. Five independent factors including white blood cell counts (WBC), prothrombin time (PT), albumin (ALB), serum creatinine (SCR) and triglyceride (TG) were associated with in-hospital incidence of ARDS in Patients with AP. A nomogram was constructed based on the five independent factors with primary cohort of AUC=0.821 and validation cohort of AUC=0.823. Calibration curve analysis indicated that the predicted probability was in accordance with the observed probability in both primary and validation cohorts. CONCLUSIONS The study developed an intuitive nomogram with easily available laboratory parameters for the prediction of in-hospital incidence of ARDS in patients with AP. The incidence of ARDS for an individual patient can be fast and conveniently evaluated by our nomogram.
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Abstract
Hypertriglyceridemic acute pancreatitis is an emerging issue in gastroenterology, frequently underdiagnosed in clinical practice. Despite the rarity of the disease, hypertriglyceridemia should be considered as a leading cause of acute pancreatitis, especially in defined subsets of patients. Primary and secondary forms of hypertriglyceridemia need to be considered and excluded during the diagnostic work-up of all patients with acute pancreatitis. An accurate diagnosis is crucial to establish an appropriate treatment and to reduce the risk of recurrences. The aim of the present article is to briefly review epidemiology, etiology, diagnosis and therapy of hypertriglyceridemic acute pancreatitis, based on a clinical and practical point of view.
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Affiliation(s)
| | | | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy -
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Pan J, Yang X, Zhu W. Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report. BMC Endocr Disord 2021; 21:109. [PMID: 34039339 PMCID: PMC8157700 DOI: 10.1186/s12902-021-00768-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis. CASE PRESENTATION A 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient's postoperative recovery was remarkable. CONCLUSIONS Long-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.
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Affiliation(s)
- JinYu Pan
- Graduate Department, BengBu Medical College, 233030, Bengbu, Anhui, China
| | - XiangHong Yang
- Department of Intensive Care Uint, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 310014, Hangzhou, Zhejiang, China
| | - Wei Zhu
- Department of Emergency Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 158 Shangtang Road, 310014, Hangzhou, Zhejiang, People's Republic of China.
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8
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Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient. Mayo Clin Proc Innov Qual Outcomes 2021; 5:520-524. [PMID: 33997648 PMCID: PMC8105512 DOI: 10.1016/j.mayocpiqo.2020.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Treatment strategies for hypertriglyceridemia-induced acute pancreatitis are not well defined in the current literature or guidelines. One therapeutic option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic woman treated with a reduced-dose insulin infusion that was complicated by hypoglycemic episodes requiring dextrose infusion titrations. Empirical initiation of a higher dextrose concentration infusion with glucose level titrations should be considered to avoid hypoglycemia for nondiabetic patients treated with an insulin infusion to lower triglyceride levels. In this case, clinical pharmacy assistance was imperative for successful treatment with a reduced-dose insulin infusion and titrated dextrose infusion in the management of hypertriglyceridemia-induced acute pancreatitis.
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9
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Reed JM, Hogan BM, Nasser-Ghodsi N, Loftus CG. Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient. Mayo Clin Proc Innov Qual Outcomes 2021; 5:230-235. [PMID: 33718798 PMCID: PMC7930755 DOI: 10.1016/j.mayocpiqo.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Hypertriglyceridemia-induced acute pancreatitis treatment strategies are not well defined in current literature or guidelines. One therapy option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic female patient treated with a reduced-dose insulin infusion, complicated by hypoglycemic episodes requiring dextrose infusion titrations. Empirical initiation of a higher dextrose concentration infusion with glucose level titrations should be considered to avoid hypoglycemia for nondiabetic patients treated with an insulin infusion to lower triglyceride levels. In this case, clinical pharmacy assistance was imperative for successful treatment with a reduced-dose insulin infusion and titrated dextrose infusion in the management of hypertriglyceridemia-induced acute pancreatitis.
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Affiliation(s)
- Jamie M. Reed
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Pharmacy, Indiana University Health, Indianapolis
- Correspondence: Address to Jamie M. Reed, PharmD, BCPS, 550 N University Blvd, Indianapolis, IN 46202.
| | | | | | - Conor G. Loftus
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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10
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Secondary Causes of Hypertriglyceridemia are Prevalent Among Patients Presenting With Hypertriglyceridemia Induced Acute Pancreatitis. Am J Med Sci 2021; 361:616-623. [PMID: 33618838 DOI: 10.1016/j.amjms.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/19/2020] [Accepted: 01/08/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypertriglyceridemia induced acute pancreatitis (HIAP) is the third common cause of acute pancreatitis. HIAP can result in recurrent attacks of severe AP with significant morbidity and mortality. Hypertriglyceridemia (HTG) could be primary or secondary. Although genetic causes of HTG are well studied, the prevalence of secondary causes of HTG in patients presenting with HIAP is not well characterized. This study aimed to identify the prevalence of risk factors for secondary hypertriglyceridemia among patients presenting with HIAP in a tertiary referral center in a large metropolitan area. METHODS This is a retrospective analysis of all patients admitted with AP from August 2012-2017. A subgroup of patients with triglycerides >880 mg/dl were included for analysis. Secondary causes of HTG were identified. Secondary analysis evaluating the severity of pancreatitis was performed. RESULTS There were 3,746 patients admitted for AP of which 57 patients had AP and HTG. Of these 57 patients, 70.2% had history of diabetes mellitus, 26.3% had history of heavy alcohol use, 22.8% had chronic kidney disease, 47.3% with obesity, and 21.1% with metabolic syndrome. Two patients were classified as unexplained HTG. Secondary analysis showed a total of 45.6% of patients requiring ICU admission. 26.3% of patients with severe inflammatory pancreatitis and 17.5% of patients with severe necrotizing pancreatitis. CONCLUSIONS In our cohort of HIAP, 55 out of 57 patients had secondary causes for HTG. Identifying secondary causes of HTG during acute hospitalization is important to tailor outpatient treatment in order to prevent future admissions with HIAP.
