The role of apheresis in hypertriglyceridemia-induced acute pancreatitis: A systematic review

Long-term clinical outcomes and management of hypertriglyceridemia in children with Apo-CII deficiency

BACKGROUND AND AIM

APO CII, one of several cofactors which regulate lipoprotein lipase enzyme activity, plays an essential role in lipid metabolism. Deficiency of APO CII is an ultra-rare autosomal recessive cause of familial chylomicronemia syndrome. We present the long-term clinical outcomes of 12 children with APO CII deficiency.

METHODS AND RESULTS

The data of children with genetically confirmed APO CII deficiency were evaluated retrospectively. Twelve children (8 females) with a mean follow-up of 10.1 years (±3.9) were included. At diagnosis, the median age was 60 days (13 days-10 years). Initial clinical findings included lipemic serum (41.6%), abdominal pain (41.6%), and vomiting (16.6%). At presentation, the median triglyceride (TG) value was 4341 mg/dL (range 1277-14,110). All patients were treated with a restricted fat diet, medium-chain triglyceride (MCT), and omega-3-fatty acids. In addition, seven patients (58.3%) received fibrate. Fibrate was discontinued in two patients due to rhabdomyolysis and in one patient because of cholelithiasis. Seven (58.3%) patients experienced pancreatitis during the follow-up period. One female experienced recurrent pancreatitis and was treated with fresh frozen plasma (FFP).

CONCLUSIONS

Apo CII deficiency is an ultra-rare autosomal recessive condition of hypertriglyceridemia associated with significant morbidity and mortality. Low-fat diet and MCT supplementation are the mainstays of therapy, while the benefit of TG-lowering agents are less well-defined.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Application of Lipid Apheresis in Acute Lipogenic Pancreatitis

INTRODUCTION

Recently, the incidence of hypertriglyceridemia-associated pancreatitis (HTG-AP) has been increasing. The pathogenesis of lipogenic pancreatitis is not fully understood. This study aimed to retrospectively analyze the laboratory data, clinical manifestations, and prognosis of patients with lipid-derived pancreatitis who received lipid purification, to explore whether lipid purification is a better treatment for acute hyperlipidemic pancreatitis.

METHODS

In this study, we enrolled five subjects diagnosed with HTG-AP at the Second Xiangya Hospital of Central South University between 2021 and 2022. We collected demographic data, medical histories, clinical manifestations, and laboratory data. All patients received routine therapy. Blood lipid purification was conducted using the double filtration plasmapheresis (DFPP) method. Plasma was separated from blood cells and purified to remove cholesterol, triglycerides, and low-density lipoprotein (LDL). SPSS was used for statistical analyses.

RESULTS

Following a single lipoprotein apheresis (LA) treatment, significant improvements in serum lipid levels were observed. Three patients achieved triglyceride levels below 5.65 mmol/L within 24 h, while the remaining 2 patients experienced reductions of 82% and 78%, respectively. The average triglyceride level decreased from 36.82 to 7.27 mmol/L, representing an 80% reduction from baseline. Total cholesterol decreased by 59% on average, and LDL levels decreased by 69%. Statistically significant differences were observed in triglyceride and cholesterol levels before and after treatment. Four patients exhibited increased HDL levels posttreatment, while 1 patient showed a decrease. The average HDL/TC level was 21% higher after treatment.

CONCLUSION

LA in HTG-AP effectively improves clinical symptoms, rapidly lowers lipid levels, and achieves good therapeutic outcomes.

Diabetic Ketoacidosis and Hypertriglyceridemia-Induced Acute Pancreatitis Requiring Plasmapheresis: A Case Report of a Rare Presentation of Type 2 Diabetes Mellitus in Adults

The triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis is a rare presentation of diabetes mellitus type 2 in adults. We report a case of a 41-year-old male who presented at the emergency department with a sudden onset of severe abdominal pain. Diagnosis of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis was made. Triglyceride level was 6056 mg/dL and glycated hemoglobin was 12.6%. Vigorous fluid therapy and continuous infusion of insulin were started, but due to maintained symptoms, a single plasmapheresis session was performed, with significant clinical improvement. This case emphasizes the diagnostic challenges of the triad and highlights the potential role of plasmapheresis in rapidly reducing triglyceride levels.

