Severe hypertriglyceridemia influenced by alcohol (SHIBA)

Genetic Variants Linked to Myocardial Infarction in Individuals with Non-Alcoholic Fatty Liver Disease and Their Potential Interaction with Dietary Patterns

In recent studies, non-alcoholic fatty liver disease (NAFLD) has been associated with a high risk of ischemic heart disease. This study aimed to investigate a genetic variant within a specific gene associated with myocardial infarction (MI) among patients with NAFLD. We included 57,205 participants from a Korean genome and epidemiology study. The baseline population consisted of 45,400 individuals, with 11,805 identified as patients with NAFLD. Genome-wide association studies were conducted for three groups: the entire sample, the healthy population, and patients with NAFLD. We defined the p-value < 1 × 10-5 as the nominal significance and the p-value < 5 × 10-2 as statistically significant for the gene-by-nutrient interaction. Among the significant single-nucleotide polymorphisms (SNPs), the lead SNP of each locus was further analyzed. In this cross-sectional study, a total of 1529 participants (2.8%) had experienced MI. Multivariable logistic regression was performed to evaluate the association of 102 SNPs across nine loci. Nine SNPs (rs11891202, rs2278549, rs13146480, rs17293047, rs184257317, rs183081683, rs1887427, rs146939423, and rs76662689) demonstrated an association with MI in the group with NAFLD Notably, the MI-associated SNP, rs134146480, located within the SORCS2 gene, known for its role in secreting insulin in islet cells, showed the most significant association with MI (p-value = 2.55 × 10-7). Our study identifies candidate genetic polymorphisms associated with NAFLD-related MI. These findings may serve as valuable indicators for estimating MI risk and for conducting future investigations into the underlying mechanisms of NAFLD-related MI.

Prevalence of dyslipidemia and associated factors in sedentary occupational population from Shanghai: a cross-sectional study

BACKGROUND

Dyslipidemia is a major risk factor for cardiovascular diseases, but its prevalence and determinants among sedentary occupational population are poorly understood. This study aimed to investigate the prevalence and associated factors for dyslipidemia among a sedentary occupational population in Shanghai, China.

METHODS

We collected data from 35,950 sedentary occupational workers on their demographics, social, medical, and family history, lifestyle, anthropometry, and biochemistry. We used the 2016 Chinese guideline for the management of dyslipidemia in adults to define dyslipidemia and its subtypes. We performed multivariate logistic regression to examine the factors associated with dyslipidemia.

RESULTS

The prevalence of dyslipidemia was 29.10%, with 15.86% for high triglycerides (TG), 6.43% for high total cholesterol (TC), 5.37% for high low-density lipoprotein cholesterol (LDL-C), and 14.68% for low high-density lipoprotein cholesterol (HDL-C). Men had a significantly higher prevalence of dyslipidemia than women (39.64% vs. 12.43%, P < 0.01). Factors associated with dyslipidemia included older age, being married, longer sedentary time while resting, frequent intake of animal viscera, current smoking, hypertension, diabetes, and obesity. Current drinking was associated with a 1.24 times higher prevalence of high TG (P < 0.01). Current smokers were less likely to have low HDL-C than non-smokers.

CONCLUSIONS

Our present study, in a population of 35,950 sedentary occupational workers from Shanghai, demonstrated a prevalence of dyslipidemia, but lower than in other previous studies without the limitation of occupational characteristics. Prevention and control measures for dyslipidemia should take into account the characteristics and related factors for this population group.

Triglyceride Clearance in Hypertriglyceridemic Pancreatitis: Time Course and Its Implications for Management

OBJECTIVE

To characterize the time course of triglyceride (Tg) lowering in hypertriglyceridemic (HTg) pancreatitis according to the initial Tg values, causes, and interventions.

METHODS

Patients hospitalized from October 2013 through December of 2018 with a diagnosis of pancreatitis associated with HTg (Tg level, ≥500 mg/dL), in the absence of other causes, were identified by medical record review. Tg lowering was retrospectively assessed for differences in relation to the initial Tg values, use of intravenous insulin, ethanol-associated versus nonethanol-associated causes, and time to Tg values of <500 versus <1000 mg/dL.

RESULTS

Sixty-six cases were identified, and 45 had multiple measurements for time-course evaluation. Those with initial Tg values of <4000 mg/dL achieved Tg levels of <1000 mg/dL in <3 days, whereas 18.8% with higher values took 5-9 days. Insulin therapy was associated with a longer duration of HTg, whereas ethanol was associated with a shorter duration. Tg clearance in ethanol-associated HTg appeared independent of insulin treatment. Time to Tg levels of <500 mg/dL versus <1000 mg/dL was significantly longer when the initial Tg levels were >2000 mg/dL.

CONCLUSION

A threshold of 4000 mg/dL for the initial Tg levels in HTg pancreatitis appears to separate patients who are likely to achieve Tg levels of <1000 mg/dL in <3 versus >3 days, independent of cause or treatment. Insulin therapy is appropriate for patients with hyperglycemia but appears unnecessary for those with isolated ethanol-associated HTg. A threshold Tg level of <1000 mg/dL appears more practical than that of <500 mg/dL for resuming nutritional intake.

Associations of habitual alcohol drinking with HDL cholesterol and D-dimer in patients with peripheral arterial disease

BACKGROUND

The risk of cardiovascular disease is lower in light-to-moderate alcohol drinkers than in nondrinkers in the general population. However, it remains to be clarified whether these beneficial effects of alcohol are shown in patients with peripheral arterial disease (PAD).

METHODS

The subjects were 153 male outpatients with PAD and they were divided by frequency of drinking into nondrinkers, occasional drinkers (1-4 day/wk) and regular drinkers (5-7 day/wk). Relationships of alcohol drinking with variables related to progression of atherosclerosis and cardiovascular risk were investigated.

RESULTS

The levels of HDL cholesterol and d-dimer were significantly higher and lower, respectively, in regular drinkers than in nondrinkers, while there were no significant differences in BMI, blood pressure, total cholesterol, LDL cholesterol, triglycerides, hemoglobin A_1c, platelet count, fibrinogen, ankle brachial index and intima-media thickness of the carotid artery in non-, occasional and regular drinkers. Odds ratios of regular drinkers vs. nondrinkers for low HDL cholesterol (0.24 [0.08∼0.70]) and high d-dimer (0.29 [0.14∼0.61]) were significantly lower than the reference level.

CONCLUSIONS

In patients with PAD, habitual alcohol drinking was associated with increase of HDL cholesterol and suppression of blood coagulability. However, progression of atherosclerosis was not different in nondrinkers and drinkers.

A Case of Hypertriglyceridemia-Induced Acute Pancreatitis in the Setting of Alcohol Abuse

Acute pancreatitis (AP) is the painful inflammation of the pancreas. It is commonly associated with gallstones, excessive alcohol use, and certain medications. We report a case of hypertriglyceridemia-induced pancreatitis in a 35-year-old African American male with a history of alcohol abuse, tobacco use, and hyperlipidemia who presented with abdominal pain and intractable vomiting. During history taking, he reported chronic alcohol abuse over the past 10 years. On physical examination, he was ill-looking, with a dry mucous membrane and reproducible epigastric tenderness. Laboratory testing indicated markedly elevated triglycerides and lipase levels. Computed Tomography imaging showed signs of pancreatic inflammation. He was treated with aggressive intravenous fluid hydration, insulin infusion, and pain control medications. He demonstrated significant improvement and then transitioned to oral fibrates. Community resources for alcohol abuse treatment were provided and a referral was made to endocrinology for outpatient follow-up. This case highlights acute pancreatitis in a person with high alcohol use with elevated triglyceride and explores possible associations between these three.

Hypertriglyceridemia-Induced Acute Pancreatitis - Course, Outcome, and Comparison with Non-Hypertriglyceridemia Associated Pancreatitis

Background

Although hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis (AP), there are no definitive management guidelines. Studies comparing clinical severity and outcome of hypertriglyceridemia-induced acute pancreatitis (HTGAP) and non- HTGAP are scarce. Hence, the present study was undertaken.

