The role of hypertriglyceridemia for acute kidney injury in the course of acute pancreatitis and an animal model

Etiological Changes and Prognosis of Hospitalized Patients with Acute Pancreatitis Over a 15-Year Period

BACKGROUND

The worldwide incidence of acute pancreatitis (AP) is increasing, but the dominant etiology of AP may vary by country. Mixed etiologies are involved in the increase in the number of AP patients.

AIMS

This study was to analyze the etiological changes and prognosis of AP patients and explore the prognosis of AP patients with mixed etiologies.

METHODS

Using a retrospective analysis method, AP patients hospitalized from January 2007 to December 2021 were selected from a pancreatic center in Nanchang, China. Trends in the main etiologies were analyzed, and the severity and prognosis of different etiologies were compared.

RESULTS

A total of 10,071 patients were included. Cholelithiasis (56.0%), hyperlipidemia (25.3%), and alcohol (6.5%) were the top three etiologies. The proportion of acute biliary pancreatitis (ABP) showed a decreasing trend, while the proportion of hypertriglyceridemic pancreatitis (HTGP) and alcoholic AP showed an increasing trend (all ptrend < 0.001). The incidence of organ failure and necrotizing pancreatitis was higher in patients with HTGP than in those with AP induced by other etiologies (all p < 0.05). There was no statistically significant difference in mortality among patients with different etiologies. Patients with AP due to a mixed hypertriglyceridemia-alcoholic etiology had higher ICU admission rates and were more severe than those with AP induced by other mixed etiologies.

CONCLUSION

In the past 15 years, the proportion of ABP has trended downward, while those of HTGP and alcoholic AP have risen. Among patients with mixed etiologies, those with a mixed hypertriglyceridemia-alcoholic etiology had a worse prognosis.

Ferroptosis inhibition attenuates inflammatory response in mice with acute hypertriglyceridemic pancreatitis

BACKGROUND

Ferroptosis is involved in developing inflammatory diseases; yet, its role in acute hypertriglyceridemic pancreatitis (HTGP) remains unclear.

AIM

To explore whether ferroptosis is involved in the process of HTGP and elucidate its potential mechanisms.

METHODS

An HTGP mouse model was induced using intraperitoneal injection of P-407 and caerulein (CAE). Then, pancreatic tissues from the model animals were subjected to proteome sequencing analysis. The pathological changes and scores of the pancreas, lung, and kidney were determined using hematoxylin-eosin staining. The levels of serum amylase (AMY), triglyceride, and total cholesterol were measured with an automatic blood cell analyzer. Additionally, the serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-1β were determined by enzyme linked immunosorbent assay. Malonaldehyde (MDA), glutathione (GSH), and Fe²⁺ were detected in the pancreas. Finally, immunohistochemistry was performed to assess the expression of ferroptosis-related proteins.

RESULTS

Proteome sequencing revealed that ferroptosis was involved in the process of HTGP and that NADPH oxidase (NOX) 2 may participate in ferroptosis regulation. Moreover, the levels of serum AMY, TNF-α, IL-6, and IL-1β were significantly increased, MDA and Fe²⁺ were upregulated, GSH and ferroptosis-related proteins were reduced, and the injury of the pancreas, lung, and kidney were aggravated in the P407 + CAE group compared to CAE and wild type groups (all P < 0.05). Notably, the inhibition of ferroptosis and NOX2 attenuated the pathological damage and the release of TNF-α, IL-6, and IL-1β in the serum of the mice.

CONCLUSION

Ferroptosis was found to have an important role in HTGP and may be considered a potential target for clinical treatment.

Mechanisms linking hypertriglyceridemia to acute pancreatitis

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

Hypertriglyceridemia Acute Pancreatitis: Animal Experiment Research

In recent years, the number of acute pancreatitis cases caused by hypertriglyceridemia has increased gradually, which has caught the attention of the medical community. However, because the exact mechanism of hypertriglyceridemic acute pancreatitis (HTG-AP) is not clear, treatment and prevention in clinical practice face enormous challenges. Animal models are useful for elucidating the pathogenesis of diseases and developing and testing novel interventions. Therefore, animal experiments have become the key research means for us to understand and treat this disease. We searched almost all HTG-AP animal models by collecting many studies and finally collated common animals such as rats, mice and included some rare animals that are not commonly used, summarizing the methods to model spontaneous pancreatitis and induce pancreatitis. We sorted them on the basis of three aspects, including the selection of different animals, analyzed the characteristics of different animals, different approaches to establish hypertriglyceridemic pancreatitis and their relative advantages and disadvantages, and introduced the applications of these models in studies of pathogenesis and drug therapy. We hope this review can provide relevant comparisons and analyses for researchers who intend to carry out animal experiments and will help researchers to select and establish more suitable animal experimental models according to their own experimental design.