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

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

Initiation time of double-filtration plasma apheresis affects the risk of persistent organ failure in hypertriglyceridaemia-induced acute pancreatitis: a retrospective study

The effect of double filtration plasma apheresis (DFPP) on improving the outcomes of patients with hypertriglyceridaemia-induced acute pancreatitis (HTG-AP) remains unclear. The aim of this study was to evaluate the relationship between the initiation time of DFPP and the risk of persistent organ failure (POF) in an HTG-AP cohort in China. We retrospectively evaluated data from HTG-AP patients treated with DFPP 48 h after diagnosis between January 2017 and January 2022. Comparisons across tertiles of the interval from diagnosis to completion of one DFPP session (DTD) were analysed. Logistic regression models and restricted cubic splines (RCS) were used to determine the correlation between the DTD time and risk of POF. Of the 89 patients enrolled, 46 patients (51.69%) suffered POF in the first week of HTG-AP. DFPP was initiated at a median of 17 h after the diagnosis was confirmed. The patients in the highest tertile of DTD time had a significantly increased prevalence of POF. After multivariate adjustment, the logistic regression models found a significant decrease in the odds ratios (OR) of POF from the highest to the lowest DTD tertile (P for trend = 0.006). Moreover, the RCS curves showed a nonlinear relationship in the adjusted OR of POF and DTD time, which remained relatively low and flat during the early DTD time but increased sharply afterwards. Early initiation of DFPP treatment correlates with a reduced risk of POF in HTG-AP patients.

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

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

Acute Pancreatitis Secondary to Pembrolizumab-Induced Hypertriglyceridemia

Pembrolizumab is a humanized monoclonal antibody targeted against programmed cell death protein 1 (PD-1) receptor of lymphocytes. It is used alone or in combination with many chemotherapy regimens for a wide variety of cancers. It has been reported to cause various side effects including endocrinopathies, colitis, rash, and pneumonitis. Hypertriglyceridemia (HTG) has been recently added to its side effect profile with a possible pathogenic mechanism involving autoantibodies against glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GP1HBP1). We are presenting a case of acute pancreatitis secondary to HTG in a cervical cancer patient. HTG was successfully treated with insulin infusion. As the patient's symptoms improved, she was started on the diet. She was discharged on statin and fibrate therapy. We are reporting this case to increase awareness of this rare side effect, inpatient management, and outpatient screening while on immunotherapy.

Successful multimodal treatment of extreme hypertriglyceridemia in a juvenile diabetic dog

OBJECTIVE

To describe the therapeutic protocol used to normalize severe hypertriglyceridemia in a dog.

CASE SUMMARY

A 7-month-old, 1.2-kg female Pomeranian presented with acute polyuria, polydipsia, and ocular discoloration. Diagnoses included diabetic ketosis, severe hypertriglyceridemia (>225 mmol/L [>20,000 mg/dl]), lipemia retinalis, and bilateral uveitis. The triglyceride concentration was near normal within 2 days of initiating treatment with fenofibrate, regular insulin constant rate infusion (CRI), manual therapeutic plasma exchange (TPE), and a low-fat diet. All clinical signs resolved. The dog has had no relapse of hypertriglyceridemia at the time of writing the manuscript, 6 months later, with continued treatment of diabetes mellitus.

NEW OR UNIQUE INFORMATION PROVIDED

This is the first case report documenting the combination of fenofibrate, insulin CRI, and manual TPE for treatment of severe hyperlipidemia in a dog. Detailed protocols for manual TPE and a novel insulin CRI are provided. A discussion of multiple spurious biochemical and hematologic errors associated with the severe hypertriglyceridemia is also provided.

The role of high serum triglyceride levels on pancreatic necrosis development and related complications

BACKGROUND

The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis.

METHODS

We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150-199 mg/dL), High TG (200-499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis.

RESULTS

A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI - 6.27, p < 0.001).

CONCLUSIONS

An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.

Rapid resolution of hypertriglyceridemia-induced pancreatitis via plasmapheresis: A unique case report

Hypertriglyceridemia is a well-established cause of acute pancreatitis. Initial treatment for hypertriglyceridemia-induced pancreatitis has consisted of supportive measures; however, triglyceride levels can remain high, causing prolonged organ failure and sepsis. Plasmapheresis has been proposed as a treatment option to effectively reduce triglyceride levels. We present a patient case of hypertriglyceridemia-induced pancreatitis that was treated with standard acute pancreatitis interventions along with plasmapheresis, after which triglyceride levels reduced significantly. Further research is necessary to determine the clinical benefits of plasmapheresis in treating this type of pancreatitis.

