Hypertriglyceridemia-induced pancreatitis and risk of persistent systemic inflammatory response syndrome. Am J Med Sci. 2015;349:206-211. [PMID: 25545390 DOI: 10.1097/maj.0000000000000392]

Integrated serum pharmacochemistry, 16S rDNA sequencing, and metabolomics to reveal the material basis and mechanism of Shouhui Tongbian capsule against diphenoxylate-induced slow transit constipation in rats

BACKGROUND

Slow transit constipation (STC) is highly prevalent and has rising incidence. Shouhui Tongbian capsule (SHTB) is a traditional Chinese Medicine formula with extensive and highly efficacious usage in STC treatment, however, its mechanism of action, especially the regulation of microbiome and lipid metabolites, remains unclear.

METHODS

After quality control of SHTB using LC‒MS to obtain its material basis, we tried to elucidate the cohesive modulatory network of SHTB against STC using hyphenated methods from microbiomics, lipidomics, mass spectrometry imaging (MSI) and molecular methods.

RESULTS

SHTB could repair intestinal barrier damage, reduce systemic inflammation and increase intestinal motility in a diphenoxylate-induced STC rat model. Based on 16S rDNA sequencing results, SHTB rehabilitated the abnormal changes in Alloprevotella, Coprococcus, Marvinbryantia, etc., which were associated with STC symptoms. Meanwhile, microbial functional prediction showed that lipid metabolism was improved with SHTB administration. The differential lipids, including fatty acids, lysophosphatidylcholine, phosphatidylcholine, sphingomyelin triglyceride and ceramide, that are closely related to STC disease and SHTB efficacy. Furthermore, SHTB significantly reversed the abnormal expression of these key target enzymes in colon samples, including CTP-phosphocholine cytidylyltransferase, CTP-phosphoethanolamine cytidylyltransferase, phosphatidic acid phosphatase, acid sphingomyelinase etc. CONCLUSIONS: Combined analysis demonstrated that SHTB reducing lipid accumulation and recovery of intestinal microbial homeostasis was the critical mechanism by which SHTB treats STC.

Intestinal GSTpi deficiency exacerbates the severity of experimental hyperlipidemic acute pancreatitis

Intestinal dysfunction plays a pivotal role in the development of acute pancreatitis (AP), however, the underlying mechanisms of intestinal dysfunction on severity of hyperlipidemic acute pancreatitis (HLAP) are still unclear. Herein, we explored the role of intestinal function on the severity of HLAP. We found that HLAP patients exhibit higher lipid and inflammatory response than AP patients. Hyperlipidemia significantly elevates serum lipids and worsen pancreatic damage in AP mice. In addition, significant exacerbated intestinal barrier damage and inflammation were observed in experimental HLAP mice, as evidenced by increased serum amylase and lipase levels, and pancreatic edema. Further, RNA-Seq showed that a markedly decrease of glutathione S-transferase pi (GSTpi) in colonic tissue of HLAP mice compared with AP mice, accompanied with increased serum lipopolysaccharides level. However, colonic GSTpi overexpression by adeno-associated virus significantly attenuated intestinal damage and subsequent pancreatic inflammation in HLAP mice. Mechanistically, GSTpi mitigated HLAP-mediated colonic NLRP3 inflammasome activation and barrier dysfunction. These results suggest that intestinal GSTpi deficiency exacerbates the severity of experimental HLAP, providing new insights for the clinical treatment of HLAP.

Novel anthropometric indicators of visceral obesity predict the severity of hyperlipidemic acute pancreatitis

BACKGROUND

Obesity substantially contributes to the onset of acute pancreatitis (AP) and influences its progression to severe AP. Although body mass index (BMI) is a widely used anthropometric parameter, it fails to delineate the distribution pattern of adipose tissue. To circumvent this shortcoming, the predictive efficacies of novel anthropometric indicators of visceral obesity, such as lipid accumulation products (LAP), cardiometabolic index (CMI), body roundness index (BRI), visceral adiposity index (VAI), A Body Shape Index (ABSI), and Chinese visceral adiposity index (CVAI) were examined to assess the severity of AP.

