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Abboud Y, Shah M, Simmons B, Mandava K, Morales JEM, Jaber F, Alsakarneh S, Ismail M, Hajifathalian K. Hypertriglyceridemia-induced acute necrotizing pancreatitis: Poor clinical outcomes requiring revisiting management modalities. JGH Open 2024; 8:e13061. [PMID: 38617108 PMCID: PMC11015164 DOI: 10.1002/jgh3.13061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 04/16/2024]
Abstract
Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is the third most common cause of AP after gallstones and alcohol. Supportive measures, intravenous insulin, and plasmapheresis are possible treatment modalities for HTG-AP; however, definitive guidelines evaluating the best therapeutic approach are not clearly established. We present a rare case of a 42-year-old male without known comorbidities who was found to have HTG-AP. Despite early initiation of intravenous insulin and plasmapheresis and the initial decline in his triglycerides level, his condition was complicated by necrotizing pancreatitis and subsequent multi-organ failure. Future studies are warranted to evaluate the role of plasmapheresis in HTG-AP and its efficacy.
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Affiliation(s)
- Yazan Abboud
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Meet Shah
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Benjamin Simmons
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Kranthi Mandava
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - John E M Morales
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Fouad Jaber
- Department of Internal MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Saqer Alsakarneh
- Department of Internal MedicineUniversity of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Mohamed Ismail
- Department of Internal MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Kaveh Hajifathalian
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
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2
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Kavathia S, Kataria S, Patel N, Patel S. Diabetic Ketoacidosis-Induced "Terrible Triad" Associated With Seizures and Acute Renal Failure: A Report of a Rare Case. Cureus 2023; 15:e45214. [PMID: 37720132 PMCID: PMC10500620 DOI: 10.7759/cureus.45214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 09/19/2023] Open
Abstract
We report a case of a 17-year-old male patient who came to the emergency department with abdominal pain, headaches for two days, lethargy, and Kussmaul breathing. Diabetic ketoacidosis (DKA) was diagnosed. The patient's clinical course was complicated with a severely elevated triglyceride (TG) level (25,585 mg/dL), acute pancreatitis, renal involvement, and generalized seizures. The proposed mechanism is triglyceride excess due to increased lipolysis, resulting in the formation of excess free fatty acids. The objective of this case report is to present and describe the clinical features, laboratory investigations, case management, and natural course of hypertriglyceridemia in DKA.
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Affiliation(s)
- Shrenil Kavathia
- Internal Medicine, Shri Jalaram Arogya Seva Trust Hospital, Meghraj, IND
| | - Sharvil Kataria
- Internal Medicine, Siddhi Heart and Medical Hospital, Ahmedabad, IND
| | - Nirav Patel
- Neonatology, Orange Neonatal and Pediatric Hospital, Ahmedabad, IND
| | - Sagar Patel
- Neonatology, Orange Neonatal and Pediatric Hospital, Ahmedabad, IND
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3
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Ultrasound-induced destruction of heparin-loaded microbubbles attenuates L-arginine-induced acute pancreatitis. Eur J Pharm Sci 2023; 180:106318. [PMID: 36332825 DOI: 10.1016/j.ejps.2022.106318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Acute pancreatitis (AP) involves sudden inflammation caused by abnormal activation of pancreatic enzymes. The mechanisms underlying AP include oxidative stress, high levels of inflammatory mediators and inflammatory cell infiltration. Heparin, a key therapeutic drug, exerts anti-inflammatory, antioxidative, and anticoagulative effects. However, safe and effective drug delivery remains an obstacle. This study is the first to investigate the therapeutic effects of heparin-loaded microbubbles (HPMB) combined with ultrasound (UHPMB) and the role of heparin in acoustic cavitation. METHODS The characteristics of the microbubbles, including particle size, concentration, release, stability, and development, were studied. Heparin concentration in the HPMB was measured, and heparin-induced anticoagulation was evaluated. Drug safety was explored using hemolysis and cell viability assessments. The ability of HPMB to alleviate oxidative stress and inflammation were investigated in vitro. L-arginine induces AP in vivo. UHPMB was used for AP treatment. Serum amylase levels were measured and pancreatic architecture and pathological features were evaluated to determine AP severity. In vivo efficacy was evaluated, and the underlying mechanism of heparin action during acoustic cavitation was explored. RESULTS HPMB was spherical and presented as an emulsion-like solution without aggregation. HPMB was visible and stable and effectively released the drug under ultrasound (US). HPMB and UHPMB led to lower AP severity than in the untreated group. US-targeted microbubble destruction (UTMD) enhanced the therapeutic effect by decreasing oxidative stress and inflammation in AP models without injuring vital organs. UHPMB regulated VEGF/Flt-1 and SOD-1 expression. HPMB can also mitigate oxidative stress and inflammation in H2O2-pretreated cells. CONCLUSION UHPMB exhibits a strong ability not only to selectively target pancreatic lesions and release heparin but also to provide efficient protection by inhibiting oxidative stress and inflammation.