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11
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Drake M, Dodwad SJM, Davis J, Kao LS, Cao Y, Ko TC. Sex-Related Differences of Acute and Chronic Pancreatitis in Adults. J Clin Med 2021; 10:300. [PMID: 33467580 PMCID: PMC7830423 DOI: 10.3390/jcm10020300] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
The incidence of acute and chronic pancreatitis is increasing in the United States. Rates of acute pancreatitis (AP) are similar in both sexes, but chronic pancreatitis (CP) is more common in males. When stratified by etiology, women have higher rates of gallstone AP, while men have higher rates of alcohol- and tobacco-related AP and CP, hypercalcemic AP, hypertriglyceridemic AP, malignancy-related AP, and type 1 autoimmune pancreatitis (AIP). No significant sex-related differences have been reported in medication-induced AP or type 2 AIP. Whether post-endoscopic retrograde cholangiopancreatography pancreatitis is sex-associated remains controversial. Animal models have demonstrated sex-related differences in the rates of induction and severity of AP, CP, and AIP. Animal and human studies have suggested that a combination of risk factor profiles, as well as genes, may be responsible for the observed differences. More investigation into the sex-related differences of AP and CP is desired in order to improve clinical management by developing effective prevention strategies, diagnostics, and therapeutics.
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Affiliation(s)
| | | | | | | | - Yanna Cao
- Department of Surgery, UT Health Houston, Houston, TX 77030, USA; (M.D.); (S.-J.M.D.); (J.D.); (L.S.K.)
| | - Tien C. Ko
- Department of Surgery, UT Health Houston, Houston, TX 77030, USA; (M.D.); (S.-J.M.D.); (J.D.); (L.S.K.)
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12
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Jiang JP, Sheng JY, Fang C. Effect of different degrees of hypertriglyceridemia on severity of acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2020; 28:730-734. [DOI: 10.11569/wcjd.v28.i15.730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Too much free fatty acids in the body can damage pancreatic acinar cells and result in the generation of a large number of inflammatory factors, leading to multiple organ dysfunction. By observing the influence of different degrees of hypertriglyceridemia (HTG) on the severity of acute pancreatitis, this study confirmed that the risk of severe pancreatitis increases with the increase of blood lipid level.
AIM To investigate the effect of different degrees of HTG at the early onset stage on the severity of hyperlipidemic acute pancreatitis (HLAP).
METHODS Eighty-seven patients with HLAP treated from June 2016 to December 2019 at our hospital were retrospectively analyzed. According to the levels of serum triglyceride (TG) on admission, they were divided into three groups: (1) Moderate HTG group (TG: 5.65-11.30 mmol/L); (2) severe HTG group (TG: 11.3-22.3 mmol/L); and (3) very severe HTG group (TG: ≥ 22.4 mmol/L). The changes in biochemical indicators, the modified CT severity index (MCTSI) score, and disease severity were observed.
RESULTS Compared with the moderate HTG group, MCTSI scores, the levels of C-reactive protein (CRP), and the incidence of moderately severe acute pancreatitis/severe acute pancreatitis were significantly higher in the severe HTG group and very severe HTG group, but there was no significant difference in MCTSI or CRP between the severe HTG group and very severe HTG group.
CONCLUSION The level of TG within 24 h after onset has an effect on HLAP severity, and the severity of acute pancreatitis induced by moderate HTG is mild and the risk of severe pancreatitis is low. Severe/very severe HTG may be associated with a high risk of severe HLAP.
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Affiliation(s)
- Jing-Ping Jiang
- Department of Gastroenterology, Jingdezhen First People's Hospital, Jingdezhen 333000, Jiangxi Province, China
| | - Jin-Yi Sheng
- Department of Gastroenterology, Jingdezhen First People's Hospital, Jingdezhen 333000, Jiangxi Province, China
| | - Cong Fang
- Department of Gastroenterology, Jingdezhen First People's Hospital, Jingdezhen 333000, Jiangxi Province, China
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13
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Baass A, Paquette M, Bernard S, Hegele RA. Familial chylomicronemia syndrome: an under-recognized cause of severe hypertriglyceridaemia. J Intern Med 2020; 287:340-348. [PMID: 31840878 DOI: 10.1111/joim.13016] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Familial chylomicronemia syndrome (FCS) is a rare autosomal recessive disorder of chylomicron metabolism causing severe elevation of triglyceride (TG) levels (>10 mmol L-1 ). This condition is associated with a significant risk of recurrent acute pancreatitis (AP). AP caused by hypertriglyceridaemia (HTG) has been associated with a worse prognosis and higher mortality rates compared to pancreatitis of other aetiology. Despite its association with poor quality of life and increased lifelong risk of HTG-AP, few healthcare providers are familiar with FCS. Because this condition is under-recognized, the majority of FCS patients are diagnosed after age 20 often after consulting several physicians. Although other forms of severe HTG such as multifactorial chylomicronemia have been associated with high atherosclerotic cardiovascular disease (ASCVD) risk and metabolic abnormalities, ASCVD and metabolic syndrome are not usually observed in FCS patients. Because FCS is a genetic condition, the optimal diagnosis strategy remains genetic testing. The presence of bi-allelic pathogenic mutations in LPL, APOC2, GPIHBP1, APOA5 or LMF1 genes confirms the diagnosis. However, some cases of FCS caused by autoantibodies against LPL or GPIHBP1 proteins have also been reported. Furthermore, a clinical score for the diagnosis of FCS has been proposed but needs further validation. Available treatment options to lower triglycerides such as fibrates or omega-3 fatty acids are not efficacious in FCS patients. Currently, the cornerstone of treatment remains a lifelong very low-fat diet, which prevents the formation of chylomicrons. Finally, inhibitors of apo C-III and ANGPTL3 are in development and may eventually constitute additional treatment options for FCS patients.