Acute pancreatitis due to hypertriglyceridemia: Plasmapheresis versus medical treatment

OBJECTIVE

Hypertriglyceridemia (HTG) is the third-most common cause of acute pancreatitis. Plasmapheresis is an extracorporeal treatment method used for treatment. This study aimed to investigate the efficacy of medical treatment and plasmapheresis in patients with acute pancreatitis due to HTG.

METHODS

This was a retrospective cross-sectional study. The patients were divided into two groups according to the treatment they received as those who received only medical treatment and those who performed plasmapheresis with medical treatment. According to the treatment received by the patients; clinical, demographic, and laboratory data, Ranson scores, and bedside index of severity in acute pancreatitis (BISAP) scores, decrease in triglyceride levels in 24 h, length of hospital stay, and outcomes were recorded.

RESULTS

Forty-seven patients were included in the study. The level of triglyceride decreases at the 24^th h was 59.7% ±17.3% in those who received medical treatment and was 70.4% ±15.1% in those who received plasmapheresis (P = 0.032). Receiver operating characteristic curve analysis was performed to predict the need for plasmapheresis treatment, area under the curve (AUC) value of the triglyceride level was the highest (AUC: 0.822, 95% confidence interval: [0.703-0.940]; P < 0.001), the sensitivity and specificity were 83.3% and 72.4%, respectively, and the cut-off value of triglyceride was accepted as 3079.5 mg/dL.

CONCLUSION

Plasma triglyceride levels and BISAP score on admission may help physicians to predict the need for plasmapheresis. Plasmapheresis helps to rapidly reduce triglyceride levels in patients with HTG-associated acute pancreatitis.

EFFICACY OF DOUBLE FILTRATION PLASMAPHERESIS TREATMENT IN ACUTE PANCREATITIS ASSOCIATED WITH SEVERE HYPERTRIGLYCERIDEMIA

Background and aim

Hypertriglyceridemia is one of the leading causes of acute pancreatitis and is associated with increased morbidity and mortality. Today the recommended treatment options are fasting, hydration, if necessary antibiotics and there is not a standard recommendation to decrease triglycerides rapidly. Double Fıltratıon Plasmapheresis (DFPP) may be an option to decrease triglycerides rapidly but its effect on the disease course is unknown.

Method

In the present study, we present results of four acute pancreatitis cases associated with hypertriglyceridemia treated with DFPP. All of the patients were diagnosed as acute pancreatitis at emergency room and no complications were observed in sessions. A 76.3% reduction in triglyceride levels was observed in one or two treatment sessions.

Results and conclusion

DFPP is an effective and safe option to decrease triglyceride levels rapidly but further research is needed to show the effect on mortality and morbidity.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Value of BISAP score for predicting severity of hyperlipidemic acute pancreatitis: A meta-analysis

BACKGROUND

Early identification of hyperlipidemic acute pancreatitis (HLAP) patients at risk of developing potentially lethal complications is of great clinical significance. Studies have suggested that the bedside index for in acute pancreatitis (BISAP) score is associated with adverse outcomes.

AIM

To assess the accuracy of BISAP score as a prognostic marker for severity of HLAP.

METHODS

A systematic search of main computerized databases was performed to identify eligible cohort studies on the predictive value of BISAP score for severity of HLAP. The STATA software and Meta-disc software were applied to carry out the meta-analysis.

RESULTS

Ten studies (n = 1591) were included. The overall sensitivity and specificity of BISAP score ≥ 3 for predicting mortality in HLAP were 0.85 (95% confidence interval [CI]: 0.65-0.96) and 0.86 (95%CI: 0.82-0.88), respectively; the area under the curve (AUC) was 0.937, and the diagnostic odds ratio (DOR) was 42.00 (95%CI: 12.86-139.12). Regarding the increase of BISAP score for prediction of severe acute pancreatitis (SAP), the pooled sensitivity was 0.69 (95%CI: 0.61-0.76), and the specificity was 0.82 (95%CI: 0.78-0.85), with AUC and DOR being 0.900 and 18.47 (95%CI: 6.82-42.03), respectively. The pooled sensitivity, specificity, and DOR for prediction of moderately severe acute pancreatitis (MASP) + SAP were 0.54 (95%CI: 0.50-0.63), 0.91 (95%CI: 0.89-0.93), and 15.55 (95%CI: 6.91-34.99), respectively; the AUC was 0.724. BISAP score was superior to APACH Ⅱ and Ranson score in predicting the severity of HLAP.