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Shaka H, El-amir Z, Jamil A, Kwei-Nsoro R, Wani F, Dahiya DS, Kichloo A, Amblee A. Plasmapheresis in hypertriglyceridemia-induced acute pancreatitis. Proc (Bayl Univ Med Cent) 2022; 35:768-772. [DOI: 10.1080/08998280.2022.2106531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Hafeez Shaka
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Zain El-amir
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Abdul Jamil
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Robert Kwei-Nsoro
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Farah Wani
- Department of Medicine, Samaritan Medical Center, Watertown, New York
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, Michigan
- Department of Medicine, Samaritan Medical Center, Watertown, New York
| | - Ambika Amblee
- Division of Endocrinology, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
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Kandemir A, Coşkun A, Yavaşoğlu İ, Bolaman Z, Ünübol M, Yaşa MH, Kadıköylü G. Therapeutic plasma exchange for hypertriglyceridemia induced acut pancreatitis: the 33 cases experience from a tertiary reference center in Turkey. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 29:676-683. [PMID: 30289402 DOI: 10.5152/tjg.2018.17627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Altay Kandemir
- Department of Gastroenterology, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - Adil Coşkun
- Department of Gastroenterology, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - İrfan Yavaşoğlu
- Department of Hematology, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - Zahit Bolaman
- Department of Hematology, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - Mustafa Ünübol
- Department of Endocrinology, Adnan Menderes University School of Medicine, Aydın, Turkey
| | - Mehmet Hadi Yaşa
- Department of Gastroenterology, Adnan Menderes University School of Medicine, Aydın, Turkey
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Huang SP, Toh DE, Sue YM, Chen TH, Cheng SW, Cheng CY. Double filtration plasmapheresis in treatment of acute pancreatitis associated with severe hypertriglyceridemia: Three case reports. Medicine (Baltimore) 2018; 97:e12987. [PMID: 30383651 PMCID: PMC6221692 DOI: 10.1097/md.0000000000012987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Ding-Ek Toh
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Yuh-Mou Sue
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Tso-Hsiao Chen
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Sheng-Wei Cheng
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Yi Cheng
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
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Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review. Case Rep Gastrointest Med 2018; 2018:8714390. [PMID: 30345124 PMCID: PMC6174808 DOI: 10.1155/2018/8714390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/19/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022] Open
Abstract
Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL.
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Gayam V, Mandal AK, Gill A, Khalid M, Sangha R, Khalid M, Garlapati P, Bhattarai B. 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. J Investig Med High Impact Case Rep 2018; 6:2324709618798399. [PMID: 30186885 PMCID: PMC6120174 DOI: 10.1177/2324709618798399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Vijay Gayam
- Interfaith Medical Center, New York, NY, USA
| | | | | | | | - Ruby Sangha
- Interfaith Medical Center, New York, NY, USA
| | - Mowyad Khalid
- Detroit Medical Center, Wayne State University, MI, USA
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9
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Total Plasma Exchange in Hypertriglyceridemia-Induced Pancreatitis: Case Report and Literature Review. Case Rep Med 2018; 2018:4017573. [PMID: 29686710 PMCID: PMC5857338 DOI: 10.1155/2018/4017573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/13/2018] [Indexed: 12/13/2022] Open
Abstract
Objective To emphasize the role of apheresis in management of pancreatitis. Methods The clinical course of a patient admitted for hypertriglyceridemia-induced pancreatitis (HTGP) complicated by multiorgan dysfunction is described, who demonstrated dramatic improvement in his clinical status after total plasma exchange (TPE). In addition, the current guidelines for TPE and the alternative treatment options for HTGP are also presented. Results A patient presenting with pancreatitis associated with severe systemic inflammatory response was admitted to our hospital with an initial triglyceride level of 1181 mg/dL. Given the patient's worsening clinical condition, he was started on TPE with a rapid fall in his serum TG levels, in turn leading to early clinical recovery. Conclusion Though various therapeutic options for the treatment of HTGP are described in literature, there are no set guidelines available to tackle this difficult clinical situation. TPE, albeit not very well known in this context, is one of the many therapies available. Though it leads to a rapid, precipitous fall in the TG levels and early symptom resolution, the data about the long-term morbidity as well as the effectiveness of this therapy is still lacking.
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10
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Wassay SAM, Dar FJ, Saleh AK, Mansoor I. Role of therapeutic plasma exchange in the treatment of severe hypertriglyceridemia: an experience. Ther Adv Endocrinol Metab 2017; 8:169-172. [PMID: 29238515 PMCID: PMC5721969 DOI: 10.1177/2042018817739571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/08/2017] [Indexed: 11/16/2022] Open
Abstract
Hypertriglyceridemia of obesity, the metabolic syndrome, and type II diabetes mellitus are highly prevalent in Saudi Arabia. Severe hypertriglyceridemia is a rare but well known cause of acute pancreatitis. In treatment pancreatic rest, lifestyle changes, and lipid-lowering medications are essential, but the response is slow. Recently the role of therapeutic plasma exchange (TPE) has been stressed for fast and effective management in addition to insulin and heparin infusion. TPE for hypertriglyceridemic pancreatitis resulted in drastic improvements in clinical and laboratory findings and patient outcomes as suggested in our cases. However, this procedure is limited due to its high cost and availability only in specialized hospitals.
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11
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Saleh MA, Mansoor E, Cooper GS. Case of familial hyperlipoproteinemia type III hypertriglyceridemia induced acute pancreatitis: Role for outpatient apheresis maintenance therapy. World J Gastroenterol 2017; 23:7332-7336. [PMID: 29142480 PMCID: PMC5677204 DOI: 10.3748/wjg.v23.i40.7332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/10/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
Hypertriglyceridemic pancreatitis (HTGP) accounts for up to 10% of acute pancreatitis presentations in non-pregnant individuals and is the third most common cause of acute pancreatitis after alcohol and gallstones. There are a number of retrospective studies and case reports that have suggested a role for apheresis and insulin infusion in the acute inpatient setting. We report a case of HTGP in a male with hyperlipoproteinemia type III who was treated successfully with insulin and apheresis on the initial inpatient presentation followed by bi-monthly outpatient maintenance apheresis sessions for the prevention of recurrent HTGP. We also reviewed the literature for the different inpatient and outpatient management modalities of HTGP. Given that there are no guidelines or randomized clinical trials that evaluate the outpatient management of HTGP, this case report may provide insight into a possible role for outpatient apheresis maintenance therapy.