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Affiliation(s)
- A Baass
- From the, Lipids, Nutrition and Cardiovascular Prevention Clinic, Montreal Clinical Research Institute, Québec, Canada.,Divisions of Experimental Medicine and Medical Biochemistry, Department of Medicine, McGill University, Québec, Canada
| | - M Paquette
- From the, Lipids, Nutrition and Cardiovascular Prevention Clinic, Montreal Clinical Research Institute, Québec, Canada
| | - S Bernard
- From the, Lipids, Nutrition and Cardiovascular Prevention Clinic, Montreal Clinical Research Institute, Québec, Canada.,Division of Endocrinology, Department of Medicine, Université de Montreal, Montreal, Canada
| | - R A Hegele
- Department of Medicine, University of Western Ontario and Robarts Research Institute, Ontario, Canada
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14
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Burbridge C, Randall JA, Sanchez RJ, Dansky H, Symonds T, Girman CJ, Strayer JA, Selk KL, Whitcomb DC, Kershaw EE. Symptoms and Dietary Impact in Hypertriglyceridemia-Associated Pancreatitis: Development and Content Validity of Two New Measures. PHARMACOECONOMICS - OPEN 2020; 4:191-201. [PMID: 31250380 PMCID: PMC7018925 DOI: 10.1007/s41669-019-0155-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Severe hypertriglyceridemia (sHTG) is a rare condition, complicated by episodes of acute pancreatitis (AP), which can cause pain and/or life-threatening multi-organ dysfunction. Currently, there are no disease-specific patient-reported outcome (PRO) measures evaluating symptoms or dietary impact for this condition. OBJECTIVE The objective of this study was to explore patient-reported symptoms and impacts of sHTG and AP and develop new measures to capture the symptoms and dietary impacts of this condition using patient language. METHODS In-depth, semi-structured concept elicitation interviews were conducted with 12 US-based participants to explore their experience and identify key symptoms and impact on dietary behavior, both during and between episodes of AP. Participants had a range of AP severity with a previous triglyceride reading > 1000 mg/dL, and at least one attack of AP within the last 12 months. Transcripts were coded using thematic analysis. RESULTS Qualitative data analysis revealed the substantial burden of AP associated with sHTG. Participants reported experiencing symptoms, especially abdominal pain, both during and between attacks of AP, and discussed considerable diet changes to prevent or minimize future attacks. A conceptual model was refined, based on patient input, and reviewed by clinical experts to determine key concepts for inclusion within two PRO measures, one evaluating symptoms and another evaluating impact on dietary behavior. Items were drafted using patient-derived language. A 19-item symptoms measure [Hypertriglyceridemia and Acute Pancreatitis Symptom Scale (HAP-SS)] and a 6-item dietary impact measure (Hypertriglyceridemia and Acute Pancreatitis Dietary Behavior (HAP-DB) measure) were developed, both with a 24-h recall period. CONCLUSIONS The qualitative analysis confirmed the substantial burden of AP associated with sHTG. This research resulted in development of two disease-specific PRO measures for use during and between attacks of AP. These measures are being utilized in a clinical trial, which will confirm content, structure, and psychometric properties.
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Affiliation(s)
- Claire Burbridge
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
| | - Jason A. Randall
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
| | | | | | - Tara Symonds
- Clinical Outcomes Solutions, Unit 68 Basepoint, Shearway Business Park, Shearway Road, Folkestone, Kent, CT19 4RH UK
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15
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Goldberg RB, Chait A. A Comprehensive Update on the Chylomicronemia Syndrome. Front Endocrinol (Lausanne) 2020; 11:593931. [PMID: 33193106 PMCID: PMC7644836 DOI: 10.3389/fendo.2020.593931] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022] Open
Abstract
The chylomicronemia syndrome is characterized by severe hypertriglyceridemia and fasting chylomicronemia and predisposes affected individuals to acute pancreatitis. When due to very rare monogenic mutations in the genes encoding the enzyme, lipoprotein lipase, or its regulators, APOC2, APOA5, GPIHBP1, and LMF1, it is referred to as the familial chylomicronemia syndrome. Much more frequently, the chylomicronemia syndrome results from a cluster of minor genetic variants causing polygenic hypertriglyceridemia, which is exacerbated by conditions or medications which increase triglyceride levels beyond the saturation point of triglyceride removal systems. This situation is termed the multifactorial chylomicronemia syndrome. These aggravating factors include common conditions such as uncontrolled diabetes, overweight and obesity, alcohol excess, chronic kidney disease and pregnancy and several medications, including diuretics, non-selective beta blockers, estrogenic compounds, corticosteroids, protease inhibitors, immunosuppressives, antipsychotics, antidepressants, retinoids, L-asparaginase, and propofol. A third uncommon cause of the chylomicronemia syndrome is familial forms of partial lipodystrophy. Development of pancreatitis is the most feared complication of the chylomicronemia syndrome, but the risk of cardiovascular disease as well as non-alcoholic steatohepatitis is also increased. Treatment consists of dietary fat restriction and weight reduction combined with the use of triglyceride lowering medications such as fibrates, omega 3 fatty acids and niacin. Effective management of aggravating factors such as improving diabetes control, discontinuing alcohol and replacing or reducing the dose of medications that raise triglyceride levels is essential. Importantly, many if not most cases of the chylomicronemia syndrome can be prevented by effective identification of polygenic hypertriglyceridemia in people with conditions that increase its likelihood or before starting medications that may increase triglyceride levels. Several new pharmacotherapeutic agents are being tested that are likely to considerably improve treatment of hypertriglyceridemia in people at risk.