Materials and Methods

All consecutive patients admitted with AP from January 2017 to August 2021 at university teaching hospital were included in this study. Data with regards to patient demographics; clinical, laboratory, and radiologic parameters; management strategies; and outcome were collected and compared between HTGAP and non-HTGAP patients.

Results

Overall, 550 patients with AP were admitted during the study period, of which 21 (3.8%) were HTG related. Mean age of HTGAP patients was 34.3 years (M: F = 14:7), and the mean serum triglyceride (TG) levels on admission were 3,718.9 mg/dL (range 1,094-11,991). Insulin infusion therapy was used in 18 patients with HTGAP and the target TG levels of ≤500 mg/dL was achieved in 4.2 days (mean). Compared to non-HTGAP patients, HTGAP patients had higher body mass index (29.2 vs. 25.6), higher clinical (BISAP 2.6 vs. 2.06) and radiologic severity scores (CT severity score 7.5 v/s 4.8), and required prolonged hospital stay (12.9 vs. 6.5 days).

Conclusion

HTGAP occurred in young patients with high BMI and was associated with more severe disease, that required prolonged hospitalization than patients with non-HTGAP. Insulin infusion therapy was effective in reducing serum TG levels.

A Clinical Case of a Homozygous Deletion in the APOA5 Gene with Severe Hypertriglyceridemia

Background: Hypertriglyceridemia (HTG) is one of the most common forms of lipid metabolism disorders. The leading clinical manifestations are pancreatitis, atherosclerotic vascular lesions, and the formation of eruptive xanthomas. The most severe type of HTG is primary (or hereditary) hypertriglyceridemia, linked to pathogenic genetic variants in LPL, APOC2, LMF1, and APOA5 genes. Case: We present a clinical case of severe primary hypertriglyceridemia (TG level > 55 mmol/L in a 4-year-old boy) in a consanguineous family. The disease developed due to a previously undescribed homozygous deletion in the APOA5 gene (NM_052968: c.579_592delATACGCCGAGAGCC p.Tyr194Gly*68). We also evaluate the clinical significance of a genetic variant in the LPL gene (NM_000237.2: c.106G>A (rs1801177) p.Asp36Asn), which was previously described as a polymorphism. In one family, we also present a different clinical significance even in heterozygous carriers: from hypertriglyceridemia to normotriglyceridemia. We provide evidence that this heterogeneity has developed due to polymorphism in the LPL gene, which plays the role of an additional trigger. Conclusions: The homozygous deletion of the APOA5 gene is responsible for the severe hypertriglyceridemia, and another SNP in the LPL gene worsens the course of the disease.

Factors associated with dyslipidemia and its prevalence among Awash wine factory employees, Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

Dyslipidemia is a highly prevalent and modifiable risk factor for atherosclerotic cardiovascular diseases. Though the problem is significant in Ethiopia, available data in this regard is very poor among alcoholic beverage industrial workers. This study aimed to assess factors associated with dyslipidemia and its prevalence among Awash wine factory employees in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was conducted among 335 randomly selected employees of Awash wine factory, Addis Ababa, Ethiopia from January to February 2021. Data was collected by a face-to-face interview technique using the WHO STEPwise approach. Data were entered and analyzed using Epi Info 7 and SPSS version 26, respectively. Both bivariable and multivariable logistic regression analyses were performed to identify factors associated with dyslipidemia. All statistical tests were declared significant at p-value < 0.05.

RESULTS

The overall prevalence of dyslipidemia was 67.8% (95% CI 62.5-72.7%). Elevated total cholesterol, elevated triglycerides, reduced high-density lipoprotein, and elevated low-density lipoprotein was found in 25.4%, 33.4%, 50.7%, and 21.5% of participants, respectively. Dyslipidemia was significantly associated with age group 30-39 years (AOR = 2.51; 95% CI 1.16-5.44, p = 0.019), ≥ 40 years (AOR = 6.45; 95% CI 2.01-20.71, p = 0.002), current alcohol consumption (AOR = 3.37; 95% CI 1.70-6.66, p < 0.001), eating vegetables < 2 days per week (AOR = 2.89; 95% CI 1.54-5.43, p = 0.001), sitting duration of > 4 h per day (AOR = 1.96; 95% CI 1.03-3.74, p = 0.041), and raised waist circumference (AOR = 4.56; 95% CI 2.07-10.08, p < 0.001).

CONCLUSIONS

High prevalence of dyslipidemia was found among Awash wine factory employees in Addis Ababa. Periodic screening of high-risk groups along with effective health promotion and education which encourages a healthy lifestyle is essential.

Targeting Endoplasmic Reticulum Stress as an Effective Treatment for Alcoholic Pancreatitis

Pancreatitis and alcoholic pancreatitis are serious health concerns with an urgent need for effective treatment strategies. Alcohol is a known etiological factor for pancreatitis, including acute pancreatitis (AP) and chronic pancreatitis (CP). Excessive alcohol consumption induces many pathological stress responses; of particular note is endoplasmic reticulum (ER) stress and adaptive unfolded protein response (UPR). ER stress results from the accumulation of unfolded/misfolded protein in the ER and is implicated in the pathogenesis of alcoholic pancreatitis. Here, we summarize the possible mechanisms by which ER stress contributes to alcoholic pancreatitis. We also discuss potential approaches targeting ER stress and UPR in developing novel therapeutic strategies for the disease.

Clinical Characteristics of Concomitant Diabetic Ketoacidosis in Type 2 Diabetes Patients with Acute Pancreatitis

OBJECTIVE

The objective of this retrospective study was to evaluate the clinical characteristics of diabetic ketoacidosis (DKA) in type 2 diabetes mellitus (T2DM) patients with acute pancreatitis (AP) in a cohort from China and to identify simple laboratory parameters to discriminate high-risk patients.

METHODS

Patients diagnosed with AP and T2DM from January 2015 to December 2020 were retrospectively enrolled. They were divided into DKA group and non-DKA group. We calculated etiologies of AP, compared demographic and clinical features, laboratory findings on admission and clinical course. The receiver operating characteristic (ROC) curve was used to explore the ability of clinical parameters to identify high-risk patients.

RESULTS

A total of 136 patients were enrolled, of which 19.9% (27 patients) concomitant with DKA. Compared with patients without DKA, patients with DKA were younger and more obese with higher levels of serum triglycerides (TGs), blood glucose and hemoglobin A₁c (HbA_1C). There was a significant difference in etiology between the two groups. Compared with the non-DKA group, the DKA group showed higher rate of HTG, lower rates of gallstones and alcohol abuse. And patients in the DKA group were more likely to be admitted to intensive care unit (ICU) and have longer hospital stays. ROC analyses showed that blood glucose concentration at a cutoff value of 21.75 mmol/L resulted in the highest Youden index with sensitivity and specificity at 81.5% and 94.5%, respectively, for identifying concomitant DKA (AUC = 0.949).

CONCLUSION

The prevalence of concomitant DKA in T2DM patients with AP was 19.9%, concomitant DKA patients tend to be younger, more obese and have higher blood glucose and TGs levels on admission. We found that blood glucose >21.75mmol/L could potentially be used as a simple laboratory parameter to identify high-risk patients.

Comparison of the Development and Prognosis in Patients of Hypertriglyceridemic Pancreatitis with and without Diabetes

Aim

To investigate the clinical features and prognosis in patients of hyperlipidemic acute pancreatitis with or without diabetes.

Methods

157 patients with hypertriglyceridemic pancreatitis (HTGP) were included in this study. Patients with a previous history of diabetes were identified in the group of HTGP with diabetes (HTGPD), while patients without a history of diabetes were identified in the group of HTGP. The clinical characteristics and prognosis data of these patients in the two groups were analyzed.