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Affiliation(s)
- Mohannad Abou Saleh
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Emad Mansoor
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Gregory S Cooper
- Division of Gastroenterology and Liver Disease, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
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13
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Zeitler H, Balta Z, Klein B, Strassburg CP. Extracorporeal Treatment in Severe Hypertriglyceridemia-Induced Pancreatitis. Ther Apher Dial 2015; 19:405-10. [DOI: 10.1111/1744-9987.12286] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Heike Zeitler
- Internal Medical Clinic I; Centre of Extracorporeal Therapy and Autoimmunity (CETA); University of Bonn; Bonn Germany
| | - Zeynep Balta
- Internal Medical Clinic I; Centre of Extracorporeal Therapy and Autoimmunity (CETA); University of Bonn; Bonn Germany
| | - Burkhard Klein
- Internal Medical Clinic I; Centre of Extracorporeal Therapy and Autoimmunity (CETA); University of Bonn; Bonn Germany
| | - Christian P. Strassburg
- Internal Medical Clinic I; Centre of Extracorporeal Therapy and Autoimmunity (CETA); University of Bonn; Bonn Germany
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14
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Pérez-Martínez D, Martínez-Quintana ME. [Plasmapheresis in hypertriglyceridemic acute pancreatitis]. Med Intensiva 2014; 39:387-8. [PMID: 25499461 DOI: 10.1016/j.medin.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 10/18/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
Affiliation(s)
- D Pérez-Martínez
- Unidad de Cuidados Intensivos, Hospital General Universitario Los Arcos del Mar Menor, Pozo Aledo, San Javier, Murcia, España
| | - M E Martínez-Quintana
- Unidad de Cuidados Intensivos, Hospital General Universitario Los Arcos del Mar Menor, Pozo Aledo, San Javier, Murcia, España.
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15
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Severe/Extreme Hypertriglyceridemia and LDL Apheretic Treatment: Review of the Literature, Original Findings. CHOLESTEROL 2014; 2014:109263. [PMID: 25580288 PMCID: PMC4279422 DOI: 10.1155/2014/109263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 12/31/2022]
Abstract
Hypertriglyceridemia (HTG) is a feature of numerous metabolic disorders including dyslipidemias, metabolic syndrome, and diabetes mellitus type 2 and can increase the risk of premature coronary artery disease. HTG may also be due to genetic factors (called primary HTG) and particularly the severe/extreme HTG (SEHTG), which is a usually rare genetic disorder. Even rarer are secondary cases of SEHTG caused by autoimmune disease. This review considers the causes of SEHTG, and their management including treatment with low density lipoprotein apheresis and analyzes the original findings.
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16
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Ábel T, Sándor K, Tremmel A, Pénzes I, Gamal EM, Lengyel G, Szabolcs I. [Plasmapheresis in the treatment of hypertriglyceridemia]. Orv Hetil 2014; 155:1203-6. [PMID: 25063703 DOI: 10.1556/oh.2014.29954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The authors present the case of a 38-year-old woman with severe hypertriglyceridemia-induced acute recurrent pancreatitis (triglyceride 16 761 mg/dl, 189.4 mmol/l). According to the knowledge of the authors, such a high triglyceride has not been previously reported in Hungarian and international scientific literature. The patient received conventional treatment (fluid replacement, analgesic, antibiotics, discontinuation of oral intake) and plasmapheresis too. After two sessions of plasmapheresis with one month interval the clinical and laboratory parameters greatly improved. Severe hypertriglyceridemia (triglyceride level more than 1000 mg/dl, ≈11.3 mmol/l) is an independent risk factor for acute pancreatitis. Plasmapheresis seems to be safe and effective to rapidly decrease triglyceride levels and to remove the causative agent for pancreatitis in a patient with severe hypertriglyceridemia.
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Affiliation(s)
- Tatjána Ábel
- Magyar Honvédség Egészségügyi Központ Szakrendelő Intézet Budapest Róbert Károly krt. 44. 1134 Europ-Med Egészség Központ Budaörs Semmelweis Egyetem, Egészségtudományi Kar Dietetikai és Táplálkozástudományi Tanszék Budapest
| | - Katalin Sándor
- Szent Lázár Megyei Kórház Perioperatív Medicina, Aneszteziológia és Intenzív Terápiás Osztály Salgótarján
| | - Anna Tremmel
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest
| | - István Pénzes
- Semmelweis Egyetem, Általános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Klinika Budapest
| | | | - Gabriella Lengyel
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
| | - István Szabolcs
- Europ-Med Egészség Központ Budaörs Semmelweis Egyetem, Egészségtudományi Kar Dietetikai és Táplálkozástudományi Tanszék Budapest
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18
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Stefanutti C, Labbadia G, Morozzi C. Severe hypertriglyceridemia-related acute pancreatitis. Ther Apher Dial 2013; 17:130-7. [PMID: 23551669 DOI: 10.1111/1744-9987.12008] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute pancreatitis is a potentially life-threatening complication of severe hypertriglyceridemia. In some cases, inborn errors of metabolism such as lipoprotein lipase deficiency, apoprotein C-II deficiency, and familial hypertriglyceridemia have been reported as causes of severe hypertriglyceridemia. More often, severe hypertriglyceridemia describes various clinical conditions characterized by high plasma levels of triglycerides (>1000 mg/dL), chylomicron remnants, or intermediate density lipoprotein like particles, and/or chylomicrons. International guidelines on the management of acute pancreatitis are currently available. Standard therapeutic measures are based on the use of lipid-lowering agents (fenofibrate, gemfibrozil, niacin, Ω-3 fatty acids), low molecular weight heparin, and insulin in diabetic patients. However, when standard medical therapies have failed, non-pharmacological approaches based upon the removal of triglycerides with therapeutic plasma exchange can also provide benefit to patients with severe hypertriglyceridemia and acute pancreatitis. Plasma exchange could be very helpful in reducing triglycerides levels during the acute phase of hyperlipidemic pancreatitis, and in the prevention of recurrence. The current evidence on management of acute pancreatitis and severe hypertriglyceridemia, focusing on symptoms, treatment and potential complications is reviewed herein.