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Affiliation(s)
- Ronald B. Goldberg
- Departments of Medicine, Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, FL, United States
- *Correspondence: Ronald B. Goldberg,
| | - Alan Chait
- Department of Medicine, University of Washington, Seattle, WA, United States
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Zhang Q, Qin M, Liang Z, Huang H, Tang Y, Qin L, Wei Z, Xu M, Tang G. The relationship between serum triglyceride levels and acute pancreatitis in an animal model and a 14-year retrospective clinical study. Lipids Health Dis 2019; 18:183. [PMID: 31647014 PMCID: PMC6813107 DOI: 10.1186/s12944-019-1126-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives The aim of the current study was to evaluate influence of serum triglyceride levels on the course of acute pancreatitis (AP). Methods Rats models of hypertriglyceridemic were used in animal experiments. Following induction of acute pancreatitis, amylase, and pancreas histological scores were all compared. In addition, in a clinical study, clinical data were collected from 1681 AP patients admitted from 2003 to 2016 who were divided into 4 groups based on their serum triglyceride (TG) levels. The clinical features among these 4 groups were compared, and a receiver operating characteristic (ROC) curve analysis was also performed on TG values to estimate their relationship with severity. Results In animal experiments, the hypertriglyceridemic pancreatitis (HTGP) group had markedly higher serum amylase, and histological scores relative to the other animal groups. In the clinical study, we identified significant differences in gender, age, body mass index (BMI), cost, and incidence of partial complications among the 4 TG-based groups. Importantly, the TG levels on day 3–4 after admission could be used to accurately predict disease severity. Conclusions Hypertriglyceridemia (HTG) can aggravate pancreatic injury, and hypertriglyceridemia patients are more likely to suffer from severe pancreatic injury with a higher possibility of complications. In addition, triglyceride levels are correlated with the severity of AP positively.
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Affiliation(s)
- Qiyue Zhang
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Mengbin Qin
- Department of Gastroenterology, Second Affiliated Hospital, Guangxi Medical University, Nanning, 530007, Guangxi, China
| | - Zhihai Liang
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Huali Huang
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Yongfeng Tang
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Lingyan Qin
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Zhenping Wei
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Mengtao Xu
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Guodu Tang
- Department of Gastroenterology, First Affiliated Hospital, Guangxi Medical University, Nanning, 530021, Guangxi, China.
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Diabetes and Younger Age Are Vital and Independent Risk Factors for Acute Pancreatitis in Patients with Severe Hypertriglyceridemia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2620750. [PMID: 31737657 PMCID: PMC6817920 DOI: 10.1155/2019/2620750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/24/2019] [Indexed: 02/04/2023]
Abstract
Background. The incidence of hypertriglyceridemia-induced acute pancreatitis (HIAP) is increasing worldwide, and now it is the third leading cause of acute pancreatitis in the United States. But, there are only 5% of patients with severe hypertriglyceridemia (>1000 mg/dl) which might generate acute pancreatitis. In order to explore which part of the patients is easy to develop into pancreatitis, a case-control study was performed by us to consider which patient population tend to develop acute pancreatitis in patients with severe hypertriglyceridemia. To perform a retrospective case-control study, we identified severe hypertriglyceridemia patients without AP (HNAP) and with HIAP with a fasting triglyceride level of >1000 mg/dl from The First Affiliated Hospital of Nanjing Medical University during January 1, 2014, to December 31, 2016. Baseline patient characteristics, comorbidities, and risk factors were recorded and evaluated by the univariate and multivariate logistic regression analysis for HIAP and HNAP patients. A total of 124 patients with severe hypertriglyceridemia were included in this study; of which, 62 patients were in the HIAP group and 62 were in the HNAP group. Univariate logistic regression analysis showed that there was no gender difference in both groups; however, there were more younger patients in the HIAP group than in the HNAP group (P value < 0.001), and the HIAP group had low level of high-density lipoprotein compared to the HNAP group (P<0.05). Meanwhile, the presence of pancreatitis was associated with higher level of glycemia and a history of diabetes (P<0.05). Multivariate logistic regression analysis indicated that a history of diabetes and younger age were independent risk factors for acute pancreatitis in patients with severe hypertriglyceridemia. Uncontrolled diabetes and younger age are potential risk factors in patients with severe hypertriglyceridemia to develop acute pancreatitis.
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Relationships between Metabolic Comorbidities and Occurrence, Severity, and Outcomes in Patients with Acute Pancreatitis: A Narrative Review. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2645926. [PMID: 31687382 PMCID: PMC6800961 DOI: 10.1155/2019/2645926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 12/16/2022]
Abstract
Background. The population of patients with acute pancreatitis treated by the staff at our department of gastroenterology includes those with mild and self-limited disease ranging to those with severe and fatal disease. Early diagnosis and accurate prediction of the severity and outcome of this disease, which is commonly seen by our department, is important for a successful outcome. Metabolic comorbidities (e.g., diabetes mellitus, fatty liver, obesity, and metabolic syndrome) are relevant to the severity and progression of many diseases. The objective of this review was to examine clinical relationships between metabolic comorbidities and occurrence, severity, and outcome of acute pancreatitis.