Acute kidney injury in paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is not associated with progression to chronic kidney disease

BACKGROUND

Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a rare complication of SARS-CoV-2 associated with single or multiorgan dysfunction.

OBJECTIVE

We aimed to evaluate the incidence of acute kidney injury (AKI) and risk factors for kidney dysfunction in PIMS-TS, with reporting of 6-month renal follow-up data. We also evaluated renal involvement between first and second waves of the SARS-CoV-2 pandemic in the UK, the latter attributed to the Alpha variant.

DESIGN

A single-centre observational study was conducted through patient chart analysis.

SETTING

Data were collected from patients admitted to Great Ormond Street Hospital, London, UK, between April 2020 and March 2021.

PATIENTS

110 patients <18 years of age.

MAIN OUTCOME MEASURE

AKI during hospitalisation. AKI classification was based on upper limit of reference interval (ULRI) serum creatinine (sCr) values.

RESULTS

AKI occurred in 33 (30%) patients. Hypotension/hypoperfusion was associated with almost all cases. In univariate analysis, the AKI cohort had higher peak levels of triglycerides (OR, 1.27 (95% CI, 1.05 to 1.6) per 1 mmol/L increase) and C reactive protein (OR, 1.06 (95% CI, 1.02 to 1.12) per 10 mg/L increase), with higher requirement for mechanical ventilation (OR, 3.8 (95% CI, 1.46 to 10.4)) and inotropic support (OR, 15.4 (95% CI, 3.02 to 2.81)). In multivariate analysis, triglycerides were independently associated with AKI stages 2-3 (adjusted OR, 1.26 (95% CI, 1.04 to 1.6)). At follow-up, none had macroalbuminuria and all had sCr values

CONCLUSION

Despite a high incidence of AKI in PIMS-TS, renal recovery occurs rapidly with current therapies, and no patients developed chronic kidney disease.

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Key Words

• COVID-19
• nephrology
• paediatrics

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MESH Headings

• Acute Kidney Injury/complications
• Acute Kidney Injury/epidemiology
• Acute Kidney Injury/etiology
• C-Reactive Protein/analysis
• COVID-19/blood
• COVID-19/complications
• COVID-19/therapy
• Child
• Disease Progression
• Female
• Follow-Up Studies
• Humans
• Incidence
• Male
• Pandemics
• Renal Insufficiency, Chronic/epidemiology
• Renal Insufficiency, Chronic/etiology
• Respiration, Artificial
• Risk Factors
• SARS-CoV-2
• Systemic Inflammatory Response Syndrome/blood
• Systemic Inflammatory Response Syndrome/complications
• Systemic Inflammatory Response Syndrome/therapy
• Triglycerides/blood
• United Kingdom/epidemiology

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Affiliation(s)

Douglas John Stewart Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Nadeesha Lakmal Mudalige Institute of Child Health, University College London, London, UK
Mae Johnson Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Rukshana Shroff Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Institute of Child Health, University College London, London, UK
Pascale du Pré Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Jelena Stojanovic Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK

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Apolipoprotein C3 aggravates diabetic nephropathy in type 1 diabetes by activating the renal TLR2/NF-κB pathway

OBJECTIVE

Apolipoprotein C3 (ApoC3) is a regulator of triglyceride metabolism and inflammation, and its plasma levels are positively correlated with the progression of diabetic nephropathy (DN) in patients. However, the role and underlying mechanism of ApoC3 in DN remain unclear.

METHODS

Diabetes was induced in ApoC3 transgenic (Tg) and knockout (KO) mice by injection of streptozotocin. We studied the effect of ApoC3 on type 1 DN after 4 months of diabetes. Plasma glucose and lipid levels, renal function parameters and inflammation- and fibrogenesis-related gene and protein expression levels were studied. In vitro, human mesangial cells (HMCs) were incubated with high levels of glucose or/and triglyceride-rich lipoproteins (TRLs) with a high or low ApoC3 content isolated from Tg or wild-type (WT) mice, respectively, to explore the mechanisms of ApoC3 on development of DN.

RESULTS

We found that compared to WT mice, Tg mice exhibited hypertriglyceridemia (HTG), aggravated early renal function injury and inflammation, enlarged glomerular and mesangial surface areas, renal lipid deposition and elevated fibrogenesis-related gene expression levels after 4 months of diabetes. ApoC3 overexpression activated the renal Toll-like receptor 2 (TLR2) and nuclear factor-κB (NF-κB) signaling pathways and increased the renal gene and protein expression levels of the downstream inflammatory factors TNF-α, VCAM-1 and MCP-1. Unfortunately, we did not find that ApoC3 deficiency had an obvious protective effect against DN. In vitro, we found that TRLs with a high ApoC3 content increased the gene and protein expression levels of inflammation- and fibrogenesis-related factors in HMCs compared to those following administration of the same concentration of TRLs with a low ApoC3 content. These effects of ApoC3 were inhibited by blockade of TLR2 or NF-κB.