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Affiliation(s)
- Claudia Stefanutti
- Department of Immunohematology and Transfusion Medicine,, Extracorporeal Therapeutic Techniques Unit, Rome, Italy.
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Ewald N, Kloer HU. Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis. Clin Res Cardiol Suppl 2013; 7:31-5. [PMID: 22528130 PMCID: PMC3374106 DOI: 10.1007/s11789-012-0042-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hypertriglyceridemia is associated with a number of severe diseases such as acute pancreatitis and coronary artery disease. In severe hypertriglyceridemia (SHTG, triglycerides > 1,000 mg/dL), rapid lowering of plasma triglycerides (TG) has to be achieved. Treatment regimes include nutritional intervention, the use of antihyperlipidemic drugs, and therapeutic apheresis. Apheretic treatment is indicated in medical emergencies such as hypertriglyceridemic pancreatitis. Reviewing the current literature, plasmapheresis appears to be a safe and useful therapeutic tool in patients suffering from SHTG. Apheretic treatment is able to remove the causative agent for pancreatic inflammation. Data suggests that the use of apheresis should be performed as early as possible in order to achieve best results. The use of plasmapheresis, however, is limited due to the rather high costs and the limited availability of the procedure.
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Affiliation(s)
- Nils Ewald
- Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Klinikstr. 33, 35392 Giessen, Germany.
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20
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Abstract
Environmental and lifestyle changes have led to an increasing incidence of primary or secondary high triglycerides. As elevated triglycerides are an important risk factor for acute pancreatitis (AP), the incidence of AP of this cause has also been gradually increasing. Patients with hyperlipidemic AP often suffer severely and develop more complications. Crucial therapy is to lower serum triglyceride levels. In this article, we will summarize the recent progress in the treatment of hyperlipidemic pancreatitis.
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Huang P, Wang CY, Wu HS, Wu GJ, Li JJ. Treatment of hyperlipidemic acute pancreatitis by continuous venovenous hemofiltration: an analysis of 24 cases. Shijie Huaren Xiaohua Zazhi 2012; 20:964-968. [DOI: 10.11569/wcjd.v20.i11.964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To observe the treatment effect of continuous veno-venous hemofiltration (CVVH) in patients with hyperlipidemic acute pancreatitis (HLP).
METHODS: Forty-nine HLP patients were randomly divided into two groups: CVVH group (A, n = 24) and control group (B, n = 25). Both groups underwent conventional therapy, and patients in group A additionally underwent CVVH. Heart rate (HR), respiration, PO2/FiO2, SaO2, triglyceride (TG), IL-6 and TNF-α were monitored. APACHE Ⅱ score was used to evaluate patients' condition. The incidences of acute complications and survival rate were compared between the two groups.
RESULTS: After treatment by CVVH, HR, respiration, APACHE Ⅱ (10.8 ± 5.1 vs 15.5 ± 6.9, P < 0.05) as well as serum levels of TG, IL-6 and TNF-α (6.8 ± 3.7 vs 18.5 ± 6.3, 39.8 ± 16.7 vs 72.4 ± 25.1, 37.5 ± 14.1 vs 61.2 ± 16.1, all P < 0.05) decreased significantly. Seven days later, shock was corrected in both groups (P < 0.05). In group A, the incidences of acute renal failure (ARF) and acute respiratory distress syndrome (ARDS) were significantly decreased (5.0% vs 37.5%, 5.0% vs 25%, both P < 0.05). Compared to group B, group A had a higher survival rate (8.3% vs 20%).
CONCLUSION: CVVH is effective in treating HLP and is associated with a lower case fatality rate.
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Kella DK, Shoukat S, Sperling L. Plasma exchange for severe hypertriglyceridemia-induced pancreatitis in an orthotopic heart transplant recipient. J Clin Lipidol 2012; 6:474-6. [PMID: 23009784 DOI: 10.1016/j.jacl.2012.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 12/18/2011] [Accepted: 01/18/2012] [Indexed: 12/21/2022]
Abstract
We here report a 33-year old male with diabetes, hypertension and history of orthotopic heart transplantation treated by plasma exchange for severe HTG (hypertriglyceridemia) induced pancreatitis. At the time of presentation, his serum TG (triglyceride) level was 10,278 mg/dL. He underwent one of the three planned sessions of plasma exchange, resulting in a decrease in TG level from 4728 mg/dL to 1708 mg/dL. The hospital course was complicated with shock, hemorrhagic transformation of the pancreatitis and acute respiratory distress syndrome. This prevented any further plasma exchange sessions. He was subsequently discharged home in a stable state and TG level of 80 mg/dL. Plasma exchange can be safely used to manage HTG induced pancreatitis in heart transplant recipients.
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Affiliation(s)
- Danesh K Kella
- Emory University School of Medicine, 1365 Clifton Road, NE Building A, Suite 2200, Atlanta, GA 30322, USA
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23
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Lutfi R, Huang J, Wong HR. Plasmapheresis to treat hypertriglyceridemia in a child with diabetic ketoacidosis and pancreatitis. Pediatrics 2012; 129:e195-8. [PMID: 22201145 DOI: 10.1542/peds.2011-0217] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 10-year-old girl presented with diabetic ketoacidosis, shock, and severe abdominal pain. She was found to have acute pancreatitis and acute kidney injury after shock resuscitation and severe persistent hypertriglyceridemia. The severe hypertriglyceridemia was treated with 1 course of plasmapheresis, which corrected the triglyceride level and was temporally associated with improvement of the abdominal pain and renal dysfunction. Diabetes is known to contribute to an elevated triglyceride level, especially in the setting of an underlying lipid disorder. However, no such disorders were found in this patient. To the best of our knowledge, this is the first report of a pediatric patient presenting with the triad of severe hypertriglyceridemia, diabetic ketoacidosis, and pancreatitis treated successfully with plasmapheresis.