CONCLUSION

BISAP score is a reliable tool to identify the severity of HLAP, but it has a suboptimal sensitivity for predicting SAP and SAP + MSAP.

Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early

Background

The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP.

Methods

The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected.

Results

From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05).

Conclusions

In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06533-w.

Hypertriglyceridemia-Induced Pancreatitis and a Lipemic Blood Sample: A Case Report and Brief Clinical Review

Hypertriglyceridemia is the third most common cause of acute pancreatitis after gallstones and long-term alcohol use. There are specific therapeutic options unique to hyperglyceridemia-induced pancreatitis, such as continuous insulin therapy and plasmapheresis, emphasizing the importance of identifying hypertriglyceridemia as the cause. Triglyceride levels > 1000 mg/dL may result in a visibly lipemic blood sample. Lipemic samples may interfere with laboratory equipment, resulting in erroneous levels or the inability to measure several serum blood tests. Consider hypertriglyceridemia as a cause for acute pancreatitis in the setting of a lipemic blood sample or when gallstones have been excluded.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review

Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

STUDY DESIGN AND METHODS

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

RESULTS

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

DISCUSSION

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

Acute pancreatitis due to severe hypertriglyceridemia in the COVID-19 era: The role of therapeutic plasma exchange

The psychosocial consequences of the COVID-19 pandemic caused multifaceted challenges in clinical and therapeutic practices. This was the case at the Therapeutic Apheresis Unit of the Padua University Hospital too. Several published reports describe the increase in alcohol and food addiction diseases. In this context, during the last months, the Padua Therapeutic Apheresis Unit treated many more patients with acute pancreatitis due to severe hypertriglyceridemia with therapeutic plasma exchange than in the previous ten years. Furthermore, retrospective cohort studies have been recently published describing the onset of acute pancreatitis during the COVID-19 infection even if, to date, there is still insufficient evidence to estabilish a direct causality. Anyway, the COVID-19 pandemic translated into changes of the overall disease prevalence scenario and therefore the Padua Therapeutic Apheresis Unit will need to reorganise its Therapeutic Apheresis activity.

Plasmapheresis as an Early Treatment for Severe Hypertriglyceridemia, Acute Pancreatitis, and Diabetic Ketoacidosis

Objective

Severe hypertriglyceridemia (SHTG; plasma triglycerides >1000 mg/dL) is a rare but serious complication in children who develop diabetic ketoacidosis (DKA) from uncontrolled or new-onset type 1 diabetes.

Methods

We present the case of a severely malnourished 16-year-old with a 10-month history of presumed type 2 diabetes managed with lifestyle modifications and metformin, who presented with SHTG, acute pancreatitis, and DKA. On examination, there was no evidence of lipemia retinalis, cutaneous xanthomas, or xanthelasma. He was initially treated with an insulin infusion and intravenous fluids. Despite this treatment, his pancreatitis symptoms worseneed and lipase level increased, necessitating 2 courses of plasmapheresis that immediately resolved his symptoms and dramatically improved his clinical status. He was discharged on hospital day 5. During his hospital admission, islet cell antigen 512, insulin, glutamic acid decarboxylase 65, and zinc transporter 8 autoantibodies were positive in the presence of insulinopenia, consistent with type 1 diabetes.

Results

Hypertriglyceridemia and hypercholesterolemia did not recur during follow-up, suggesting that the underlying mechanism for SHTG was insulin deficiency.

Conclusion

This report of SHTG, DKA, and pancreatitis in an adolescent highlights the safe, early initiation of plasmapheresis as an effective treatment. To our knowledge, plasmapheresis has rarely been used so early in the course of treatment for an adolescent with SHTG, DKA, and acute pancreatitis.

Effect of TPE vs medical management on patient outcomes in the setting of hypertriglyceridemia-induced acute pancreatitis with severely elevated triglycerides

OBJECTIVES

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) accounts for 1 to 10% of pancreatitis cases, and is associated with a more severe clinical course. Therapeutic plasma exchange (TPE) is a potential treatment option for quickly lowering plasma triglycerides (TG). Current ASFA guidelines define HTG-AP as a Category III disorder, indicating the role of apheresis is not firmly established. Here, we examine clinical data regarding its effectiveness on morbidity and mortality in patients with HTG-AP presenting with severely elevated plasma triglycerides (>4000 mg/dl).