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Wei HF, Tang GD, Liang ZH, Qin MB, Yang HY, Wu Q, Tang YF, Zhang QY, Xu MT. Clinical features of acute pancreatitis in people of different age groups: A retrospective analysis. Shijie Huaren Xiaohua Zazhi 2019; 27:624-631. [DOI: 10.11569/wcjd.v27.i10.624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is one of the common causes of acute abdomen in clinical practice. In the past, patients with AP were mostly young adults. However, in recent years, with the growth and aging of our country's population, the incidence of AP in the elderly and children is also on the rise. The clinical manifestations of AP at different age groups are slightly different due to their physiological characteristics. The clinical manifestations of elderly and children are atypical, which can easily lead to misdiagnosis and missed diagnosis.
AIM To analyze the clinical features of AP in people of different age groups.
METHODS In this retrospective clinical trial, 1758 cases of AP were enrolled from January 2003 to June 2016, and they were divided into three groups according to age: <18, 18-60, and ≥ 60 years old. The general clinical data, etiology, severity of AP, complications, clinical course, prognosis, and biochemical criteria for AP were summarized in different age groups.
RESULTS In the < 18 age group, the incidence of AP in male patients (53.8%) was slightly higher than that of females (46.2%); the proportion of mild AP (MAP) (78.5%) was higher than those the other two groups; and the rates of complications and mortality were significantly lower than those of the other two groups (P < 0.05). In the 18-60 age group, the incidence of AP in male patients (71.0%) was higher than that of the other two groups (P < 0.05); the incidence of alcoholic and hyperlipidemic pancreatitis (13.4%, 21.5%) was higher than that of the other two groups (P < 0.05); the incidence of pancreatic necrosis in this group of patients was the highest (23.4%); and the rates of peripancreatic exudation, pleural effusion, acute respiratory distress syndrome, and acute renal insufficiency (54.3%, 36.9%, 5.6%, and 6.5%, respectively) were significantly higher than those of the < 18 age group (P < 0.05). In the ≥ 60 age group, the incidence of AP in male patients (57.7%) was slightly higher than that in females (42.3%); the rate of nausea (58.2%) was significantly higher than those of the other two groups (P < 0.05); the incidence of biliary pancreatitis (61.2%) was the highest (P < 0.05); and the proportion of patients with moderately severe AP (43.5%) was higher than those of the other two groups (P < 0.05). The patients in the < 18 age group had the longest hospital stay (17.97 ± 12.14 d; P < 0.05). The proportion of patients staying in the intensive care unit and the mortality rate in the ≥ 60 age group were the highest (4.1% and 13.1%, respectively; P < 0.05). There was no difference in hospitalization cost among patients of different age groups (P > 0.05). There was no significant difference in peripheral blood leukocyte count among the three groups (P > 0.05). Mean C-reactive protein level in the < 18 age group was higher than those of the other two groups. Serum amylase was higher in the ≥ 60 age group than in the < 18 age group. Lipase (LPS) in the ≥ 60 age group was higher than those of the other two groups (P < 0.05), and mean LPS did not differ significantly between the18-60 and < 18 age groups (P > 0.05).
CONCLUSION The incidence of alcoholic and hyperlipidemic pancreatitis is higher in middle-aged people. Elderly patients with AP are most prone to nausea, and the mortality rate is the highest. When young people have unexplained vomiting and bloating, AP should be suspected.
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Affiliation(s)
- Hui-Fen Wei
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Guo-Du Tang
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Zhi-Hai Liang
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Meng-Bin Qin
- Department of Gastroenterology, the Second Affiliated Hospital of Guangxi Medical University, Nanning 530001, Guangxi Zhuang Autonomous Region, China
| | - Hui-Ying Yang
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Qing Wu
- Department of Gastroenterology, the Second Affiliated Hospital of Guangxi Medical University, Nanning 530001, Guangxi Zhuang Autonomous Region, China
| | - Yong-Feng Tang
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Qi-Yue Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Meng-Tao Xu
- Department of Gastroenterology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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Abstract
OBJECTIVES The diagnosis of severe hypertriglyceridemia (HTG) as a cause for acute pancreatitis is often delayed with limited data on the characteristics and predictors of recurrent pancreatitis in this population. METHODS A regional database of severe HTG level of 1000 mg/dL or greater was analyzed to identify subjects with acute pancreatitis. Factors associated with recurrent pancreatitis during long-term follow-up were investigated. RESULTS Severe HTG-associated pancreatitis was evident in 171 patients (75% diabetics). Recurrent pancreatitis was observed in 16%; this was associated with younger age, alcohol abuse, and an increase in triglyceride levels. In multivariable analysis, peak triglycerides level of greater than 3000 mg/dL (hazard ratio, 2.92; 95% confidence interval, 1.28-6.64; P = 0.011) and most recent triglycerides level of greater than 500 mg/dL (hazard ratio, 3.72; 95% confidence interval, 1.60-8.66; P = 0.002) remained independently associated with recurrent pancreatitis. These lipid measures as well as alcohol abuse were additionally correlated with a stepwise increase in the number of pancreatitis episodes. CONCLUSIONS Severe HTG-related pancreatitis was closely associated with diabetes. Extreme HTG and a lack of attainment of lower triglyceride levels were independent long-term predictors of recurrent pancreatitis. These findings emphasize the importance of early identification and successful treatment of severe HTG and its underlying disorders to reduce the burden of recurrent pancreatitis.