METHOD

The body parameters and laboratory indices of 283 patients with hyperlipidemic acute pancreatitis (HLAP) were retrospectively analysed, and the six novel anthropometric indicators of visceral obesity were calculated. The severity of HLAP was determined using the revised Atlanta classification. The correlation between the six indicators and HLAP severity was evaluated, and the predictive efficacy of the indicators was assessed using area under the curve (AUC). The differences in diagnostic values of the six indicators were also compared using the DeLong test.

RESULTS

Patients with moderate to severe AP had higher VAI, CMI, and LAP than patients with mild AP (all P < 0.001). The highest AUC in predicting HLAP severity was observed for VAI, with a value of 0.733 and 95% confidence interval of 0.678-0.784.

CONCLUSIONS

This study demonstrated significant correlations between HLAP severity and VAI, CMI, and LAP indicators. These indicators, particularly VAI, which displayed the highest predictive power, were instrumental in forecasting and evaluating the severity of HLAP.

A nomogram for predicting in-hospital overall survival of hypertriglyceridemia-induced severe acute pancreatitis: A single center, cross-sectional study

Background

Hypertriglyceridemia-induced severe acute pancreatitis (HTG-SAP) is a type of pancreatitis characterized by an abnormal elevation of plasma triglyceride. HTG-SAP has been associated with various complications and a high mortality rate. In this study, we established a nomogram for predicting the overall survival (OS) of HTG-SAP patients during hospitalization.

Methods

128 HTG-SAP cases hospitalized at the Affiliated Huadu Hospital, Southern Medical University, from 2019 to 2022 were analyzed retrospectively. A nomogram including prognostic factors correlated with OS during hospitalization was established by multivariate Cox regression analysis. We internally validated the nomogram using time-dependent (at 1-, 2-, and 3- months) survival receiver operating characteristic (SROC) and calibration curve with 500 iterations of bootstrap resampling. Time-dependent decision curve analysis (DCA) was employed to validate the clinical value of the nomogram.

Results

Multivariate Cox regression indicated that serum triglyceride, red blood cell distribution width (RDW), lactic acid, and interleukin-6 (IL6) were independent prognostic factors for OS of HTG-SAP patients during hospitalization and were used to construct a nomogram. The time-dependent area under the curve (AUC) values at 1-, 2-, and 3- months were 0.946, 0.913, and 0.929, respectively, and the Concordance index (C-index) of the nomogram was 0.916 (95%CI 0.871-0.961). The time-dependent calibration curves indicated good consistency between the observed and predicted outcomes. The time-dependent DCAs also revealed that the nomogram yielded a high clinical net benefit. After stratifying the included cases into two risk groups based on the risk score obtained from the nomogram, the high-risk group exhibited a significantly inferior overall survival (OS) compared to the low-risk group (p < 0.0001).

Conclusions

Our nomogram exhibited good performance in predicting the overall survival of HTG-SAP patients during hospitalization.

NLR48 is Better Than CRP, and mCTSI, and Similar to BISAP and SOFA Scores for Mortality Prediction in Acute Pancreatitis: A Comparison of 6 Scores

Introduction

The neutrophil-lymphocyte ratio (NLR) has been suggested as a reliable marker for predicting inflammation progression and severity of acute pancreatitis, although the role of the NLR stratified by etiology is still insufficiently studied. However, the NLR's role in mortality prediction was poorly evaluated in the literature.

Patients and Methods

We performed a retrospective, cross-sectional study to analyze the role of NLR0 (at admission) and NLR48 (at 48 hours) in acute pancreatitis as compared with CRP, BISAP, SOFA, and modified CTSI (mCTSI) for the prediction of mortality and severe acute pancreatitis (SAP) in patients admitted into the Emergency Clinical County Hospital of Craiova during 48 months. The primary assessed outcomes were the rate of in-hospital mortality, the rate of persistent organ failure, and ICU admissions. We analyzed mortality prediction for all acute pancreatitis, for biliary, alcoholic, and hypertriglyceridemic acute pancreatitis, for severe forms, and for patients admitted to the ICU.