CONCLUSIONS

These findings suggest that ApoC3 aggravates early-stage DN by activating the renal TLR2/NF-κB pathway which is partially independent of HTG.

Factors associated with the severity of hypertriglyceridemia induced acute pancreatitis

Hypertriglyceridemia induced acute pancreatitis (HTGP) was associated with increased risk of local complications, recurrent acute pancreatitis (AP), the frequency of other complications, and its high mortality as compared to other causes. Determining the factors associated with the severity of HTGP was necessary and important in the management of patients with AP.This study aims to examine the clinical and biochemical characteristics of HTGP patients, and to determine the factors associated with the severity of HTGP according to the revised Atlanta classification.This retrospective and prospective study enrolled 157 HTGP patients from January 2016 to May 2019 at Cho Ray Hospital who had serum TG levels measured within the first 48 hours of admittance with a TG concentration ≥ 1000 mg/dL and excluded other causes. The clinical features and outcomes of patients with HTGP were determined in terms of demographics, clinical symptoms, laboratory data, system complications, local complications, disease severity, and length of hospital stay. The primary outcome was the severity of HTGP as based according to the revised Atlanta classification. We evaluated the relationship between general information, clinical factors and laboratory data in the study population.There were 157 HTGP patients participated in this study. Patients with HTGP had evidence of obese or overweight range (61.2%), history of diabetes mellitus (32.5%) or undiagnosed diabetes (28.0%), history of AP (35.7%), alcohol use (23.6%), hypertension (15.9%), dyslipidemia (13.4%). The patients had typical symptoms of AP, including pancreatic abdominal pain (upper abdominal pain) (93%), nausea/vomiting (80.9%), fever (59.2%), distension abdomen (84.7%), and resistance of abdominal wall (24.8%). The severity of HTGP was significantly associated with fever, altered mental status, rapid pulse, and hypotension (P < .05). Patients with severe HTGP had significantly more pancreatic necrosis, higher values of Blood urea nitrogen and creatinine, longer prothrombin time and activated partial thromboplastin time on admission and higher CRP48 than not severe HTGP (P < .05).The severity of HTGP was significantly related to clinical factors including fever, altered mental status, rapid pulse, hypotension, and pancreatic necrosis. The value of Blood urea nitrogen, creatinine, prothrombin time, and activated partial thromboplastin time at admission is higher and longer in the severe AP group with P < .05.

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.

Risk Factors for Acute Kidney Injury in Acute Pancreatitis: A 7-Year Retrospective Analysis of Patients in a Large Tertiary Hospital

OBJECTIVE

The aim of our study was to investigate the risk factors for acute kidney injury (AKI) in patients with acute pancreatitis (AP).

METHODS

Acute pancreatitis patients were retrospectively divided into 2 groups: AKI and non-AKI. We used logistic regression analysis to investigate the risk factors for AP patients with AKI. We also compared the incidence of complications and mortality between the non-AKI and AKI groups.

RESULTS

A total of 1255 AP patients without AKI and 430 AP patients with AKI were included. The risk factors for AKI in AP were hypertriglyceridemia (P = 0.001), severity (P = 0.001), etiology (P = 0.001), and Acute Physiology and Chronic Health Evaluation II scores (P = 0.001). The incidences of organ failure (P = 0.001), pancreatic necrosis (P = 0.001), and mortality (P = 0.001) were greater in the AKI group than in the non-AKI group.

CONCLUSIONS

Hypertriglyceridemia, severity, etiology, and Acute Physiology and Chronic Health Evaluation II scores are independent risk factors for AKI in AP patients. Those patients have serious outcomes such as high rate of organ failure, pancreatic necrosis, and debridement of necrosis.

The relationship between serum triglyceride levels and acute pancreatitis in an animal model and a 14-year retrospective clinical study

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.