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Shemesh E, Zafrir B. Hypertriglyceridemia-Related Pancreatitis In Patients With Type 2 Diabetes: Links And Risks. Diabetes Metab Syndr Obes 2019; 12:2041-2052. [PMID: 31632114 PMCID: PMC6789969 DOI: 10.2147/dmso.s188856] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/15/2019] [Indexed: 12/11/2022] Open
Abstract
Disturbances in glucose and lipid homeostasis are cardinal features of the metabolic syndrome that affect millions of people worldwide. These conditions have multi-organ impact, and while cardiovascular effects are usually the core for studies and preventive measures, other systems may also be affected, including the pancreas. Acute pancreatitis related to severe hypertriglyceridemia is an under-recognized condition that could lead to significant morbidity and mortality. Therefore, when suspected, prompt diagnosis and treatment should be initiated to cover the various aspects of this disorder. Though commonly known to be associated with excess of alcohol use, hypertriglyceridemia-related pancreatitis is particularly observed in diabetics, especially when uncontrolled. Here, we portray the possible mechanisms and clinical features that link type 2 diabetes, hypertriglyceridemia and pancreatitis, and discuss their health-related outcomes and the current and novel treatment options for this unique disease.
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Affiliation(s)
- Elad Shemesh
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Barak Zafrir
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
- Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel
- Correspondence: Barak Zafrir Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal Street, Haifa3436212, IsraelTel +972-48250801Fax +972-48250916 Email
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Adiamah A, Psaltis E, Crook M, Lobo DN. A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis. Clin Nutr 2018; 37:1810-1822. [PMID: 29056284 DOI: 10.1016/j.clnu.2017.09.028] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies. METHODS The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included. RESULTS Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis. CONCLUSION The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.
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Affiliation(s)
- Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Emmanouil Psaltis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Martin Crook
- Department of Clinical Biochemistry, Guy's and St. Thomas' Hospital NHS Trust, London SE1 9RT, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Kilinc F, Senates E, Demircan F, Pekkolay Z, Gozel N, Guven M, Bahcecioglu IH, Tuzcu AK. Are There Differences in the Management of Acute Pancreatitis Cases Due to Severe Hypertriglyceridemia in Pregnant Women? Med Sci Monit 2018; 24:5619-5623. [PMID: 30100601 PMCID: PMC6104549 DOI: 10.12659/msm.910343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The aim of this study was to determine the prognosis of severe disease and treatment approaches of both normal and pregnant, especially in patients with severe pancreatitis due to hypertriglyceridemia. Material/Methods We included 30 patients (20 females and 10 males) in this study whose follow-ups and treatments were performed after a diagnosis of hypertriglyceridemia-induced acute pancreatitis between January 2011 and May 2017. Patient personal information, such as age, sex, pre-treatment and post-treatment triglyceride levels, receipt of anti-hyperlipidemic treatments or plasmapheresis, and family history, were collected from hospital records and patient files. Patients with severe pancreatitis history, score, and prognosis were included to increase the value of our study. Mild and moderate cases were excluded. Results The mean age of the patients was 35±6 years. Twenty-four patients (80%) received an anti-hyperlipidemic treatment before their pancreatitis attacks. Plasmapheresis was performed on 8 patients before their pancreatitis attacks. Eighteen patients (60%) had a family history suggesting familial hypertriglyceridemia. Twelve patients (40%) were pregnant. Conclusions The treatment of hypertriglyceridemia-induced acute pancreatitis was mostly confined to supportive, palliative treatments. However, plasmapheresis is a possible treatment option and should be used in the early stages of this disease. The response to medical treatment and support treatment was better in pregnant patients than in the other patient group, and pregnant patients did not require plasmapheresis.
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Affiliation(s)
- Faruk Kilinc
- Department of Endocrinology, Medical Faculty, Firat University, Elazig, Turkey
| | - Ebubekir Senates
- Department of Gastroenterology, Medical Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Fatih Demircan
- Department of Internal Diseases, Private Etik Life Medical Center, Istanbul, Turkey
| | - Zafer Pekkolay
- Department of Endocrinology, Medical Faculty, Dicle University, Diyarbakir, Turkey
| | - Nevzat Gozel
- Department of Internal Medicine, Medical Faculty, Firat University, Elazig, Turkey
| | - Mehmet Guven
- Department of Endocrinology, Medical Faculty, Dicle University, Diyarbakir, Turkey
| | | | - Alpaslan Kemal Tuzcu
- Department of Endocrinology, Medical Faculty, Dicle University, Diyarbakir, Turkey
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Epidemiology and Etiology of Acute Pancreatitis in Urban and Suburban Areas in Shanghai: A Retrospective Study. Gastroenterol Res Pract 2018; 2018:1420590. [PMID: 30158961 PMCID: PMC6109519 DOI: 10.1155/2018/1420590] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/14/2018] [Accepted: 05/24/2018] [Indexed: 01/30/2023] Open
Abstract
Aim To investigate the epidemiology, etiology, and severity of acute pancreatitis (AP) in urban and suburban areas of Shanghai in 2011 and 2016. Methods A retrospective study of patients admitted to Shanghai General Hospital (urban and suburban campuses) with AP in 2011 and 2016 was undertaken. Patients were divided into acute biliary pancreatitis (ABP), hypertriglyceridemic pancreatitis (HTGP), alcoholic pancreatitis, and pancreatitis of other causes according to etiology. Severity of AP was divided into mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP). Results AP patients in the suburban area increased more rapidly than those in the urban area. The mean onset age of AP in the urban area in 2016 was older than that in the suburban area (p < 0.05). The suburban patients in 2016 have significantly younger mean onset age than those in 2011 (p < 0.05). HTGP incidence in suburban patients increased from 2011 to 2016, which changed little in the urban area. Urban females were more likely to develop HTGP than suburban ones in 2011, which reversed in 2016. As to the male patients, the incidence of HTGP increased in both urban and suburban areas. Nonelderly (<60 years old) patients had higher HTGP incidence than elderly ones in both 2011 and 2016. The descending trend of SAP in the suburban area was more obvious than that in the urban area. The length of hospitalization decreased from 2011 to 2016, especially in SAP patients. Conclusions AP patients increased more rapidly in the suburban area of Shanghai with younger onset age. The incidence of HTGP increased significantly in the suburban area, reminding of the prevention and screening of HTG.