Results

A total of 725 patients were selected; 42.4% had biliary acute pancreatitis, 27.7% had alcoholic acute pancreatitis, and 8.7% had hypertriglyceridemia-induced acute pancreatitis. A total of 13.6% had POF during admission. The AUC for NLR48 in predicting mortality risk and SAP was 0.81 and 0.785, superior to NLR0, CRP48, and mCTSI but inferior to BISAP and SOFA scores. The NLR48/NLR0 ratio did not add significantly to the accuracy. NLR0 and NLR48 performed poorly for mortality prediction in severe forms and in patients admitted to the ICU. NLR48 has good accuracy in our study for predicting death risk in biliary and alcoholic acute pancreatitis but not in hypertriglyceridemic acute pancreatitis.

Conclusion

NLR48 was a good indicator in predicting mortality risk and severe forms in all patients with acute pancreatitis, but not of death in SAP and in patients admitted to ICU, with good accuracy for predicting death risk in biliary and alcoholic acute pancreatitis but not in hypertriglyceridemic acute pancreatitis.

Low-grade inflammation for predicting severe acute pancreatitis in patients with hypertriglyceridemic acute pancreatitis

OBJECTIVES

We aimed to evaluate the association between low-grade inflammation (LGI) and the severity of hypertriglyceridemic acute pancreatitis (HTG-AP).

METHODS

We retrospectively reviewed 311 patients with HTG-AP who were admitted to the Department of Gastroenterology, Fujian Provincial Hospital between April 2012 and March 2021. Inpatient medical and radiological records were reviewed to collect the clinical manifestations, disease severity, and comorbidities. C-reactive protein (CRP) level, white blood cell (WBC) count, platelet (PLT) count, and neutrophil-to-lymphocyte ratio (NLR) were considered LGI components and were combined to calculate a standardized LGI score. The association between the LGI score and the severity of HTG-AP was analyzed using univariate and multivariate logistic regression analyses.

RESULTS

Of the 311 patients with HTG-AP, 47 (15.1%) had mild acute pancreatitis (MAP), 184 (59.2%) had moderately severe acute pancreatitis (MSAP), and 80 (25.7%) had severe acute pancreatitis (SAP), respectively. Patients with MSAP and SAP had a higher LGI score than those with MAP (1.50 vs -6.00, P < 0.001). Univariate logistic regression analysis revealed that patients with LGI scores in the fourth quartile were more likely to have MSAP and SAP (odds ratio [OR] 21.925, 95% confidence interval [CI] 5.014-95.867, P < 0.001). The multivariate logistic regression analysis confirmed that low calcium (OR 0.105, 95% CI 0.011-0.969, P = 0.047) and high LGI score (OR 1.253, 95% CI 1.066-1.473, P = 0.006) were associated with MSAP and SAP. When predicting the severity of acute pancreatitis, the LGI score had the highest area under the receiver operating characteristic (ROC) curve (0.7737) compared to its individual components.

CONCLUSION

An elevated LGI score was associated with a higher risk of SAP in patients with HTG-AP.

Lipid metabolism for predicting the recurrence of hypertriglyceridemic acute pancreatitis

Rationale and objectives

To investigate the predictive value of lipid metabolism in predicting the recurrence of hypertriglyceridemic acute pancreatitis (HTG-AP).

Materials and methods

A total of 892 patients were admitted to our hospital for acute pancreatitis (AP) from January 2017 to December 2020, of whom 198 diagnosed with HTG-AP were enrolled in this retrospective study. Demographic information, length of stay, smoking index, alcohol abuse, necrosis, severity, baseline lipid metabolism and other blood biochemical indicators were recorded. The risk factors of recurrence were evaluated using univariate and multivariate Cox proportional risk analyses, and the cumulative recurrence-free survival rate of patients were calculated using Kaplan Meier method and the differences between groups were compared using the log-rank test.