Results

Multivariate Cox regression analysis showed that age, body mass index, glycated serum protein (GSP), and Acute Physiology and Chronic Health Evaluation (APACHE) II score were significantly associated with mortality in patients with HTGP. The mortality was significantly higher in the HTGPD group than in the HTGP group (p < 0.001). Compared to patients of HTGP, those of HTGPD had older age of onset, higher blood glucose levels, and higher GSP levels on admission. Electrocardiograms showed that patients of HTGPD had a significantly higher risk of heart ischemia than those of HTGP (p < 0.05). Patients of HTGPD had higher APACHE II scores than those of HTGP (p < 0.001). Single-factor analysis showed that higher triglyceride levels, GSP, LDL, and previous history of diabetes were associated with HTGP recurrence.

Conclusions

Clinicians should be alert to patients of HTGP with diabetes. Diabetes is an important risk factor for HTGP and hyperglycemia may affect the development and prognosis of HTGP.

Hypertriglyceridemia is often under recognized as an aetiologic risk factor for acute pancreatitis: A population-based cohort study

BACKGROUND

Severe hypertriglyceridemia (HTG) is a well-known risk factor for acute pancreatitis, but updated population-based estimates on incidence of HTG-associated pancreatitis are lacking.

METHODS

We identified all individuals with severe HTG (triglyceride level >10 mmol/L [886 mg/dL]) in a population-based sample from 2008 to 2019 and linked these with Danish nationwide health-registers to identify patients with acute pancreatitis. Pancreatitis cases were subsequently confirmed by a detailed medical chart review. Crude and standardized incidence rates were estimated and studied in relation to age, gender and time-period. In addition, aetiological classification designated during index hospitalization, severity and follow-up of individuals with HTG-associated pancreatitis were studied.

RESULTS

Among 2146 individuals with severe HTG during the observation period, 75 were diagnosed with acute pancreatitis (3.5%). The mean incidence rate of HTG-associated pancreatitis was 1.4 (95% CI, 1.1-1.7) per 100,000 person years for the total population, for women it was 0.7 (95% CI, 0.5-1.1) and for men 2.0 (95% CI, 1.5-2.6) per 100,000 person-years. The mean incidence rate increased from 0.7 to 1.7 per 100,000 person-years from 2008 to 2019 (p_trend = 0.01). The highest incidence rate of HTG-associated pancreatitis was observed for men in the age group 50-59 years. An elevated triglyceride level was recognized as aetiological risk factor in 35% of patients during index hospitalization.

CONCLUSIONS

Only a fraction of patients with severe HTG are hospitalized for acute pancreatitis, but the incidence is increasing. In more than half of patients elevated triglycerides is not recognized as a risk factor for acute pancreatitis during index hospitalization.

Secondary Causes of Hypertriglyceridemia are Prevalent Among Patients Presenting With Hypertriglyceridemia Induced Acute Pancreatitis

BACKGROUND

Hypertriglyceridemia induced acute pancreatitis (HIAP) is the third common cause of acute pancreatitis. HIAP can result in recurrent attacks of severe AP with significant morbidity and mortality. Hypertriglyceridemia (HTG) could be primary or secondary. Although genetic causes of HTG are well studied, the prevalence of secondary causes of HTG in patients presenting with HIAP is not well characterized. This study aimed to identify the prevalence of risk factors for secondary hypertriglyceridemia among patients presenting with HIAP in a tertiary referral center in a large metropolitan area.

METHODS

This is a retrospective analysis of all patients admitted with AP from August 2012-2017. A subgroup of patients with triglycerides >880 mg/dl were included for analysis. Secondary causes of HTG were identified. Secondary analysis evaluating the severity of pancreatitis was performed.

RESULTS

There were 3,746 patients admitted for AP of which 57 patients had AP and HTG. Of these 57 patients, 70.2% had history of diabetes mellitus, 26.3% had history of heavy alcohol use, 22.8% had chronic kidney disease, 47.3% with obesity, and 21.1% with metabolic syndrome. Two patients were classified as unexplained HTG. Secondary analysis showed a total of 45.6% of patients requiring ICU admission. 26.3% of patients with severe inflammatory pancreatitis and 17.5% of patients with severe necrotizing pancreatitis.

CONCLUSIONS

In our cohort of HIAP, 55 out of 57 patients had secondary causes for HTG. Identifying secondary causes of HTG during acute hospitalization is important to tailor outpatient treatment in order to prevent future admissions with HIAP.

Gamma-Glutamyl Transferase: A Useful Marker of Habitual Drinking in Cases of Alcohol-Associated Osteonecrosis of the Femoral Head

AIMS

Alcohol intake is one of the factors associated with the occurrence of osteonecrosis of the femoral head (ONFH), and its epidemiological information regarding alcohol intake depends on patients' self-reports. Therefore, we analysed the efficacy of laboratory tests as an objective diagnostic tool to indicate habitual drinking in patients with alcohol-associated ONFH.

METHODS

This study included 109 consecutive patients diagnosed with ONFH who underwent primary hip surgery in our institution between 2010 and 2018. The patients were classified into group AL (alcohol-associated ONFH; n = 26) and group NO (alcohol-unassociated ONFH; n = 83), based on their self-reported information. Serum levels of gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV), aspartate aminotransferase (AST), alanine aminotransferase (ALT), total cholesterol and triglycerides were compared between both groups. The sensitivities and specificities with the optimal cut-off values for detecting alcohol-associated ONFH were compared among these markers.

RESULTS

The median serum levels of GGT, AST and ALT were significantly higher in the AL group than in the NO group. The receiver operating characteristic curve analysis demonstrated an area under the curve of 0.795 for GGT, 0.731 for AST and 0.709 for ALT. The optimal cut-off level of GGT as a marker for alcohol-associated ONFH was 36.5 units/L, with a sensitivity of 76% and specificity of 80%, and it was found to be the best marker among the other examined laboratory markers.

CONCLUSION

Serum GGT level is a useful laboratory marker with moderate accuracy that indicates habitual drinking in patients with alcohol-associated ONFH.

Management of hypertriglyceridemia

Hypertriglyceridemia is one of the most common lipid abnormalities encountered in clinical practice. Many monogenic disorders causing severe hypertriglyceridemia have been identified, but in most patients triglyceride elevations result from a combination of multiple genetic variations with small effects and environmental factors. Common secondary causes include obesity, uncontrolled diabetes, alcohol misuse, and various commonly used drugs. Correcting these factors and optimizing lifestyle choices, including dietary modification, is important before starting drug treatment. The goal of drug treatment is to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia and cardiovascular disease in those with moderate hypertriglyceridemia. This review discusses the various genetic and acquired causes of hypertriglyceridemia, as well as current management strategies. Evidence supporting the different drug and non-drug approaches to treating hypertriglyceridemia is examined, and an easy to adopt step-by-step management strategy is presented.

Hypertriglyceridemia and acute pancreatitis

Hypertriglyceridemia is the third most common cause of acute pancreatitis. It typically occurs in patients with an underlying disorder of lipoprotein metabolism and in the presence of a secondary condition such as uncontrolled diabetes, alcohol abuse, or medication use. The presentation of hypertriglyceridemia-induced pancreatitis is similar to that of acute pancreatitis due to other causes; however, patients with hypertriglyceridemia-induced pancreatitis are more likely to have severe disease courses and have a higher likelihood of persistent organ failure. The initial treatment of hypertriglyceridemia-induced pancreatitis is also similar to acute pancreatitis from other causes and consists of aggressive fluid resuscitation, pain control, and nutritional support. Hypertriglyceridemia is specifically treated with apheresis or insulin therapy when necessary. The prompt recognition of hypertriglyceridemia in the setting of acute pancreatitis is essential in both the initial and long-term management of this disease and are essential to prevent recurrent acute pancreatitis. The review seeks to highlight the etiology, pathogenesis, and clinical course of hypertriglyceridemia-induced acute pancreatitis.