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Affiliation(s)
- Riad Lutfi
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati OH 45229, USA.
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Stefanutti C, Di Giacomo S, Labbadia G. Timing clinical events in the treatment of pancreatitis and hypertriglyceridemia with therapeutic plasmapheresis. Transfus Apher Sci 2011; 45:3-7. [PMID: 21723786 DOI: 10.1016/j.transci.2011.06.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hyperlipidemic pancreatitis (HP) is caused by severe hypertriglyceridemia (SHTG). Evidence of SHTG refractoriness to standard medical treatment but not to therapeutic apheresis has increased in the last years. METHODS Described is the timing of clinical events and the sequence of therapeutic plasma-exchange (TPE) procedures to treat pancreatitis due to SHTG in a male patient, Caucasian, aged 49years, referred to emergency for severe epigastric pain. There was no history of alcohol consumption, a pre-existing mild hyperlipidemia was treated with diet alone, and biliary imaging was normal. Physical examination revealed epigastric tenderness. Laboratory investigation revealed marked hypertriglyceridemia (11,355mg/dL; range: 30-150), and hypercholesterolemia (941mg/dL; range: 80-200). Serum amylase (Amy) and lipase (Lip) were increased: 160UI/L (range: 20-100) and 175UI/L (range: 13-60), respectively. A computerized tomography (CT) scan of the abdomen revealed a picture compatible with acute pancreatic phlogosis. It was diagnosed as "acute secondary pancreatitis (AP) and SHTG". RESULTS The patient was successfully submitted to three sessions of TPE in emergency. He was released from hospital after 13 days of hospitalization. The levels of lipids and lipoproteins in his plasma were as follows: triglycerides (TG) 185mg/dL; total cholesterol (TC) 179mg/dL; HDL-cholesterol (HDLC) 22mg/dL; LDL-cholesterol (LDLC) 120mg/dL. CONCLUSIONS The decision to submit the patient with clinical evidence of HP caused by SHTG to apheresis was correct. The improvement in the clinical picture was fast and the recovery was complete.
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Affiliation(s)
- C Stefanutti
- Therapeutic Plasmapheresis Unit - Department of Clinical and Medical Therapy, University of Rome La Sapienza - Umberto I Hospital, 155, V.le del Policlinico, I-00161 (EU) Rome, Italy.
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25
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Plasmaféresis como tratamiento de la hipertrigliceridemia grave. ACTA ACUST UNITED AC 2011; 58:319-20. [DOI: 10.1016/j.endonu.2010.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 12/11/2010] [Accepted: 12/14/2010] [Indexed: 11/19/2022]
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Ewald N, Kloer HU. Severe hypertriglyceridemia: an indication for apheresis? ATHEROSCLEROSIS SUPP 2011; 10:49-52. [PMID: 20129374 DOI: 10.1016/s1567-5688(09)71810-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Severe hypertriglyceridemia is associated with a number of severe complications such as acute pancreatitis. Rapid lowering of excessively elevated triglyceride (TG) levels is therefore a primary medical goal in these patients. According to previous reports, immediate apheretic treatment might be an interesting option in order to rapidly lower excessively elevated TG levels. METHODS A review of the current available literature was therefore conducted in order to provide an overview of the present data on apheretic treatment for patients with severe hypertriglyceridemia. RESULTS A single session of plasmapheresis proofs capable of lowering TG levels by up to 70%, producing clear clinical and laboratory improval. The best clinical benefit concerning reduction in morbitity and mortality can be achieved when apheresis is used as early as possible. Even repetitive use of apheresis is reported. There is controversy on technical details, such as different apheresis techniques (plasma exchange versus double-membrane filtration), slightly favoring plasma exchange. CONCLUSIONS In patients with severe hypertriglyceridemia plasmapheresis seems to be a safe and useful tool in rapidly lowering excessively elevated TG levels. Apheresis can be used to rapidly decrease triglyceride levels, and thus remove the causative agent for continuing damage. The indications are medical emergencies such as hypertriglyceridemic pancreatitis with excessively elevated TG levels (TG > 1000 mg/dl). If indicated, it should be used as early as possible.
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Affiliation(s)
- Nils Ewald
- Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Rodthohl 6, 35392 Giessen, Germany.
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27
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Kadikoylu G, Yukselen V, Yavasoglu I, Coşkun A, Karaoglu AO, Bolaman Z. Emergent therapy with therapeutic plasma exchange in acute recurrent pancreatitis due to severe hypertriglyceridemia. Transfus Apher Sci 2011; 43:285-289. [PMID: 20926345 DOI: 10.1016/j.transci.2010.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hypertriglyceridemia causes acute pancreatitis in 1.3-3.8% of patients. We report here on two cases with severe (triglyceride level >1000 mg/dL) hypertriglyceridemia-induced acute recurrent pancreatitis. Both patients had uncontrolled hypertriglyceridemia and suffered from acute pancreatitis. No cause of secondary hypertriglyceridemia was detected. While stage E pancreatitis (Ranson's score: 2) was diagnosed in the first case, stage D pancreatitis with a null Ranson's score was detected in the second case. Both patients were treated with classical treatment with fluid replacement, analgesic, antibiotics and discontinuation of oral intake. Therapeutic plasma exchange (TPE) with fresh frozen plasma was performed consecutively and with two procedures on the 2nd and 3rd day in the first case. After TPE, while the triglyceride levels decreased from 4408 to 302 mg/dL, the amylase levels dropped from 4234 to 171 IU/L. In the second case, TPE was performed once daily. After TPE, the levels of triglyceride and amylase decreased from 2210 mg/dL and 1618 IU/L to 154 mg/dL and 110 IU/L, respectively. Local and systemic complications due to acute pancreatitis were not observed. Clinical signs and laboratory values improved. At the two-year follow-up of both patients, acute pancreatitis had not recurred with regular fenofibrate treatment. Hypertriglyceridemia should be considered in patients with acute recurrent pancreatitis. Although there is no definitive evidence for early application of TPE in severe hypertriglyceridemia-induced acute pancreatitis yet, therapy with TPE may be of benefit, improving the clinical course.