Results

Univariate and multivariate analysis showed that triglyceride (hazard ratio, 2.421; 95% CI, 1.152-5.076; P = 0.020), non high-density lipoprotein (hazard ratio, 4.630; 95% CI, 1.692-12.658; P = 0.003) and apolipoprotein A1 (hazard ratio, 1.735; 95% CI, 1.093-2.754; P = 0.019) were important predictors for recurrence of HTG-AP. Subsequently, patients were divided into four groups according to the cut off values of triglyceride, non high-density lipoprotein and apolipoprotein A1. It was found that the cumulative recurrence-free survival rate of patients in highest-risk group or high-risk group was significantly lower than that of medium-risk group (P < 0.001, P = 0.003) or low risk group (P < 0.001).

Conclusion

Serum triglycerides, non high-density lipoprotein and apolipoprotein A1 are independent predictors of recurrence in HTG-AP patients, which can provide reference for individualized treatment and prevention of recurrence in HTG-AP patients.

Relationship between blood glucose levels and length of hospital stay in patients with acute pancreatitis: An analysis of MIMIC-III database

We aimed to investigate the effect of blood glucose levels on length of stay (LOS) in patients hospitalized with acute pancreatitis (AP). We retrospectively collected clinical data of patients diagnosed with AP from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Dose-response analysis curves of restricted cubic spline (RCS) function and multivariate logistic regression models were used to confirm the relationship between blood glucose levels and LOS. A total of 3656 patients with AP were included according to the inclusion and exclusion criteria. According to RCS, all patients were divided into three groups, namely the less than 68 mg/dl group, the 68-104 mg/dl group, and the >104 mg/dl group. RCS showed a significant nonlinear correlation between blood glucose levels and LOS (p < 0.001). Multivariate logistic regression revealed a 53% higher risk of LOS greater than or equal to 2 days (adjusted odds ratio [aOR] = 1.53, 95% confidence interval [CI] 1.24-1.89, p < 0.001), a 114% higher risk of LOS greater than or equal to 5 days (aOR = 2.14, 95% CI 1.86-2.47, p < 0.001), and a 130% higher risk of LOS greater than or equal to 7 days (aOR = 2.30, 95% CI 1.97-2.69, p < 0.001) in patients with glucose levels greater than 104 mg/dl than patients with glucose levels 68-104 mg/dl. The risk of LOS greater than or equal to 7 days was higher in patients with blood glucose less than 68 mg/dl than patients with glucose levels 68-104 mg/dl (aOR = 1.45, 95% CI 1.02-2.05, p = 0.040). In addition, we observed similar results in many subgroups. Our findings suggest that either hyperglycemia or hypoglycemia increase LOS in patients hospitalized with AP. For hospitalized patients with AP, blood glucose control in a reasonable range of 68-104 mg/dl is required.

Incidence and clinical characteristics of hypertriglyceridemic acute pancreatitis: A retrospective single-center study

BACKGROUND

The incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) has increased yearly, but updated population-based estimates on the incidence of HTG-AP are lacking. Reducing serum triglyceride (TG) levels quickly is crucial in the early treatment of HTG-AP. Decreased serum TG levels are treated by non-invasive methods, which include anti-lipidemic agents, heparin, low-molecular weight heparin, and insulin, and invasive methods, such as blood purification including hemoperfusion (HP), plasmapheresis, and continuous renal replacement therapy. However, authoritative guidelines have not been established. Early selection of appropriate treatment is important and beneficial in controlling the development of HTG-AP.

AIM

To evaluate the effect between patients treated with intravenous insulin (INS) and HP to guide clinical treatment.