METHODS

We retrospectively examined clinical data and outcomes from 67 consecutive episodes of HTG-AP over a 5-year period in which either medical management alone or medical management plus adjunct TPE was employed to reduce plasma triglycerides.

RESULTS

16/67 admissions involved TPE, initiated at a mean of 0.7 days from the time of presentation, while 51 received medical management alone. After only one TPE procedure, the mean TG values decreased from 4103 to 1045 mg/dl (a reduction of 74.7%), and those receiving TPE reached plasma TG < 1000 mg/dl 0.99 days faster than the medical group. One patient in the TPE group died. However, when excluding patients with hospital courses complicated by multiple organ dysfunction, there was no significant difference in mortality or hospital length of stay (LOS) between the groups.

CONCLUSIONS

In uncomplicated cases of HTG-AP with an absence of multiorgan dysfunction, there is no significant benefit to either mortality or LOS when adding adjunct TPE to medical management, even when patients present with severely elevated levels of TG.

Current Diagnosis and Management of Primary Chylomicronemia

Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.

PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes ( LPL , LMF1 , GPIHBP1 , APOC2 , and APOA5 ). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).

The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive.

The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life.

Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease.

Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.

The Efficacy of Intravenous Insulin Infusion in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Rural Community Hospital

A 28-year-old female presented to the emergency room with epigastric pain, nausea, and vomiting; her lipase was elevated, and computed tomography of abdomen showed evidence of acute pancreatitis. Her past medical history was significant for poorly controlled insulin requiring type 2 diabetes mellitus and 2 previous admissions for hypertriglyceridemia-induced pancreatitis. Due to the severity of her pancreatitis presentation, she was admitted to the intensive care unit. She received aggressive intravenous fluid hydration and was started on an insulin drip. Apheresis was strongly considered given the degree of her hypertriglyceridemia (11 602 mg/dL), but there was no timely access to this treatment option. She, however, significantly improved with insulin therapy alone. Her triglyceride levels decreased rather quickly to 4783 mg/dL within 24 hours and by the fourth day of admission were comfortably <1000 mg/dL with insulin infusion along with clinical improvement. She was discharged on niacin and insulin therapy along with her home medications of statin and fenofibrate.

Management strategy and novel ophthalmological findings in neonatal severe hypertriglyceridemia: a case report and literature review

Background

Neonatal severe hypertriglyceridemia is rarely reported in the literature and there is no consensus for hypertriglyceridemia management at this age group.

Methods

The index case is a 4-week-old male infant with severe hypertriglyceridemia accidentally discovered during a circumcision surgery. His clinical and genetic characteristics and his successful management strategy are described. Furthermore, a detailed ophthalmological examination of the proband was conducted at 3 and 6 months of age using Fourier-domain-optical coherence tomography.

Results

Triglycerides level at presentation was extremely high 33,727 mg/dL (380.8 mmol/L). Two sessions of exchange blood transfusion on two consecutive days successfully reduced triglycerides to 382 mg/dL (4.3 mmol/L) with no adverse effects. The infant was discharged 3 days later. At discharge, the mother was advised to continue breastfeeding together with a medium-chain triglycerides formula. Satisfactory growth parameters and lipid profile values were obtained for a follow-up duration of 5 months with no reported attacks of acute pancreatitis. Lipoprotein lipase deficiency was confirmed by the detection of the LPL homozygous pathogenic variant c.805G > A; p.(Glu269Lys). Early corneal and macular lesions were detected and persisted on follow-up despite relatively good lipemic control.

Conclusion

This case highlights the importance of the early discovery of severe hypertriglyceridemia during the neonatal period, which is needed for prompt management and prevention of severe complications. Rationalized breastfeeding can be tolerated within the diet plan of the disease with satisfactory outcomes. To our knowledge, it is the first study reporting early corneal and macular affection by severe hypertriglyceridemia in a neonate. Prolonged follow-up is needed to determine the extent of ophthalmological lesions.