Anti-oxidant and anti-hyperlipidemic effects of cordycepin-rich Cordyceps militaris in a Sprague–Dawley rat model of alcohol-induced hyperlipidemia and oxidative stress

Hyperlipidemia is involved in serious cardiovascular disease, however, synthetic drugs to reduce lipid contents in blood stream have been found to induce serious side effects. In the current study, we compared anti-oxidant and anti-hyperlipidemic effect of Paecilomyces japonica (PJ), Cordyceps militaris (CM) and cordycepin-rich Cordyceps militaris (CMα) in rats induced alcoholic hyperlipidemia (AIH) and oxidative stress. The experimental groups were divided in N (water), C (30% alcohol), PJ (30% alcohol + 3% PJ powder), CM (30% alcohol + 3% CM powder), CMα (30% alcohol + 3% CMα powder) and SM [30% alcohol + 0.1% silymarin (SM)]. Compared to C group, supplementation of PJ, CM, CMα and SM slightly alleviated the increased weight ratio of liver and kidney in the alcohol-treated rats. In addition, a significant or slight reduction was identified in total lipid, total cholesterol and HDL-cholesterol levels in the rats receiving PJ, CM and CMα as compared with C group. Administration of PJ, CM and CMα also blocked alcohol-induced lipid peroxidation via a decrease of malondialdehyde (MDA), and activated anti-oxidant enzyme, glutathione (GSH), in serum and various organ tissues. Overall, cordycepin-rich CMα showed highest anti-oxidant and anti-hyperlipidemia effect under chronic alcoholic damage. Our results indicate that CMα might be useful in inhibiting the oxidation and hyperlipidemia in alcohol-induced hepatic disease possibly because of potential anti-oxidative and anti-hyperlipidemic activities of cordycepin.

Hypertriglyceridemia Induced Pancreatitis: Inpatient Management at a Single Pediatric Institution

OBJECTIVES

Hypertriglyceridemia-induced pancreatitis is an important cause of acute pancreatitis (AP) in children, which lacks established guidelines. The aim of this study was to review management approaches at a single pediatric center.

METHODS

This retrospective study included all inpatients younger than 21 years with AP and triglycerides (TG) of 1000 mg/dL or greater. A linear mixed effect model was used to calculate drop in TGs. The patient's diet, intravenous fluid (IVF) rate, insulin, and plasmapheresis were included in the model.

RESULTS

Seventeen admissions were identified among 8 patients, average age 15 years (range, 6-19 years). Fifty percent had recurrent AP and 29% of admissions had complications including 1 death. The population was primarily female (75%), white (75%), and overweight, and 63% had diabetes. The median stay was 5.4 days. There were 14 approaches used with variations in IVF rates, insulin, plasmapheresis, and nill per os (NPO) versus feeds. Variables that reduced TG's were NPO, higher IVF rates, plasmapheresis, and insulin (P < 0.05). Importantly, NPO reduced TGs faster than those who started early nutrition.

CONCLUSIONS

Hypertriglyceridemia is an important cause of pancreatitis in children. This study shares a management algorithm from a single institution. Larger studies are needed for more evidence-based guidelines.

Ethnopharmacological Applications Targeting Alcohol Abuse: Overview and Outlook

Excessive alcohol consumption is the cause of several diseases and thus is of a major concern for society. Worldwide alcohol consumption has increased by many folds over the past decades. This urgently calls for intervention and relapse counteract measures. Modern pharmacological solutions induce complete alcohol self-restraint and prevent relapse, but they have many side effects. Natural products are most promising as they cause fewer adverse effects. Here we discuss in detail the medicinal plants used in various traditional/folklore medicine systems for targeting alcohol abuse. We also comprehensively describe preclinical and clinical studies done on some of these plants along with the possible mechanisms of action.

Effects of obesity on cholesterol metabolism and its implications for healthy ageing

The last few decades have witnessed a global rise in the number of older individuals. Despite this demographic shift, morbidity within this population group is high. Many factors influence healthspan; however, an obesity pandemic is emerging as a significant determinant of older people's health. It is well established that obesity adversely affects several metabolic systems. However, due to its close association with overall cardiometabolic health, the impact that obesity has on cholesterol metabolism needs to be recognised. The aim of the present review is to critically discuss the effects that obesity has on cholesterol metabolism and to reveal its significance for healthy ageing.

A Comprehensive Update on the Chylomicronemia Syndrome

The chylomicronemia syndrome is characterized by severe hypertriglyceridemia and fasting chylomicronemia and predisposes affected individuals to acute pancreatitis. When due to very rare monogenic mutations in the genes encoding the enzyme, lipoprotein lipase, or its regulators, APOC2, APOA5, GPIHBP1, and LMF1, it is referred to as the familial chylomicronemia syndrome. Much more frequently, the chylomicronemia syndrome results from a cluster of minor genetic variants causing polygenic hypertriglyceridemia, which is exacerbated by conditions or medications which increase triglyceride levels beyond the saturation point of triglyceride removal systems. This situation is termed the multifactorial chylomicronemia syndrome. These aggravating factors include common conditions such as uncontrolled diabetes, overweight and obesity, alcohol excess, chronic kidney disease and pregnancy and several medications, including diuretics, non-selective beta blockers, estrogenic compounds, corticosteroids, protease inhibitors, immunosuppressives, antipsychotics, antidepressants, retinoids, L-asparaginase, and propofol. A third uncommon cause of the chylomicronemia syndrome is familial forms of partial lipodystrophy. Development of pancreatitis is the most feared complication of the chylomicronemia syndrome, but the risk of cardiovascular disease as well as non-alcoholic steatohepatitis is also increased. Treatment consists of dietary fat restriction and weight reduction combined with the use of triglyceride lowering medications such as fibrates, omega 3 fatty acids and niacin. Effective management of aggravating factors such as improving diabetes control, discontinuing alcohol and replacing or reducing the dose of medications that raise triglyceride levels is essential. Importantly, many if not most cases of the chylomicronemia syndrome can be prevented by effective identification of polygenic hypertriglyceridemia in people with conditions that increase its likelihood or before starting medications that may increase triglyceride levels. Several new pharmacotherapeutic agents are being tested that are likely to considerably improve treatment of hypertriglyceridemia in people at risk.

Association of lifestyle factors with blood lipids and inflammation in adults aged 40 years and above: a population-based cross-sectional study in Taiwan

Background

Lifestyle factors were associated with an increased risk of cardiovascular disease (CVD) occurrence. We explored the associations between lifestyle factors and CVD risk factors, and assessed the interactive effects of lifestyle factors on CVD risk factors.

Methods

A cross-sectional data of 114,082 (57,680 men and 56,402 women) middle-aged adults and elderly in Taiwan were collected from 2001 to 2010. Logistic regression analysis was used to assess the associations between lifestyle factors and CVD risk factors. The relative excess risk due to interaction (RERI) and the attributable proportion due to interaction were used to explore the interactive effect of lifestyle factors on CVD risk factors.

Results

The interaction between alcohol consumption and smoking exhibited an excess risk of high triglycerides (RERI = 0.21; 95% CI: 0.14–0.29), and that of alcohol consumption and physical activity had an excess risk of high LDL-cholesterol (RERI = 0.11; 95% CI: 0.06–0.16) and high blood glucose (RERI = 0.05; 95% CI: 0.01–0.11). Alcohol consumption and vegetable-rich diet (intake of high vegetables with no or low meat) had an excess risk of high LDL-cholesterol and low HDL-cholesterol, but a reduced risk of high triglycerides (RERI = − 0.10; 95% CI: − 0.17 – -0.04). Smoking and physical activity had an increased risk of high blood glucose and a reduced risk of low HDL-cholesterol. Smoking and vegetable-rich diet reduced the risk of high triglycerides (RERI = − 0.11; 95% CI: − 0.18 – − 0.04), high blood glucose (RERI = − 0.14; 95% CI: − 0.21 – − 0.07) and low HDL-cholesterol (RERI = − 0.10; 95% CI: − 0.19 – -0.01).

Conclusions

The interaction between smoking, alcohol consumption, physical activity and diet were associated with lipid profile and blood glucose, hence there was an interaction between these lifestyle factors in an additive scale. Public health promotion should therefore consider multifaceted promotional activities that are likely to make a positive impact on the health status of the Taiwanese population.