METHODS

We retrospectively reviewed 371 patients with HTG-AP enrolled in the Department of Fujian Provincial Hospital form April 2012 to March 2021. The inpatient medical and radiologic records were reviewed to determine clinical features, severity, complications, mortality, recurrence rate, and treatment. Multivariate logistic regression analyses were used to analyze risk factors for severe HTG-AP. Propensity score matching was used to compare the clinical outcomes of INS and HP.

RESULTS

A total of 371 patients met the HTG-AP criteria. The incidence of HTG-AP was increased by approximately 2.6 times during the 10 years (8.4% in April 2012-March 2013 and 22.3% in April 2020-March 2021). The highest incidence rate of acute pancreatitis was observed for men in the age group of 30-39 years. The amylase level was elevated in 80.1% of patients but was only three times the normal value in 46.9% of patients. The frequency of severe acute pancreatitis (26.9%), organ failure (31.5%), rate of recurrence (32.9%), and mortality (3.0%) of HTG-AP was high. Improved Marshall score, modified computed tomography severity index score, baseline TG, baseline amylase, C-reactive protein (CRP), albumin, aspartate aminotransferase, low-density lipoprotein cholesterol, urea nitrogen, creatinine, calcium, hemoglobin, free triiodothyronine, admission to intensive care unit, and mortality were significantly different between patients with different grades of severity (P < 0.050). Multivariate logistic regression analysis confirmed that high CRP [P = 0.005, odds ratio (OR) = 1.011, 95%CI: 1.003-1.019], low calcium (P = 0.003, OR = 0.016, 95%CI: 0.001-0.239), and low albumin (P = 0.023, OR = 0.821, 95%CI: 0.693-0.973) were risk factors of severe HTG-AP. After propensity score matching adjusted by sex, age, severity of HTG-AP, and baseline TG, the serum TG significantly decreased in patients treated with INS (P < 0.000) and HP (P < 0.000) within 48 h. However, the clearance rate of TG (57.24 ± 33.70% vs 56.38 ± 33.61%, P = 0.927) and length of stay (13.04 ± 7.92 d vs 12.35 ± 6.40 d, P = 0.730) did not differ between the two groups.

CONCLUSION

The incidence of HTG-AP exhibited a significant increase, remarkable severity, and recurrent trend. Patients with mild and moderately severe acute pancreatitis can be treated effectively with INS safely and effectively without HP.

Resveratrol pre-treatment alleviated caerulein-induced acute pancreatitis in high-fat diet-feeding mice via suppressing the NF-κB proinflammatory signaling and improving the gut microbiota

BACKGROUND

hyperlipidemia acute pancreatitis (HTG-AP) is a major hidden danger affecting human health, however, whether there is a protective effect of resveratrol on HTG-AP is unclear. Therefore our study was aimed to investigate the preventive effect and the underlying mechanism of resveratrol in the HTG-AP mice model.

METHODS

This research was divided into two parts. In the first part, mice were adaptively fed with normal chow or HFD for 6 weeks. From the second week, resveratrol-treated mice were in intragastric administration with resveratrol (45 mg/kg/d) for 4 weeks. In the second part, the procedures were the same as the first part. After the last intragastric administration with resveratrol, all mice were intraperitoneal injections of cerulean.

RESULTS

We found resveratrol effectively inhibited pancreatic pathological injury in the HFD, AP, and HTG-AP mice. Resveratrol reduced the LPS, IL-6, TNF-α, and MCP-1 expressions in the HFD mice. Resveratrol also reduced TNF-α, MDA, and MCP-1 expressions and increased SOD and T-AOC expressions in the AP and HTG-AP mice. Furthermore, resveratrol suppressed the NF-κB pro-inflammatory signaling pathway in pancreatic tissues in the AP and HTG-AP mice. Moreover, resveratrol improved the gut microbiota in the HFD mice.

CONCLUSION

The resveratrol pre-treatment could attenuate pancreas injury, inflammation, and oxidative stress in the HTG-AP mice, via restraining the NF-κB signaling pathway and regulating gut microbiota. Therefore, Our study proved that the resveratrol pre-treatment had a preventive effect on HTG-AP.