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Affiliation(s)
- Gurhan Kadikoylu
- Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey.
| | - Vahit Yukselen
- Adnan Menderes University Medical Faculty, Division of Gastroenterology, Aydin, Turkey
| | - Irfan Yavasoglu
- Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey
| | - Adil Coşkun
- Adnan Menderes University Medical Faculty, Division of Gastroenterology, Aydin, Turkey
| | - A Onder Karaoglu
- Adnan Menderes University Medical Faculty, Division of Gastroenterology, Aydin, Turkey
| | - Zahit Bolaman
- Adnan Menderes University Medical Faculty, Division of Hematology, Aydin, Turkey
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Hahn SJ, Park JH, Lee JH, Lee JK, Kim KA. Severe hypertriglyceridemia in diabetic ketoacidosis accompanied by acute pancreatitis: case report. J Korean Med Sci 2010; 25:1375-8. [PMID: 20808685 PMCID: PMC2923793 DOI: 10.3346/jkms.2010.25.9.1375] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 10/22/2009] [Indexed: 11/20/2022] Open
Abstract
We report a case of diabetic ketoacidosis (DKA) and hypertriglyceridemia (severely elevated to 15,240 mg/dL) complicated by acute pancreatitis, which was treated successfully with insulin therapy and conservative management. A 20-yr-old woman with a history of type 1 diabetes came to the emergency department 7 months after discontinuing insulin therapy. DKA, severe hypertriglyceridemia and acute pancreatitis were diagnosed, with DKA suspected of contributing to the development of the other conditions. In Korea, two cases of DKA-induced hypertriglyceridemia and 13 cases of hypertriglyceridemia-induced acute pancreatitis have been previously reported separately.
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Affiliation(s)
- Suk Jae Hahn
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Jung-hyun Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Jong Ho Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
| | - Kyoung-Ah Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Korea
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Stefanutti C, Di Giacomo S, Vivenzio A, Labbadia G, Mazza F, D'Alessandri G, Russi G, De Silvestro G, Marson P. Therapeutic plasma exchange in patients with severe hypertriglyceridemia: a multicenter study. Artif Organs 2010; 33:1096-102. [PMID: 20091936 DOI: 10.1111/j.1525-1594.2009.00810.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Extremely high plasma triglyceride (TG) concentration is a recognized risk factor for acute pancreatitis (AP). In order to evaluate the therapeutic efficacy of plasma-exchange plasmapheresis in treating patients with severe hypertriglyceridemia (sHTG), 17 patients who had not responded to conventional medical therapy (fat-free diet plus pharmaceutical interventions) were referred for therapeutic plasma exchange (TPE) in a multicenter frame case series study. Two hundred seventeen TPE sessions were performed, and therapy is ongoing for five (30%) of the patients. After treatment, the mean plasma TG and total cholesterol concentrations were significantly reduced from 1929 and 510 mg/dL, to 762 and 227 mg/dL, respectively (P < or = 0.001 in both cases). In most cases, the interval between treatments was related to the clinical presentation and individual circumstances. The removal of TG-rich lipoproteins prevented relapses of AP. In this case series, TPE is confirmed as a safe and reliable method for treating patients with refractory sHTG when a severe complication, such as AP, is clinically demonstrated or can be actively prevented. Therefore, in cases where standard medical approaches fail to promote the clearance of TGs from plasma and a high risk of first or second hypertriglyceridemic pancreatitis persists, TPE provides a therapeutic option for preventing life-threatening sHTG.
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Affiliation(s)
- Claudia Stefanutti
- University of Rome La Sapienza, Umberto I Hospital, Department of Clinical and Medical Therapy, Plasmapheresis Unit, Rome, Italy.
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Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG) is a well recognized cause of acute pancreatitis accounting for approximately up to 10% of all cases and even up to 50% of all cases in pregnancy. Both primary and secondary disorders of lipoprotein metabolism may be associated with hypertriglyceridemic pancreatitis (HTGP). The purpose of this review is to provide an overview of the current studies on presentation and management of HTGP. RECENT FINDINGS/CONCLUSION Hydrolysis of triglycerides by pancreatic lipase and formation of free fatty acids that induce inflammatory changes are postulated to account for the development of HTGP, yet the exact pathophysiology remains unclear. The clinical features of patients with HTGP are generally not different from patients with acute pancreatitis of other causes, and there is some evidence that HTGP is associated with a higher severity or a higher complication rate. There is no clear evidence as to which HTG patients will develop pancreatitis. Several studies have evaluated the effect of apheresis, the benefit of insulin and/or heparin treatment and the use of different antihyperlipidemic agents in HTGP. Dietary modifications resemble the key features in the long-term management of HTG. Whether HTG may cause chronic pancreatitis in the long-term follow-up remains controversial.
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Affiliation(s)
- Nils Ewald
- Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Rodthohl 6, Giessen, Germany.