Subsets associated with developing acute pancreatitis in patients with severe hypertriglyceridemia and the severity of pancreatitis

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia (HTG) is a rare but well-recognized cause for acute pancreatitis (AP). This study aimed to determine subsets related to development of AP in patients with severe HTG and the severity of HTG-induced AP (HTG-AP).

METHODS

Patients who had severe HTG (serum triglyceride level >1,000 mg/dL) more than once between Jan. 2010 and Dec. 2017 in a single institute were evaluated retrospectively. Patients were divided into two groups, with AP or without AP, and were compared. HTG-APs in patients with severe HTG were compared to APs due to other causes during the same period.

RESULTS

Sixty-three patients (19.3%) presented with AP of a total 326 patients with severe HTG. The AP group displayed younger age, more alcohol consumption and diabetes mellitus, and higher initial/maximum serum levels of triglyceride, glucose, HbA1c, total cholesterol, and calculated non-high-density lipoprotein cholesterol (p < 0.05). HTG-APs were clinically more severe compared with 277 APs due to other causes in terms of CRP (p < 0.001), CT severity index (p = 0.002), revised Atlanta classification (p < 0.001), and hospital stay (p = 0.011). In logistic regression analysis, maximum serum triglyceride level (OR 2.706, p = 0.015), alcohol consumption amount (OR 5.292, p < 0.001), and age (OR 0.358, p = 0.017) were independently associated with development of AP in patients with severe HTG.

CONCLUSIONS

Development of AP in patient with severe HTG was independently associated with younger age, higher serum TG level, and more alcohol consumption. HTG-APs are clinically more severe than APs due to other causes.

Very Severe Hypertriglyceridemia in a Large US County Health Care System: Associated Conditions and Management

Context

Patients with very severe hypertriglyceridemia (triglyceride levels ≥2000 mg/dL; 22.6 mmol/L) require aggressive treatment. However, little research exists on the underlying etiologies and management of very severe hypertriglyceridemia.

Objective

We hypothesized (i) very severe hypertriglyceridemia in adults is mostly associated with secondary causes and (ii) most patients with very severe hypertriglyceridemia lack appropriate follow-up and treatment.

Design

We queried electronic medical records at Parkland Health and Hospital Systems for lipid measurements in the year 2016 and identified patients with serum triglyceride levels ≥2000 mg/dL (22.6 mmol/L). We extracted data on demographics, underlying causes, lipid-lowering therapy, and follow-up.

Results

One hundred sixty-four serum triglyceride measurements were ≥2000 mg/dL (22.6 mmol/L) in 103 unique patients. Of these, 60 patients were admitted to the hospital (39 for acute pancreatitis). Most were Hispanic (79%). The major conditions associated with very severe hypertriglyceridemia included uncontrolled diabetes mellitus (74%), heavy alcohol use (10%), medication use (7%), and hypothyroidism (2%). Two patients were known to have monogenic causes of hypertriglyceridemia. After the index measurement of triglycerides ≥2000 mg/dL (22.6 mmol/L), the use of triglyceride-lowering drugs increased, most prominently the use of fish oil supplements, which increased by 80%. However, in follow-up visits, hypertriglyceridemia was addressed in only 50% of encounters, and serum triglycerides were remeasured in only 18%.

Conclusion

In summary, very severe hypertriglyceridemia was quite prevalent (∼0.1% of all lipid measurements) in our large county health care system, especially in Hispanic men. Most cases were related to uncontrolled diabetes mellitus, and follow-up monitoring was inadequate.

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

BACKGROUND & AIMS

The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies.

METHODS

The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included.

RESULTS

Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis.

CONCLUSION

The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Management of Hypertriglyceridemia Induced Acute Pancreatitis

Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan. Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes. Currently, there is paucity of studies directly comparing different modalities. This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis. We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis.

The effect of intravenous insulin, apheresis and oral lipid-lowering agents on non-fasting hypertriglyceridemia and associated pancreatitis

OBJECTIVES

There is evidence that increasing severity of hypertriglyceridemia increases the risk of acute pancreatitis. There is a debate about superiority of treatment methods and previous works have specifically called for direct comparison between IV insulin and apheresis techniques. Identify patient characteristics predictive of lipid-lowering therapy selection in a large community hospital for treatment of hypertriglyceridemia; evaluate for a concentration-dependent relationship between hypertriglyceridemia severity and risk of acute pancreatitis; assess for differences in clinical outcomes between patients treated with IV insulin versus apheresis.

METHODS

Single center, retrospective cohort study including patients with hypertriglyceridemia between January 2007 and December 2016. Main measures included frequency of pancreatitis, choice of lipid-lowering therapy, and clinical comparisons of diet, oral lipid-lowering agents, IV insulin, and apheresis.

RESULTS

Initial serum triglyceride level and disease acuity was higher among patients in insulin and apheresis groups. Neither triglyceride level, Charlson comorbidity index, age, BISAP score, nor initial CRP predicted use of IV insulin versus apheresis. Prevalence of pancreatitis increased with higher triglyceride level, reaching 48% with triglycerides >2000 md/dL (p < 0.001). There was a significant decrease in serum triglycerides at each time interval (p < 0.05) in patients treated with IV insulin and apheresis, but no difference in clearance rate between the two. Length of stay did not differ between IV insulin and apheresis.

CONCLUSION

The presence of pancreatitis, hyperglycemia, and hypertriglyceridemia severity influenced selection of therapies like IV insulin and apheresis. We found no superiority of either IV insulin or apheresis in the treatment of severe hypertriglyceridemia among patients hospitalized for pancreatitis.

New Common and Rare Variants Influencing Metabolic Syndrome and Its Individual Components in a Korean Population

To identify novel loci for susceptibility to MetS, we conducted genome-wide association and exome wide association studies consisting of a discovery stage cohort (KARE, 1946 cases and 6427 controls), and a replication stage cohort (HEXA, 430 cases and 3,264 controls). For finding genetic variants for MetS, with its components, we performed multivariate analysis for common and rare associations, using a standard logistic regression analysis for MetS. From the discovery and replication GWA studies, we confirmed 21 genome-wide signals significantly associated with MetS. Of these 21, four were previously unreported to associate with any MetS components: rs765547 near LPL; rs3782889 in MYL2; and rs11065756 and rs10849915 in CCDC63. Using exome chip variants, gene-based analysis of rare variants revealed three genes, CETP, SH2B1, and ZFP2, in the discovery stage, among which only CETP was confirmed in the replication stage. Finally, CETP D442G (rs2303790) associated, as a less common variant, with decreased risk of MetS. In conclusion, we discovered a total of five new MetS-associated loci, and their overlap with other disease-related components, suggest roles in the various etiologies of MetS, and its possible preventive strategies.

Chylomicronemia risk factors ranked by importance for the individual and community in 108 711 women and men

BACKGROUND

Hypertriglyceridemia prevalence is increasing as more individuals become obese, and chylomicronemia risk factors for the individual and community have not been described previously.

OBJECTIVE

To describe chylomicronemia risk factors in the general population for individuals and community.

METHODS

A total of 108 711 individuals from the Copenhagen General Population Study were grouped as unlikely chylomicronemia (nonfasting triglycerides <2 mmol L^-1 (177 mg dL^-1 )), possible chylomicronemia (2-4.99 mmol L^-1 (177-442 mg dL^-1 )), probable chylomicronemia (5-9.99 mmol L^-1 (443-885 mg dL^-1 )) and definite chylomicronemia (≥10 mmol L^-1 (≥ 886 mg dL^-1 )). Relative risk (RR) from Poisson regression ranked dichotomized chylomicronemia risk factors for individuals, and population attributable fractions (PAF) for the community: type 2 diabetes, alcohol intake, obesity, fat intake, hypothyroidism, kidney function, education, sedentary lifestyle, menopause and hormone replacement (women).