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de Pretis N, Amodio A, Frulloni L. Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical management. United European Gastroenterol J 2018; 6:649-655. [PMID: 30083325 DOI: 10.1177/2050640618755002] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/26/2017] [Indexed: 12/12/2022] Open
Abstract
Hypertriglyceridemic pancreatitis (HTGP) typically occurs in patients with an underlying dyslipidemia (such as type I, IV or V dyslipidemia) and in the presence of a secondary condition, such as inadequately controlled diabetes, excess alcohol consumption or medication use. Although the symptoms of HTGP are similar to those of acute pancreatitis from other etiologies, HTGP is often associated with greater clinical severity and rate of complications. Therefore, accurate diagnosis of HTGP is essential so that patients receive the appropriate treatment. Novel therapies that aim to reduce the incidence of pancreatitis in this patient population are now available or in development. Understanding the etiology, pathophysiology and clinical characteristics of HTGP will enable future development of therapeutic agents to treat HTGP.
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Affiliation(s)
| | - Antonio Amodio
- Department of Medicine, University of Verona, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
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Wan J, He W, Zhu Y, Zhu Y, Zeng H, Liu P, Xia L, Lu N. Stratified analysis and clinical significance of elevated serum triglyceride levels in early acute pancreatitis: a retrospective study. Lipids Health Dis 2017; 16:124. [PMID: 28655321 PMCID: PMC5488442 DOI: 10.1186/s12944-017-0517-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/15/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hypertriglyceridemia is one of the three most common causes of AP, which is associated with the AP prognosis that has not been clearly defined. METHODS In this retrospective study, 1539 AP patients, who had serum triglyceride (TG) levels measured within the first 72 h, were assessed. The study groups consisted of patients with normal, mild, moderate, and severe/very severe HTG levels based on the Endocrine Society Clinical Practice Guidelines. We collected baseline demographic information, laboratory values, complications, and clinical outcome data in different HTG severity groups to analyze the clinical significance of elevated TG levels in AP. RESULTS Our study included 1539 AP patients; of these, 1078 (70%) had a normal TG levels, and 461 (30%) had elevated TG levels. The rates of severe AP increased in HTG groups of increasing severity (4% vs. 8% vs. 12%; P trend < 0.001). acute necrotic collection (ANC) and pancreatic necrosis developed in 32 and 39 of 112 patients (29% and 35%) (P trend = 0.001; P trend = 0.001) in the severe/very severe HTG group, respectively. The proportion of persistent organ failure (POF), multiple organ failure (MOF), and persistent Systemic Inflammatory Response Syndrome (SIRS) increased with higher grades of HTG (P trend < 0.001; P trend < 0.001; P trend < 0.001). The ICU admission rate was higher in the severe/very severe HTG group (57/112 patients; 51%; P trend < 0.001). A logistic multivariate regression analysis showed a positive correlation between HTG and certain AP complications. CONCLUSION In addition to other factors, an elevated TG level could be associated with the severity and prognosis of AP, including pancreatic necrosis, POF, MOF, persistent SIRS, ICU admission, and mortality.
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Affiliation(s)
- Jianhua Wan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Yong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Hao Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China.
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi, 330006, People's Republic of China.
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Wu C, Zou L, Shi S, Tong Z, Shen X, Yang D, Ke L, Li W, Li J. The role of hypertriglyceridemia for acute kidney injury in the course of acute pancreatitis and an animal model. Pancreatology 2017. [PMID: 28647101 DOI: 10.1016/j.pan.2017.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the role of hypertriglyceridemia for acute kidney injury (AKI) in the course of acute pancreatitis. METHODS Patients with acute pancreatitis were retrospectively divided into four groups according to admission triglyceride: normal group, mild HTG group, moderate HTG group and severe HTG group. Clinical characteristics were compared among these groups. Wild type (WT) mice and Human ApoC III transgenic (ApoCIIItg) mice were used in the next animal experiments. Severe acute pancreatitis (SAP) model was established by retrograde injection of 0.5% sodium taurocholate (0.1 ml/100 g) from duodenum to pancreatic duct. Histological scores, serum amylase, creatinine, usea nitrogen were compared between WT mice and ApoCIIItg mice. RESULTS Two hundred and sixty-two patients were classified into 4 groups: normal TG (104, 39.7%), mild HTG (72, 27.5%), moderate HTG (47, 17.9%), and severe HTG (39, 14.9%) groups. The proportions of AKI were 13.5% (14/104, normal), 13.9% (10/72, mild), 21.3% (10/47, moderate), and 38.5% (15/39, severe), respectively. After establishing SAP model, the levels of serum amylase (P < 0.05) and pancreatic histological score (P < 0.05) of ApoCIII-SAP-9h group were significantly higher than that of WT-SAP-9h group, respectively. ApoCIII-SAP-9h group had significantly higher levels of serum creatinine (P < 0.001), usea nitrogen (P < 0.001), and kidney histological score (P < 0.05) than that of WT-SAP-9h group, respectively. CONCLUSIONS Mild HTG has little adverse impact on disease severity of acute pancreatitis; severe HTG can aggravate kidney injury in the course of acute pancreatitis. ApoCIII-SAP mice have more serious pancreatic damage and kidney injury than WT-SAP mice.