Dysregulated SREBP1c/miR-153 signaling induced by hypertriglyceridemia worsens acute pancreatitis and delays tissue repair

Severe acute pancreatitis (AP) is a life-threatening disease with up to 30% mortality. Therefore, prevention of AP aggravation and promotion of pancreatic regeneration are critical during the course and treatment of AP. Hypertriglyceridemia (HTG) is an established aggravating factor for AP that hinders pancreatic regeneration; however, its exact mechanism remains unclear. Using miRNA sequencing and further verification, we found that miRNA-153 (miR-153) was upregulated in the pancreas of HTG animal models and in the plasma of patients with HTG-AP. Increased miR-153 aggravated HTG-AP and delayed pancreatic repair via targeting TRAF3. Furthermore, miR-153 was transcriptionally suppressed by sterol regulatory element-binding transcription factor 1c (SREBP1c), which was suppressed by lipoprotein lipase malfunction-induced HTG. Overexpressing SREBP1c suppressed miR-153 expression, alleviated the severity of AP, and facilitated tissue regeneration in vivo. Finally, therapeutic administration of insulin also protected against HTG-AP via upregulating SREBP1c. Collectively, our results not only provide evidence that HTG leads to the development of more severe AP and hinders pancreatic regeneration via inducing persistent dysregulation of SREBP1c/miR-153 signaling, but also demonstrate that SREBP1c activators, including insulin, might be used to treat HTG-AP in patients.

Hypertriglyceridemia induced pancreatitis complicated by compartment syndrome and managed by surgical decompression and plasmapheresis

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis.

The patients with pancreatitis are at risk for both local and systemic complications.

Abdominal compartment syndrome is underdiagnosed and undertreated in this patient population. We report a case of 39-year-old male with medical history of diabetes mellitus who presented with abdominal pain and was diagnosed with HTG induced pancreatitis, complicated by abdominal compartment syndrome requiring surgical decompression and plasmapheresis.

Total cholesterol concentration predicts the effect of plasmapheresis on hypertriglyceridemic acute pancreatitis: a retrospective case-control study

Background

What kind of patients with hypertriglyceridemic acute pancreatitis (HLAP) might benefit from plasmapheresis (PP) remains unknown. The objective of this study is to determine the predict function of total cholesterol (TC) on the Triglyceride (TG)-lowing effect in patients on either non-PP or PP therapy.

Methods

Patients were categorized into high total cholesterol (HTC)/low total cholesterol (LTC) groups based on TC level of 12.4 mmol/L. The primary outcome was TG reduction to below 500 mg/dL within 48 h. Linear mixed-effect model and logistic regression analyses were used to assess the association of TC level and TG-lowing efficacy in different therapy groups.

Results

Compared with LTC group, patients with HTC showed more severe imaging manifestations (p < 0.001) and higher APACH II scores (p = 0.036). Deaths occurred only in HTC groups. Significant interaction of time sequence with the 2 TGs-lowing therapy groups on TG level was only found in HTC group (p < 0.001). In patients with elevated TC level, primary outcome occurred in 66.67% of patients in the PP group, and 27.91% in the non-PP group. After adjustment for age, gender, CT grade and APACH II score, the odd ratio remain significant (OR 5.47, 95% confidence interval [CI] 1.84–16.25, p = 0.002). Furthermore, in patients with lower TC level, no significant difference was found in primary outcome between PP group and non-PP group (81.25% versus 62.30%, adjusted OR 2.05; 95% CI 0.45–9.40; p = 0.353).

Conclusions

TC could be a potential biomarker to predict the effects of TG-lowing therapy in patients with HLAP.

Progress in diagnosis and treatment of hypertriglyceridemic acute pancreatitis

At present, the incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) is on the rise, the age of onset tends to be younger, and severe HTG-AP is more common. HTG has become the second major cause of acute pancreatitis (AP) in China. Previous studies have demonstrated that the severity of hypertriglyceridemia correlates with the severity of AP. However, the pathogeneses of HTG and HTG-AP are still unknown. The treatments for HTG-AP include low-calorie diet, insulin, heparin, lipid-lowering drugs, and blood purification. Although these treatments, especially blood purification measures represented by plasma exchange, have been proven to reduce blood lipid levels, they still need to be confirmed by high-quality randomized controlled trials to improve the prognosis of HTG-AP. The value of gene diagnosis and therapy in the diagnosis and treatment of HTG-AP has attracted more and more attention, which may be an important direction of HTG-AP research in the future.