RESULTS

For women and men, chylomicronemia was unlikely in 81% and 64%, possible in 18% and 33%, probable in 1% and 3% and definite in 0.03% and 0.14%, respectively. For the individual, the three top-ranked risk factors for probable/definite versus unlikely chylomicronemia in women were type 2 diabetes (RR: 4.21; 95% confidence interval: 3.30-5.36), menopause (RR: 3.74; 2.62-5.36) and obesity (RR: 3.44; 2.81-4.21). Corresponding top-ranked risk factors in men were obesity (RR: 3.86; 3.46-4.30), type 2 diabetes (RR: 1.88; 1.61-2.19) and reduced kidney function (RR: 1.86; 1.48-2.34). For the community, top-ranked risk factors in women were menopause (PAF: 63%), obesity (PAF: 29%) and type 2 diabetes (PAF: 15%). Corresponding top-ranked risk factors in men were obesity (PAF: 29%), type 2 diabetes (PAF: 6.4%) and sedentary lifestyle (PAF: 6.0%).

CONCLUSIONS

Obesity and type 2 diabetes were the most important modifiable chylomicronemia risk factors in women and men, both for the individual and community. This could influence chylomicronemia prevention and help design randomized trials aimed at reducing triglycerides.

Lipidomics Analysis of Behavioral Variant Frontotemporal Dementia: A Scope for Biomarker Development

Behavioral variant frontotemporal dementia (bvFTD) is the most prevalent form of FTD syndromes. bvFTD is characterized clinically by changes in behavior and cognition and pathologically by focal brain atrophy and concomitant loss of lipids. bvFTD is further characterized by eating abnormalities that result in dyslipidemia. Although dyslipidemia is apparent in bvFTD, very little is known about global lipid changes in bvFTD and lipid dysregulation underlying bvFTD. Here, we undertook a comprehensive lipidomics analysis of blood plasma from patients with bvFTD, patients with Alzheimer’s disease (AD) and controls, using liquid chromatography-tandem mass spectrometry, with the aim of understanding lipid dysregulation in bvFTD. In our analysis, we detected all four major classes of lipids (glycerolipids, phospholipids, sphingolipids, sterols), 17 subclasses of lipids, and 3,225 putative individual lipid species in total, as well as a group of dietary lipids. We found that the levels of numerous lipid species were significantly altered in bvFTD compared to AD and control. We found that the total abundance of triglyceride (TG) increased significantly in bvFTD, whereas phosphatidylserine and phosphatidylglycerol decreased significantly in bvFTD. These results suggest manifestation of hypertriglyceridemia and hypoalphalipoproteinemia in bvFTD. We also identified five lipid molecules—TG (16:0/16:0/16:0), diglyceride (18:1/22:0), phosphatidylcholine (32:0), phosphatidylserine (41:5), and sphingomyelin (36:4)—that could potentially be used for developing biomarkers for bvFTD. Furthermore, an analysis of plant lipids revealed significant decreases in monogalactosyldiacylglycerol and sitosteryl ester in bvFTD, indicating altered eating behavior in bvFTD. This study represents the first lipidomics analysis of bvFTD and has provided new insights into an unrecognized perturbed pathology in bvFTD, providing evidence in support of considerable lipid dysregulation in bvFTD.

Alcohol, adipose tissue and liver disease: mechanistic links and clinical considerations

Adipose tissue represents a large volume of biologically active tissue that exerts substantial systemic effects in health and disease. Alcohol consumption can profoundly disturb the normal functions of adipose tissue by inducing adipocyte death and altering secretion of adipokines, pro-inflammatory mediators and free fatty acids from adipose tissue, which have important direct and indirect effects on the pathogenesis of alcoholic liver disease (ALD). Cessation of alcohol intake quickly reverses inflammatory changes in adipose tissue, and pharmacological treatment that normalizes adipose tissue function improves experimental ALD. Obesity exacerbates liver injury induced by chronic or binge alcohol consumption, and obesity and alcohol can synergize to increase risk of ALD and progression. Physicians who care for individuals with ALD should be aware of the effects of adipose tissue dysfunction on liver function, and consider strategies to manage obesity and insulin resistance. This Review examines the effect of alcohol on adiposity and adipose tissue and the relationship between alcohol, adipose tissue and the liver.

Inverse association between excessive alcohol drinking and cardiometabolically healthy status in middle-aged men with and without overweight and obesity

AIMS

The aim of this study was to clarify the relationship between drinking and metabolically healthy status in men with normal weight, overweight and obesity.

METHODS

The subjects were Japanese men aged from 35 to 60 years (n=31781) and they were divided by daily amount of drinking (g ethanol) into light (< 22), moderate (≥22 and <44), heavy (≥44 and <66) and very heavy (≥66) drinkers. Metabolically healthy subjects were defined as those without hypertension, dyslipidemia and diabetes.

RESULTS

The percentage of metabolically healthy subjects was much lower in the overweight (BMI≥25 and <30) and obese (BMI≥30) groups than in the normal weight group (BMI≥18.5 and <25) and was much lower in the obese group than in the overweight group. In each of the normal weight and overweight groups, percentages of metabolically healthy subjects were significantly lower in heavy and very heavy drinkers than in nondrinkers and were marginally significantly higher in light drinkers than in nondrinkers. The above associations between drinking and metabolically healthy status were confirmed by logistic regression analysis. In the obese group, the percentage of metabolically healthy subjects was significantly lower in regular drinkers (including all drinker categories) than in nondrinkers, and metabolically healthy subjects were rare (0.56%) among regular drinkers.

CONCLUSIONS

Regardless of absence and presence of overweight or obesity, excessive alcohol drinking is inversely associated with metabolically healthy status and should be avoided for prevention of cardiovascular disease.

The fasting serum triglyceride levels of elderly population with different progression stages of diabetes mellitus in China

AIMS

This cross-sectional study aimed to investigate triglyceride level among Chinese elderly population with different diabetic progressions and related factors of triglyceride.

METHODS

Study participants (≥65years) were recruited from a nationwide cross-sectional surveillance and were divided into four subgroups according to diabetic progression. Their information was obtained via questionnaire and physical examination. Their lipids in fasting serum samples were analyzed.

RESULTS

The serum triglyceride levels (mmol/L, mean±SD) were 1.3±0.8 (subgroup of no prediabetes and no DM), 1.5±1.0 (subgroup of prediabetes), 1.6±1.1 (subgroup of newly diagnosed DM) and 1.7±1.1 (subgroup of previously diagnosed DM), respectively. Only one female participant had a higher triglyceride than upper limit for prevention of acute pancreatitis (11.0mmol/L). However, 23.1% of participants and 34.8% of DM participants had higher triglyceride than upper limit for prevention of cardiovascular diseases (1.7mmol/L). Triglyceride level was positively correlated with diabetic progression (r_s=0.17, p<0.01). Age, gender, waist-to-height ratio (rather than BMI), systolic pressure, serum total cholesterol and HDL-C levels were statistically correlated with triglyceride level for total participants (R²=0.39, p<0.01).

CONCLUSIONS

Aggravation of serum triglyceride level was related to diabetic progression in Chinese elderly population. Triglyceride control was unsatisfactory in Chinese elderly population, especially in elderly population with DM.

Severe hypertriglyceridemia in Japan: Differences in causes and therapeutic responses

BACKGROUND

Severe hypertriglyceridemia (>1000 mg/dL) has a variety of causes and frequently leads to life-threating acute pancreatitis. However, the origins of this disorder are unclear for many patients.

OBJECTIVE

We aimed to characterize the causes of and responses to therapy in rare cases of severe hypertriglyceridemia in a group of Japanese patients.

METHODS

We enrolled 121 patients from a series of case studies that spanned 30 years. Subjects were divided into 3 groups: (1) primary (genetic causes); (2) secondary (acquired); and (3) disorders of uncertain causes. In the last group, we focused on 3 possible risks factors for hypertriglyceridemia: obesity, diabetes mellitus, and heavy alcohol intake.