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31
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Gubensek J, Buturović-Ponikvar J, Marn-Pernat A, Kovac J, Knap B, Premru V, Ponikvar R. Treatment of hyperlipidemic acute pancreatitis with plasma exchange: a single-center experience. Ther Apher Dial 2009; 13:314-7. [PMID: 19695066 DOI: 10.1111/j.1744-9987.2009.00731.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Of the cases of acute pancreatitis, 1-7% are caused by severe hypertriglyceridemia and can be treated with plasma exchange (PE). We report on a large series of patients with acute hyperlipidemic pancreatitis (HLP) treated with PE. In the 1992-2008 period, 50 patients (45 +/- 8 years old, 92% male) with acute HLP were treated with PE, during which 1-2 plasma volumes were exchanged. Heparin was used as anticoagulant in 85% of the procedures, and citrate in the rest. Cholesterol and triglycerides were measured before and after PE. In the 2003-2008 cohort of 40 patients, we retrospectively recorded an Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the first PE session, hospital mortality, and length of hospital stay. A total of 79 PE treatments were done, 1-5 per patient. The volume exchanged was 4890 +/- 1300 mL over a duration of 3.5 +/- 2 h. During the first PE, the triglycerides were lowered from 58.9 +/- 40.8 to 10.8 +/- 10.8 mmol/L, and the total cholesterol was lowered from 20.0 +/- 7.6 to 5.7 +/- 4.3 mmol/L. In 10% of the procedures the plasmafilter was replaced, and in 3% the filter was clotted. Hypotension occurred in 3% of PE and there was one case of gastrointestinal bleeding after PE with heparin anticoagulation. In the 2003-2008 cohort, the median APACHE II score was 5 (range 0-15), the median overall hospital stay was 18 days (range 3-142 days) and the hospital mortality was 15%. To conclude, in acute hyperlipidemic pancreatitis, one to two plasma exchanges effectively reduce the serum triglyceride level. There is a low rate of procedure-related complications. A mortality rate of 15% is considerable.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, SI-1000 Ljubljana, Slovenia.
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Muddana V, Whitcomb DC, Papachristou GI. Current management and novel insights in acute pancreatitis. Expert Rev Gastroenterol Hepatol 2009; 3:435-44. [PMID: 19673630 DOI: 10.1586/egh.09.27] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute pancreatitis (AP) is a common and potentially lethal acute inflammatory process. Approximately 10-20% of patients develop a severe course and suffer systemic inflammatory response and/or pancreatic necrosis (PNec). To date, there is no single biomarker proven to perform better than clinical judgment in predicting severe AP. The available prognostic clinical scoring systems are used primarily for research purposes. Management of AP is limited to supportive care and treatment of complications when they develop. Patients with mild AP require regular ward admission, fluid administration, bowel rest and pain management. Patients with signs of severe AP should be identified early and admitted promptly to an intensive-care unit. Nutrition support via nasojejunal feedings should be initiated. Sterile PNec is managed conservatively. Infected PNec requires minimally invasive debridement via endoscopic or surgical approaches. The lack of scientific advancements in the management of AP reflects the limited understanding of the early pathogenetic mechanisms and our moderate-to-poor ability to predict severe course at the time of admission.
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Affiliation(s)
- Venkata Muddana
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA 15219, USA
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Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104:984-91. [PMID: 19293788 DOI: 10.1038/ajg.2009.27] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hypertriglyceridemia (HTG) is reported to cause 1-4% of acute pancreatitis (AP) episodes. HTG is also implicated in more than half of gestational pancreatitis cases. Disorders of lipoprotein metabolism are conventionally divided into primary (genetic) and secondary causes, including diabetes, hypothyroidism, and obesity. Serum triglyceride (TG) levels above 1,000 mg/dl are usually considered necessary to ascribe causation for AP. The mechanism for hypertriglyceridemic pancreatitis (HTGP) is postulated to involve hydrolysis of TG by pancreatic lipase and release of free fatty acids that induce free radical damage. Multiple small studies on HTGP management have evaluated the use of insulin, heparin, or both. Many series have also reported use of apheresis to reduce TG levels. Subsequent control of HTG with dietary restrictions, antihyperlipidemic agents, and even regular apheresis has been shown anecdotally in case series to prevent future episodes of AP. However, large multicenter studies are needed to optimize future management guidelines for patients with HTGP.
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Affiliation(s)
- Wayne Tsuang
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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34
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Al-Humoud H, Alhumoud E, Al-Hilali N. Therapeutic plasma exchange for acute hyperlipidemic pancreatitis: a case series. Ther Apher Dial 2008; 12:202-4. [PMID: 18503696 DOI: 10.1111/j.1744-9987.2008.00572.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Therapeutic plasma exchange (TPE) has been used for the treatment of hyperlipidemic pancreatitis (HLP) with variable results. Eight patients with acute HLP were studied and treated with TPE, in addition to dietary fat restriction and lipid lowering agents. TPE lowered plasma levels of amylase (723.63 +/- 391.70-189.25 +/- 71.26 IU/L, P = 0.002), triglycerides (110.28 +/- 146.39-38.47 +/- 48.79 mmol/L, P = 0.048) and cholesterol (13.37 +/- 7.97-3.84 +/- 1.34 mmol/L, P < 0.001). Clinical symptoms improved in all patients with no resultant complications, and follow up of the patients for 12 months revealed no recurrence of pancreatitis. Thus, TPE is effective in lowering amylase, triglycerides and cholesterol levels, improves the acute attack of hyperlipidemic pancreatitis, and aids in preventing recurrent attacks.
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35
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Sun CY, Pan YZ. Advances in pathogenesis of hyperlipidemic acute pancreatitis and its diagnosis and treatment. Shijie Huaren Xiaohua Zazhi 2008; 16:343-349. [DOI: 10.11569/wcjd.v16.i4.343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hyperlipidemia is one of the causes for acute pancreatitis. Hyperlipidemic acute pancreatitis often occurs in patients with type Ⅰ, Ⅴ or Ⅳ hyperlipidemia. It results from chemical irritation to the pancreas and disturbance of pancreatic microcirculation due to the toxicity of free fatty acids released from massive triglycerides. When the serum triglyceride level is elevated, the incidence of complications may increase accordingly. However, serum amylase levels may be normal in serum of some patients or lightly e1evated. The diagnosis of hyperlipidemic acute pancreatitis is mainly based on the clinical manifestations of acute pancreatitis and the serum triglyceride level. Therefore, hyperlipidemic acute pancreatitis patients are treated mainly by reducing their serum triglyceride level.