Potential Prognostic Markers of Acute Kidney Injury in the Early Phase of Acute Pancreatitis

Acute kidney injury (AKI) is a serious complication of acute pancreatitis (AP), which occurs in up to 70% of patients with severe AP and significantly increases the risk of mortality. At present, AKI is diagnosed based on dynamic increase in serum creatinine and decreased urine output; however, there is a need for earlier and more accurate biomarkers. The aim of the study was to review current evidence on the laboratory tests that were studied as the potential biomarkers of AKI in AP. We also briefly summarized the knowledge coming from the studies including sepsis or ICU patients since severe acute pancreatitis is associated with systemic inflammation and organ failure. Serum cystatin C and serum or urine NGAL have been shown to predict or diagnose AKI in AP; however, this evidence come from the single center studies of low number of patients. Other markers, such as urinary kidney injury molecule-1, cell cycle arrest biomarkers (tissue inhibitor metalloproteinase-2 and urine insulin-like growth factor-binding protein 7), interleukin-18, liver-type fatty acid-binding protein, or calprotectin have been studied in other populations suffering from systemic inflammatory states. In AP, the potential markers of AKI may be significantly influenced by either dehydration or inflammation, and the impact of these factors may be difficult to distinguish from kidney injury. The subject of AKI complicating AP is understudied. More studies are needed, for both exploratory (to choose the best markers) and clinical (to evaluate the diagnostic accuracy of the chosen markers in real clinical settings).

Hypertriglyceridemia-Associated Drug-Induced Acute Pancreatitis

OBJECTIVES

The aim of our study was to investigate the cases of drug-induced acute pancreatitis (DIAP) with hypertriglyceridemia as the mechanism of injury.

METHODS

A MEDLINE search (1963-2018) of the English language literature was performed looking for all human case reports of adults (>18 years old) with hypertriglyceridemia as the mechanism of DIAP. The latest search date was February 28, 2018. Drugs were classified into probability groups based on a classification used by Badalov et al (Clin Gastroenterol Hepatol. 2007;5:648-661).

RESULTS

The search revealed a total of 76 cases in 59 published reports. A total of 25 medications were found to be implicated in DIAP secondary to hypertriglyceridemia mechanism. Most of acute pancreatitis cases were mild or moderately severe with favorable outcomes. In 3 cases involving tamoxifen, pagaspargase, and quetiapine, patient death was the outcome. Plasmapheresis was only used in 9 cases in an effort to decrease triglyceride levels.

CONCLUSIONS

Hypertriglyceridemia-associated DIAP is a rare phenomenon, and the current systematic review provides a summary of drugs that have been implicated in this phenomenon, which allow physicians to be oriented about this adverse effect when these drugs are used.

Elevated triglycerides level in hospital stay as a risk factor of mortality in patients with severe acute pancreatitis

Hypertriglyceridaemia is one of the most common causes of severe acute pancreatitis (SAP). However, the association between elevated triglycerides (TG) level in hospital stay and outcome in SAP patients with normal TG level at admission has not been clearly demonstrated. This retrospective study assessed the serum TG levels of patients with SAP admitted to the intensive care unit (ICU) in 2017. Variables with a statistically significant association with the incidence of in-hospital TG elevation, as determined by univariate analysis, were analysed using a logistic regression model to predictors. Of the 99 patients included in the study, TG levels were within the normal range in 59 (59.59%) patients at admission. Among patients with normal TG level when admitted to ICU, 28 (47.46%) experienced at least one episode of TG level elevation during their ICU stay. Elevated TG level in hospitalization is associated with an increased length of ICU stay, as well as increased mortality. In addition to other factors, propofol usage was independently associated with the occurrence of in-hospital-TG elevation. To conclude, we retrospectively investigated the incidence, outcome, and risk factors for in-hospital TG elevation events in SAP patients admitted to the ICU. We found a high incidence of both preexisting and in-hospital-acquired TG elevation in SAP patients admitted to the ICU. The TG elevation that occurred during the ICU stay was associated with worse outcomes and long-term hospitalization of the ICU. Propofol usage was independently associated with the TG elevation occurrence in the ICU.

The effect of serum triglyceride concentration on the outcome of acute pancreatitis: systematic review and meta-analysis

Elevated serum triglyceride concentration (seTG, >1.7 mM or >150 mg/dL) or in other words hypertriglyceridemia (HTG) is common in the populations of developed countries. This condition is accompanied by an increased risk for various diseases, such as acute pancreatitis (AP). It has been proposed that HTG could also worsen the course of AP. Therefore, in this meta-analysis, we aimed to compare the effects of various seTGs on the severity, mortality, local and systemic complications of AP, and on intensive care unit admission. 16 eligible studies, including 11,965 patients were retrieved from PubMed and Embase. The results showed that HTG significantly elevated the odds ratio (OR = 1.72) for severe AP when compared to patients with normal seTG (<1.7 mM). Furthermore, a significantly higher occurrence of pancreatic necrosis, persistent organ failure and renal failure was observed in groups with HTG. The rates of complications and mortality for AP were significantly increased in patients with seTG >5.6 mM or >11.3 mM versus <5.6 mM or <11.3 mM, respectively. We conclude that the presence of HTG worsens the course and outcome of AP, but we found no significant difference in AP severity based on the extent of HTG.