RESULTS

Group A (n = 20) included 13 patients with familial lipoprotein lipase deficiency, 3 patients with apolipoprotein CII deficiency, and other genetic disorders in the rest of the group. Group B patients (n = 15) had various metabolic and endocrine diseases. In Group C (uncertain causes; n = 86), there was conspicuous gender imbalance (79 males, 3 females) and most male subjects were heavy alcohol drinkers. In addition, 18 of 105 adult patients (17%) had histories of acute pancreatitis.

CONCLUSION

The cause of severe hypertriglyceridemia is uncertain in many patients. In primary genetic forms of severe hypertriglyceridemia, genetic diversity between populations is unknown. In the acquired forms, we found fewer cases of estrogen-induced hypertriglyceridemia than in Western countries. In our clinical experience, the cause of most hypertriglyceridemia is uncertain. Our work suggests that genetic factors for plasma triglyceride sensitivity to alcohol should be explored.

Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis

GOALS

To report the clinical profile and natural course in a large series of patients with hypertriglyceridemia (HTG) and acute pancreatitis (AP).

BACKGROUND

The natural history of HTG-related pancreatitis is poorly defined.

STUDY

Medical records of 121 patients with serum triglycerides (TG) levels of ≥500 mg/dL suffering 225 attacks of AP between January 2001 to August 2013 treated at the University of Pittsburgh Medical Center were retrospectively studied. Structured data were collected on initial presentation and long-term outcomes (mean follow-up 64.7±42.8 mo). AP severity was classified using Revised Atlanta Classification.

RESULTS

Most patients were young-middle aged (mean 44±12.7 y), male (70%), white (78%), and had sentinel AP (63%). Peak serum TG recorded was ≥1000 mg/dL in 48%. At least 1 secondary risk factor (diabetes, high-risk drinking, obesity, offending medications) was present in the majority (78%). Sentinel AP attack varied in severity between mild (41%), moderate (26%), and severe (33%). Recurrent AP attacks occurred in 32%, often in patients with poorly controlled diabetes, alcoholism, and TG levels. A cumulative increase in prevalence of pancreatic and/or peripancreatic necrosis was observed, with 45% patients having it at some time during observation. Local complications were higher in patients with serum TG ≥1000 mg/dL. Chronic pancreatitis was noted in 16.5% patients (new-onset in 9%).

CONCLUSIONS

Patients with HTG-related pancreatitis have a high prevalence of secondary risk factors. Frequent recurrences in them are usually due to poor control of secondary factors or TG. Serum TG ≥1000 mg/dL increases the risk of local complications. A subset can have or develop chronic pancreatitis.

Dyslipidemia associated with heavy alcohol use

BACKGROUND AND OBJECTIVES

Alcohol has many effects on lipid metabolism and has been associated with elevated triglycerides. The purpose of this paper is to report a case of globally dysregulated lipids secondary to alcohol use and to describe the natural history of this phenomenon after drinking cessation.

METHODS

We present a case of an otherwise healthy patient (N = 1) who was admitted to our facility for alcohol detoxification and found to have extreme lipid dysregulation. He was treated with benzodiazepines for alcohol withdrawal but no hypolipidemic agents were given.

RESULTS

Lipid indices self-corrected and were found to be normal following just several weeks of sobriety in the absence of treatment with any hypolipidemic agents.

DISCUSSION

The literature regarding the effects of alcohol on lipid metabolism is briefly reviewed followed by a discussion of how these findings might apply to this patient in particular as well as implications for broader clinical practice.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Alcohol has the ability to dysregulate several lipid indices in addition to elevating triglycerides. The rapid resolution of dyslipidemia suggests that additional treatment may not be necessary for patients who are able to abstain from alcohol but that hypolipidemic agents may be indicated for those patients who continue to drink. Additionally, clinicians should consider checking lipid panels in patients who present with alcohol intoxication and are found to have other laboratory abnormalites or those who have risk factors for hyperlipidemia.

Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology?

OBJECTIVE

We sought to define the severity and natural history of hypertriglyceridemia induced acute pancreatitis (HTG-AP), specifically whether HTG-AP causes more severe AP than that caused by other etiologies.

METHODS

Systematic review of the English literature.

RESULTS

Thirty-four studies (15 countries; 1972-2015) included 1340 HTG-AP patients (weighted mean prevalence of 9%). The median admission triglyceride concentration was 2622 mg/dl (range 1160-9769). Patients with HTG have a 14% weighted mean prevalence of AP. Plasmapheresis decreased circulating triglycerides, but did not conclusively affect AP mortality. Only 7 reports (n = 392 patients) compared severity of HTG-AP to that of AP from other etiologies. Of these, 2 studies found no difference in severity, while 5 suggested that HTG-AP patients may have increased severity compared to AP of other etiology.

CONCLUSIONS

1) hypertriglyceridemia is a relatively uncommon (9%) cause of acute pancreatitis; however, patients with hypertriglyceridemia have a high (14%) incidence of acute pancreatitis; 2) plasmapheresis may offer specific therapy unique to this patient population; and 3) data specifically comparing the severity of HTG-AP with AP caused by other etiologies are heterogeneous and scarce.

Translational Insights Into Peroxisome Proliferator-Activated Receptors in Experimental Acute Pancreatitis

Acute pancreatitis (AP) is an inflammatory disorder of the exocrine pancreas frequently associated with metabolic causes, contributing factors, or consequences, including hypertriglyceridemia, obesity, and disorders of intermediary metabolism, respectively. To date, there is no specific therapy for this disease. Future optimal therapy should correct both inflammatory and metabolic components of the disease. Peroxisome proliferator-activated receptors (PPARs) are lipid-sensing nuclear receptors that control inflammatory and metabolic pathways via ligand-dependent and ligand-independent mechanisms. There are 3 known subtypes, PPAR-α, PPAR-β/δ, and PPAR-γ, which are differentially expressed in various tissues. The PPARs interact closely with other transcription factors such as nuclear factor κB and signal tranducers and activators of transcription that have pivotal roles in the pathobiology of AP. In this comprehensive review, we summarize the role of PPARs in AP, highlighting important in vitro and in vivo experimental findings. Finally, we propose future research directions as well as potential translational use of PPAR agonists in the treatment of AP.

The Associations Between Smoking Habits and Serum Triglyceride or Hemoglobin A1c Levels Differ According to Visceral Fat Accumulation

BACKGROUND

Whether smokers and former smokers have worse lipid profiles or glucose levels than non-smokers remains unclear.

METHODS

The subjects were 1152 Japanese males aged 42 to 81 years. The subjects were divided according to their smoking habits (nonsmokers, former smokers, and current smokers) and their visceral fat area (VFA) (<100 cm(2) and ≥100 cm(2)).

RESULTS

The serum triglyceride (TG) levels of 835 males were assessed. In the VFA ≥100 cm(2) group, a significantly greater proportion of current smokers (47.3%) exhibited TG levels of ≥150 mg/dL compared with former smokers (36.4%) and non-smokers (18.8%). The difference in TG level distribution between former smokers and non-smokers was also significant. However, among the subjects with VFA of <100 cm(2), the TG levels of the three smoking habit groups did not differ. The serum hemoglobin A1c (HbA1c) levels of 877 males were also assessed. In the VFA <100 cm(2) group, significantly higher proportions of current smokers (17.9%) and former smokers (14.9%) demonstrated HbA1c levels of ≥5.6% compared with non-smokers (6.3%). In contrast, in the VFA ≥100 cm(2) group, significantly fewer former smokers displayed HbA1c levels of ≥5.6% compared with non-smokers and current smokers. Furthermore, the interaction between smoking habits and VFA was associated with the subjects' TG and HbA1c concentrations, and the associations of TG and HbA1c concentrations and smoking habits varied according to VFA.

CONCLUSIONS

Both smoking habits and VFA exhibited associations with TG and HbA1c concentrations. The associations between smoking habits and these parameters differed according to VFA.

PROMETHEUS: an observational, cross-sectional, retrospective study of hypertriglyceridemia in Russia

BACKGROUND

Data regarding the prevalence of hypertriglyceridemia in the Russian population are lacking, despite triglyceride (TG)-mediated pathways being causal in cardiovascular disease. The prevalence of mixed dyslipidemia and severe hypertriglyceridemia in the Russian population (PROMETHEUS) was undertaken to address this gap.