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36
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Kadikoylu G, Yavasoglu I, Bolaman Z. Plasma exchange in severe hypertriglyceridemia a clinical study. Transfus Apher Sci 2006; 34:253-7. [PMID: 16798091 DOI: 10.1016/j.transci.2005.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 11/01/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypercholesterolemia and hypertriglyceridemia are independent risk factors for atherosclerotic heart diseases. Moreover acute pancreatitis may occur in patients with severe hypertriglyceridemia. AIM OF THE STUDY To evaluate the effectiveness of plasma exchange (PE) in patients with severe hypertriglyceridemia. METHODS Seven patients with severe hypertriglyceridemia (a triglyceride level of more than 1000mg/dl) were treated with PE. After PE, lipid and hematological parameters and side effects were evaluated. RESULTS Triglyceride levels decreased below 1000mg/dl in all patients. The levels of triglyceride and very low-density lipoprotein cholesterol (p<0.05 for both), and total cholesterol (p<0.005) decreased significantly. PE was well-tolerated. Liver and renal functions, hematological parameters, except for an increase in white blood cell counts, did not change significantly. CONCLUSION PE may be used safely and effectively in severe hyperlipidemic patients at risk of acute coronary events and acute pancreatitis. Further extended studies may provide more detailed information.
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Affiliation(s)
- Gurhan Kadikoylu
- Adnan Menderes University Medical Faculty, Division of Hematology, Tip Fakultesi, Ic Hastaliklari AD, Aydin, Turkey.
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Kyriakidis AV, Karydakis P, Neofytou N, Pyrgioti M, Vasilakakis D, Digenis P, Antsaklis G. Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases. Pancreatology 2005; 5:201-4. [PMID: 15855816 DOI: 10.1159/000085272] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2003] [Accepted: 05/03/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Hyperlipidemic pancreatitis is an acute and potentially life-threatening complication of hypertriglyceridemia that can be provoked when triglyceride levels (TGL) exceed 11.3 mmol/l (1,000 mg/dl). Except for standard symptomatic treatment, plasmapheresis has been performed to rapidly reduce TGL and chylomicron levels in the blood. In 5 patients with hyperlipidemic pancreatitis, treatment with plasmapheresis was evaluated. METHODS Five male patients who suffered from acute pancreatitis with severe primary hyperlipidemia were studied. In addition to the standard treatment, they were treated with plasmapheresis. RESULTS Plasma exchange lowered the lipid level and TGLs in all cases. It also improved abdominal pain, the clinical state of the patients, and signs and symptoms of the disease. Complications of treatment were not encountered, none of the patients died and only 1 patient underwent surgery. Follow-up of the patients lasted 4-28 months, and recurrence of pancreatitis was not noted. CONCLUSION Our study showed that plasmapheresis was successfully applied in patients with hyperlipidemic pancreatitis, especially to improve the acute phase of the disease.
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Affiliation(s)
- A V Kyriakidis
- Department of Surgery, Renal Dialysis Unit, Sismanogleion Hospital, Athens, Greece.
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Iskandar SB, Olive KE. Plasmapheresis as an adjuvant therapy for hypertriglyceridemia-induced pancreatitis. Am J Med Sci 2005; 328:290-4. [PMID: 15545847 DOI: 10.1097/00000441-200411000-00010] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertriglyceridemia is an uncommon cause of pancreatitis. A serum triglyceride level of more then 1000 to 2000 mg/dL is an identifiable risk factor. Interestingly, serum pancreatic enzyme levels may be normal or only minimally elevated in such cases. The reduction of triglyceride level to below 1000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment for the hypertriglyceridemia associated with pancreatitis includes dietary restriction of fat and administration of lipid-lowering agents. It is thought that within 24 to 48 hours of the onset of pancreatitis, in the majority of patients, triglyceride levels fall rapidly as a result of fasting status, as the absorption of chylomicrons to the blood is cut off. Experiences with plasmapheresis are limited. We report a case of hypertriglyceridemic necrotizing pancreatitis with mildly elevated amylase and lipase, treated successfully with plasmapheresis.
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Affiliation(s)
- Said B Iskandar
- Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614, USA
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Abstract
AIM: To clarify the effectiveness of plasma exchange by comparing the mortality and morbidity before and after the intervention of plasma exchange.
METHODS: Plasma exchange has been available as an optional therapy for hyperlipidemic pancreatitis since August 1999 in our hospital. The patients were assorted into 2 groups (group I: before August 1999 and group II: after August 1999). Group I consisted of 34 patients (before the availability of plasma exchange). Group II consisted of 60 patients (after the availability of plasma exchange). Twenty patients in group II received plasma exchange after giving their consent. The mortality and morbidity were compared between group I and group II. Furthermore, the patients with severe hyperlipidemic pancreatitis (Ranson’s score ≥ 3) were analyzed separately. The mortality and morbidity were also compared between those receiving plasma exchange (group A) and those who did not receive plasma exchange (group B).
RESULTS: There was no statistical difference in the mortality, systemic and local complications between group I and group II. When the patients with severe hyperlipidemic pancreatitis were analyzed separately, there was no statistical difference between group A and group B.
CONCLUSION: Plasma exchange can not ameliorate the overall mortality or morbidity of hyperlipidemic pancreatitis. The time of plasma exchange might be the critical point. If patients with hyperlipidemic pancreatitis can receive plasma exchange as soon as possible, better result may be predicted. Further study with more cases is needed to clarify the role of plasma exchange in the treatment of hyperlipidemic pancreatitis.
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Affiliation(s)
- Jui-Hao Chen
- Department of Gastroenterology, Shin kong Wu-Ho-Su Memorial Hospital, 95 Wenchang Road, Shih-Lin District, Taipei, Taiwan, China.
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