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

BACKGROUND

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

STUDY DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between triglyceride level and the severity of acute hypertriglyceridemic pancreatitis in Chinese patients

BACKGROUND/AIMS

The aim of this study was to investigate the relationship between the triglyceride (TG) level and the severity of acute hypertriglyceridemic pancreatitis (AHTGP) in Chinese patients.

MATERIALS AND METHODS

On the basis of clinical data on AHTGP, patients from the period 2015-2018 were enrolled retrospectively and grouped according to the 2012 revised Atlanta classification. Kruskal-Wallis test was performed to evaluate differences among groups. Receiver operating characteristic (ROC) curves were generated to assess the ability of parameters to distinguish mild acute pancreatitis (MAP)/moderately severe acute pancreatitis (MSAP) from severe acute pancreatitis (SAP).

RESULTS

A total of 104 patients with AHTGP were enrolled and divided into three groups: 61 patients with MAP, 29 patients with MSAP, and 14 patients with SAP. The median values for the MAP, MSAP, and SAP groups were as follows: TG level 48 h after admission, 3.4, 4.5, and 14.2 mmol/L, respectively (p<0.001); ratio of TG level 48 h after admission to that 0 h after admission (48:0-h ratio), 19.4, 32.1, and 65.9, respectively (p<0.001). ROC curves showed that the areas under the curves for the TG level 48 h after admission and the TG 48:0-h ratio for predicting SAP were 0.965 and 0.917, respectively (p<0.001), and the optimal cut-off values were 7.8 mmol/L and 37.7, respectively.

CONCLUSION

The TG level 48 h after admission and the TG 48:0-h ratio may predict the severity of AHTGP, and a high TG level 48 h after admission may be correlated with the progression of SAP.

The role of double filtration plasmapheresis in hypertriglyceridemic pancreatitis: A propensity score matching analysis

INTRODUCTION

The role of double filtration plasmapheresis (DFPP) in hypertriglyceridemic pancreatitis (HTGP) is still not well established. Our study aimed to investigate the efficacy of DFPP in reducing triglyceride levels as well as their effects on the outcomes of HTGP.

MATERIAL AND METHODS

We retrospectively evaluated the data of patients with HTGP presenting within 72 hours from symptom onset between January 2016 and February 2019. Patients with DFPP treatment were compared with those without DFPP treatment. We used a propensity score matching analysis to reduce confounding factors.

RESULTS

Of the 249 patients enrolled, 88 (35.3%) were treated with DFPP. The DFPP was initiated at a median of 7.7 hours from the time of presentation. In the propensity score-matched cohort (n = 100), patients with DFPP had a significantly lower level of triglyceride (P = .034), higher triglyceride reduction (P = .005), and the proportion of triglyceride <5.65 mmol/L (P = .002) by 24 hours after admission when compared with those without DFPP. However, this efficacy did not last until 48 hours after admission. No differences were found in terms of the majority of the clinical outcomes between the two groups, including persistent organ failure (P = .098), local complications (P = .213), hospital stay (P = .657), and in-hospital mortality (P > .999).

CONCLUSIONS

HTGP patients with early initiation of DFPP were associated with rapidly and efficiently reduction of triglyceride levels compared with those without DFPP. However, DFPP showed no beneficial effects on improving the clinical outcomes of HTGP.

Temporal trends in incidence of pediatric type 1 diabetes in Alabama: 2000-2017

OBJECTIVE

The incidence of type 1 diabetes has increased in the United States and worldwide. We hypothesized that trends in the annual incidence rates of childhood-onset type 1 diabetes in the state of Alabama would be different by race and sex.

METHODS

We performed a retrospective observational cohort study, analyzing children with type 1 diabetes (n = 3770) managed at the Children's Hospital of Alabama between 2000 and 2017. We compared crude incidence rates using negative binomial regression models and analyzed differences in annual trends of age-adjusted incidence by race and sex using joinpoint regression.

RESULTS

The crude type 1 diabetes incidence rate was estimated at 16.7 per 100 000 children <19 years of age in Alabama. Between 2000 and 2007, there was an increase in age-adjusted incidence of type 1 diabetes with an annual percent change (APC) of 10% from 2000 to 2007 and a 1.7% APC decrease from 2007 to 2017. The age-adjusted incidence for Whites and Blacks increased with an average annual percentage change (AAPC) of 4.4% and 2.8%, respectively. A nearly 11% increasing trend in age-adjusted incidence was observed for both races, though the increase plateaued in 2006 for Whites and 2010 for Blacks.