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Affiliation(s)
- Congye Wu
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China; Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lei Zou
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Shujing Shi
- Department of Oncology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhihui Tong
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xiao Shen
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Dongliang Yang
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Lu Ke
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Weiqin Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China.
| | - Jieshou Li
- Department of SICU, Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
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Joglekar K, Brannick B, Kadaria D, Sodhi A. Therapeutic plasmapheresis for hypertriglyceridemia-associated acute pancreatitis: case series and review of the literature. Ther Adv Endocrinol Metab 2017; 8:59-65. [PMID: 28507728 PMCID: PMC5415006 DOI: 10.1177/2042018817695449] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/02/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (AP) in the United States. The current standard of care includes management of HTG using pharmacological therapy. More recently, plasmapheresis has been proposed as a therapeutic tool for decreasing triglyceride (TG) levels, especially in critically ill patients. Few studies are available to ascertain overall benefits of plasmapheresis over traditional management. OBJECTIVE To analyze the outcomes of patients treated with plasmapheresis for severe HTG-associated pancreatitis. METHODS We conducted a retrospective chart review of three patients with severe HTG- associated (TGs greater than 1000 mg/dl; 11.29 mmol/l) AP at the Methodist University Hospital. All the patients underwent plasmapheresis as part of their treatment. RESULTS The average TG level before plasmapheresis was 3532 mg/dl (range: 2524-4562 mg/dl; 39.9 mmol/l; range: 28.5-51.6 mmol/l). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 1.3 (range 1-2), and mean TG level after plasmapheresis was 1051 mg/dl (range: 509-1771 mg/dl; 11.9 mmol/l; range: 5.8-20 mmol/l). After the first session, the average reduction of TG level was 2481 mg/dl (range 753-3750 mg/dl; 28 mmol/l; range: 8.5-42.4 mmol/l) or approximately 70%. None of the patients developed complications related to plasmapheresis. CONCLUSIONS Plasmapheresis can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.
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Affiliation(s)
- Kiran Joglekar
- Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Ben Brannick
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Dipen Kadaria
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
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Zhang Y, Zhao J, Zhou SF, Yu ZL, Wang XY, Zhu PL, Chu ZS, Pan SY, Xie M, Ko KM. Biochemical mechanism underlying hypertriglyceridemia and hepatic steatosis/hepatomegaly induced by acute schisandrin B treatment in mice. Lipids Health Dis 2017; 16:8. [PMID: 28086886 PMCID: PMC5237187 DOI: 10.1186/s12944-017-0406-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 01/02/2017] [Indexed: 12/15/2022] Open
Abstract
Background It has been demonstrated that acute oral administration of schisandrin B (Sch B), an active dibenzocyclooctadiene isolated from Schisandrae Fructus (a commonly used traditional Chinese herb), increased serum and hepatic triglyceride (TG) levels and hepatic mass in mice. The present study aimed to investigate the biochemical mechanism underlying the Sch B-induced hypertriglyceridemia, hepatic steatosis and hepatomegaly. Methods Male ICR mice were given a single oral dose of Sch B (0.25–2 g/kg). Sch B-induced changes in serum levels of biomarkers, such as TG, total cholesterol (TC), apolipoprotein B48 (ApoB 48), very-low-density lipoprotein (VLDL), non-esterified fatty acid (NEFA) and hepatic growth factor (HGF), as well as hepatic lipids and mass, epididymal adipose tissue (EAT) and adipocyte size, and histological changes of the liver and EAT were examined over a period of 12–120 h after Sch B treatment. Results Serum and hepatic TG levels were increased by 1.0–4.3 fold and 40–158% at 12–72 h and 12–96 h, respectively, after Sch B administration. Sch B treatment elevated serum ApoB 48 level (up to 12%), a marker of exogenous TG, but not VLDL, as compared with the vehicle treatment. Treatment with Sch B caused a time-/dose-dependent reduction in EAT index (up to 39%) and adipocyte size (up to 67%) and elevation in serum NEFA level (up to 55%). Sch B treatment induced hepatic steatosis in a time-/dose-dependent manner, as indicated by increases in total vacuole area (up to 3.2 fold vs. the vehicle control) and lipid positive staining area (up to 17.5 × 103 μm2) in liver tissue. Hepatic index and serum HGF levels were increased by 18–60% and 42–71% at 12–120 h and 24–72 h post-Sch B dosing, respectively. In addition, ultrastructural changes, such as increase in size and disruption of cristae, in hepatic mitochondria were observed in Sch B-treated mice. Conclusion Our findings suggest that exogenous sources of TG and the breakdown of fat storage in the body contribute to Sch B-induced hypertriglyceridemia and hepatic steatosis in mice. Hepatomegaly (a probable hepatotoxic action) caused by Sch B may result from the fat accumulation and mitochondrial damage in liver tissue.
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Affiliation(s)
- Yi Zhang
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China
| | - Jing Zhao
- Institute of Integrated Bioinfomedicine & Translational Science, HKBU Shenzhen Research and Continuing Education, Shenzhen, 518057, China
| | - Shu-Feng Zhou
- Department of Bioengineering and Biotechnology, College of Chemical Engineering, Huaqiao University, Xiamen, Fujian, 361021, China
| | - Zhi-Ling Yu
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, SAR, China
| | - Xiao-Yan Wang
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China
| | - Pei-Li Zhu
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China
| | - Zhu-Sheng Chu
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China
| | - Si-Yuan Pan
- Department of Pharmacology, Beijing University of Chinese Medicine, Beijing, 100102, China.
| | - Ming Xie
- Department of Formulaology, Beijing University of Chinese Medicine, Beijing, 100029, China.
| | - Kam-Ming Ko
- Division of Life Science, Hong Kong University of Science & Technology, Hong Kong, SAR, China
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