METHODS

This was an observational, cross-sectional retrospective study. Data from adults with a full/partial lipoprotein record who had blood analyses done at an INVITRO laboratory in Russia between January 1, 2011 and December 31, 2013 were analyzed. The primary endpoint was the prevalence of hypertriglyceridemia (TG ≥ 1.7 mmol/L); secondary endpoints included prevalence of borderline high, high, and very high TG and severe hypertriglyceridemia, defined as a TG level of 1.7 to <2.3, 2.3 to <5.6, ≥5.6, and ≥10.0 mmol/L, respectively. Statistical analyses involved the Wilcoxon and the Chi square tests. Correlations between log-transformed TG and low- and high-density lipoprotein cholesterol (LDL-C and HDL-C) and total cholesterol (TC) were assessed. The correlation between glycated hemoglobin (HbA1c) and TG levels in a nested sample of subjects with HbA1c and TG data was also assessed using a log-linear model.

RESULTS

The full dataset and nested sample comprised 357,072 and 54,602 individuals, respectively. Prevalence of hypertriglyceridemia, borderline high TG, high TG, very high TG, and severe hypertriglyceridemia in the full dataset was 29.2, 16.2, 12.9, 0.11, and 0.011%, respectively; corresponding rates in the nested sample were 19.0, 17.2, 0.25, and 0.016%, respectively. TG levels were 16.4% higher in males versus females; males had a greater risk of hypertriglyceridemia (risk ratio 1.25; 95% CI 1.24, 1.26; P < 0.0001). Prevalence of hypertriglyceridemia increased with age, peaking at 40-49 years in males (42.8%) and 60-69 years in females (34.4%); a 0.61% increase in TG levels for each year of life was predicted. Hypertriglyceridemia prevalence increased over time. Correlations between TG and LDL-C, HDL-C, TC, and HbA1c (nested sample only) were observed.

CONCLUSIONS

Almost one-third of Russians have hypertriglyceridemia, but severe disease (TG ≥ 10.0 mmol/L) is rare. Although the risk of hypertriglyceridemia was greater in males versus females, its prevalence increased with age, regardless of sex. TG was associated with HbA1c, LDL-C, HDL-C, and TC.

Combined hormonal contraceptive use among women with known dyslipidemias: a systematic review of critical safety outcomes

CONTEXT

Dyslipidemias represent a spectrum of lipid disorders that are important risk factors for cardiovascular disease. In addition, elevated triglycerides are known to be associated with pancreatitis. Though less clear, it is possible that dyslipidemias may also contribute to risk for venous thromboembolism (VTE). Ethinyl estradiol and progestogen, contained within combined hormonal contraception, are known to impact lipid metabolism.

OBJECTIVES

To evaluate from the literature whether use of combined hormonal contraception (CHC), including combined oral contraception (COC) pills, transdermal patch, vaginal ring or injectables, modifies the relative risk of acute myocardial infarction (MI), stroke, VTE or pancreatitis among women with known dyslipidemias and to determine if existing lipid abnormalities worsen with CHC use.

METHODS

PubMed and the Cochrane Library databases were searched for all articles in all languages published between inception and September 2014 relevant to dyslipidemia, CHC use and serious adverse events (MI, stroke, VTE or pancreatitis). The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force.

RESULTS

From 306 articles identified by our search strategy, 3 articles met inclusion criteria. In a poor-quality case-control study, women with hypercholesterolemia but no COC use had an increased risk of MI (adjusted odds ratio [adj OR] 3.3, 95% confidence interval [CI] 1.6-6.8), as did women who used COCs but did not have hypercholesterolemia (adj OR 2.0, 95% CI 1.4-2.8), compared with non-COC users without hypercholesterolemia; women with both COC use and hypercholesterolemia had an adjusted OR of 24.7 (95% CI 5.6-108.5) compared with women with neither risk factor. A poor-quality cohort study examined COC users and reported that women with dyslipidemia had increased risk for VTE [crude risk ratio (RR) 1.39, 95% CI 1.04-1.85] and transient ischemic attacks or cerebrovascular accidents (CVAs) (RR 1.76, 95% CI 1.51-2.06) compared to those without dyslipidemia. Another poor-quality cohort study provided direct evidence on changes in lipid levels among COC users with dyslipidemia. A minority of women with elevated total cholesterol or triglyceride levels at baseline showed normal results (25% and 28%, respectively) after 6 cycles of COC use. No evidence regarding risks associated with use of other CHC methods was identified. No evidence was identified for the outcome of pancreatitis.

CONCLUSION

Limited data from poor-quality observational studies suggest that women with known dyslipidemias using CHC may be at increased risk for MI and may experience a minimal increase in risk for CVA or VTE. No evidence was identified on risk for pancreatitis in this context. The impact of CHC exposure on the status of lipid abnormalities over time, an intermediate marker for disease, is also unclear. Given the significant limitations of this body of evidence, the importance of access to effective contraception and theoretical concerns raised about the use of CHCs by women with known dyslipidemias, additional rigorous studies are needed to best estimate true associations. Contraceptive decision making should include consideration of both the known and theoretical risks of a given CHC method, safety and acceptability of alternative contraceptive methods, and risks associated with unintended pregnancy.

Hypertriglyceridemia in the genomic era: a new paradigm

Hypertriglyceridemia (HTG) is a highly prevalent condition that is associated with increased cardiovascular disease risk. HTG may arise as a result of defective metabolism of triglyceride-rich lipoproteins and their remnants, ie, impaired clearance, or increased production, or both. Current categorization of HTG segregates primary and secondary cases, implying genetic and nongenetic causes for each category. Many common and rare variants of the genes encoding factors involved in these pathways have been identified. Although monogenic forms of HTG do occur, most cases are polygenic and often coexist with nongenetic conditions. Cumulative, multiple genetic variants can increase the risks for HTG, whereas environmental and lifestyle factors can force expression of a dyslipidemic phenotype in a genetically susceptible person. HTG states are therefore best viewed as a complex phenotype resulting from the interaction of cumulated multiple susceptibility genes and environmental stressors. In view of the heterogeneity of the HTG states, the absence of a unifying metabolic or genetic abnormality, overlap with the metabolic syndrome and other features of insulin resistance, and evidence in some patients that accumulation of numerous small-effect genetic variants determines whether an individual is susceptible to HTG only or to HTG plus elevated low-density lipoprotein cholesterol, we propose that the diagnosis of primary HTG and further delineation of familial combined hyperlipidemia from familial HTG is neither feasible nor clinically relevant at the present time. The hope is that with greater understanding of genetic and environmental causes and their interaction, therapy can be intelligently targeted in the future.

Role of Nrf2 in chronic liver disease

Nuclear erythroid 2-related factor 2 (Nrf2) is a central regulator of antioxidative response elements-mediated gene expression. It has a significant role in adaptive responses to oxidative stress by interacting with the antioxidant response element, which induces the expression of a variety of downstream targets aimed at cytoprotection. Previous studies suggested oxidative stress and associated damage could represent a common link between different forms of diseases. Oxidative stress has been implicated in various liver diseases, including viral hepatitis, nonalcoholic fatty liver disease/steatohepatitis, alcoholic liver disease and drug-induced liver injury. Nrf2 activation is initiated by oxidative or electrophilic stress, and aids in the detoxification and elimination of potentially harmful exogenous chemicals and their metabolites. The expression of Nrf2 has been observed throughout human tissue, with high expression in detoxification organs, especially the liver. Thus, Nrf2 may serve as a major regulator of several cellular defense associated pathways by which hepatic cells combat oxidative stress. We review the relevant literature concerning the crucial role of Nrf2 and its signaling pathways against oxidative stress to protect hepatic cell from oxidative damage during development of common chronic liver diseases. We also review the use of Nrf2 as a therapeutic target to prevent and treat liver diseases.