CONCLUSIONS

Following significantly increasing annual trends for both races, the age-adjusted rate remained statistically stable for Whites and decreased significantly for Blacks. Longer-sustained trend increases for Blacks resulted in type 1 diabetes incidence tripling compared to the doubling of the rate for Whites.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Conservative management in hypertriglyceridemia-associated pancreatitis

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

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

BACKGROUND/AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

EFFICACY OF INSULIN, HEPARIN AND FENOFIBRATE COMBINATION TREATMENT IN SEVERE HYPERTRIGLYCERIDEMIA: DOUBLE CENTER EXPERIENCE

Context

Severe hypertriglyceridemia (SH), which calls for a triglyceride (TG) level above 1000 mg/dL, remains an important health issue. While some data exist to offer combination of heparin, insulin and fenofibrate as a reasonable treatment option, safety and benefits of this therapy have not been accurately weighted, largely due to the limited sample size of the relevant studies.

Aim

Assess the efficacy and safety of the heparin, insulin and fenofibrate combination in the treatment of patients with SH.

Patients - Methods

Patients aged ≥18 years with TG level above 1000 mg/dL and adequate organ function were included. Triglyceride levels were measured immediately before the treatment and on the 3^rd and 6^th days of the treatment. Treatment dosage, duration, response and side effects were assessed. Patients with hypertriglyceridemia presenting with acute pancreatitis were treated additionally with lipid apheresis.

Results

A total of 42 patients were included. Of these, 85.8% came to medical attention with some kind of secondary hypertriglyceridemia causes. The baseline median TG value of the cases was 2141.0 mg/ dL (1026-12250). There were 6 patients (14.3%) with acute pancreatitis at presentation. In patients without pancreatitis, with administration of insulin infusion, unfractionated heparin infusion and fenofibrate capsule, median TG values decreased to 921 mg/ dL (190-6400) on the 3^rd day and to 437 mg/ dL (112-1950) on the 6^th day of the treatment (p<0.0001, Friedman test). Potential toxicities related to insulin, heparin and fenofibrate combination treatment including hypoglycemia, hemorrhage, rise in creatine kinase levels, hepato - and nephrotoxicity were not observed.

Conclusion

In this trial involving patients with SH, our data suggest that insulin, heparin and fenofibrate combination therapy was safe and effective.

Continuous intravenous infusion of insulin and heparin vs plasma exchange in hypertriglyceridemia-induced acute pancreatitis

OBJECTIVE

Acute triglyceride-lowering therapy is crucial in the early treatment of hypertriglyceridemia-induced pancreatitis. This study aimed to compare the efficacy of continuous i.v. infusion of insulin and heparin therapy (IHT) and plasma exchange to lower triglyceride levels in the acute phase of hypertriglyceridemia-induced pancreatitis.

METHODS

A retrospective observational study was conducted in a tertiary teaching hospital. Patients with hypertriglyceridemia-induced pancreatitis were consecutively enrolled from 2012 to 2017. Serum triglyceride levels and clinical data during hospitalization were collected. The primary outcome was the rapid reduction of triglyceride levels.

RESULTS

Of the 62 patients enrolled, 34 (54.8%) were treated with IHT and the others with plasma exchange. A reduced triglyceride level of (66.9 ± 21.5)% after the first plasma exchange session and that of (75.0 ± 14.6)% after the first day of IHT were observed. There were no significant differences in the reduction of triglyceride (F = 0.334), high sensitivity C-reactive protein (F = 0.127) and the acute physiology and chronic health evaluation II score (F = 2.589) between the two groups (all P > 0.05). The medical cost during hospitalization was significantly lower in the IHT group than in the plasma exchange group (RMB [59 512.4 ± 23 645.1] vs RMB [89 461.9 ± 48 324.0], P < 0.05). Adverse effects were observed in six patients in the plasma exchange group but none in the IHT group.

CONCLUSION

As a minimally invasive and economical strategy, IHT is effective and non-inferior to plasma exchange in achieving a rapid reduction of triglyceride levels.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

Patients received double filtration plasmapheresis.

OUTCOMES

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

LESSONS

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

A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other.