Identification and Validation of Hub Genes in Acute Pancreatitis and Hypertriglyceridemia

BACKGROUND

The pathogenesis of acute pancreatitis (AP) and the relationship between acute pancreatitis and hypertriglyceridemia are complex and not fully understood. The purpose of this study was to identify the hub genes along with common differentially expressed genes (DEGs) between acute pancreatitis and hypertriglyceridemia.

METHODS

We downloaded three gene expression profiles of AP and one gene expression profile of hypertriglyceridemia from the Gene Expression Omnibus (GEO) database and filtered the DEGs based on the above four datasets. Next, we identified the hub genes by performing the Gene Ontology (GO) term analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis, and protein-protein interaction (PPI) construction. We also constructed the miRNA-hub gene network and established mouse models with hypertriglyceridemia and AP using a high-fat diet and injection of caerulein (CAE), respectively. Finally, the immunohistochemical analysis was used to verify the differential expressions of hub genes in AP, hypertriglyceridemia, and normal pancreatic tissue.

RESULTS

A total of 105 DEGs associated with AP and 149 DEGs associated with hypertriglyceridemia were identified. Additionally, we identified six hub genes of AP, all of which were closely related to the cytoskeleton while two DEGs genes were common in both AP and hypertriglyceridemia. We also verified their expression in mouse models. Finally, a network of miRNA-mRNA was also constructed, and the top seven interactive miRNAs (hsa-mir-1-3p, hsa-mir-5195-3p, hsa-mir-145-5p, hsa-let-7b-5p, hsa-mir-10b-5p, hsa-mir-206, and hsa-mir-613) targeting the most hub genes were identified.

CONCLUSION

Overall, we identified six hub genes associated with AP and two common DEGs associated with AP and hypertriglyceridemia along with seven miRNAs that may regulate AP. This study could provide new ideas for further elucidation of the pathogenesis of hypertriglyceridemia-induced acute pancreatitis in the future.

Hypertriglyceridemia is a risk factor for treatment failure in patients with peritoneal dialysis-related peritonitis

OBJECTIVE

Disorders of triglycerides (TG) are common in patients with peritoneal dialysis (PD). Hypertriglyceridemia has been demonstrated in various infections. The association between triglycerides and the outcomes of peritoneal dialysis-related peritonitis (PDRP) was investigated in this study.

METHODS

We retrospectively investigated patients with PDRP from January 1, 2013 to October 31, 2020. Hypertriglyceridemia was defined as triglycerides ≥ 1.7 mmol/L. PDRP episodes were divided into two groups: hypertriglyceridemia and normal levels of triglycerides. The clinical and laboratory baseline data of the two groups were collected and compared. The association between triglycerides and treatment failure was analyzed by logistic regression analysis.

RESULTS

Ninety episodes in 66 patients were recorded in our center. Hypertriglyceridemia occurred in 38% (34/90) of episodes. Twenty-five episodes were not cured in 90 episodes (27.8%, 25/90). The levels of thrombocytes, high-sensitivity C-reactive protein (hs-CRP), low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin, were higher in hypertriglyceridemia episodes of PDRP at baseline. The bacterial classification was different between elevated triglyceride group and normal triglyceride group. Adjusted for age, duration of dialysis, residual renal function, diabetes, thrombocytes, hs-CRP, serum albumin, cholesterol, HDL-C, LDL-C, intact parathyroid hormone (iPTH), glycated hemoglobin and spectrum of bacteria, hypertriglyceridemia were associated significantly with treatment failure of PDRP in our study (OR 3.416, 95% CI 1.223-9.540 p < 0.05).

CONCLUSION

Hypertriglyceridemia at baseline was an independent risk factor for treatment failure of PDRP.

Low-Molecular-Weight Heparin Combined With Insulin Versus Insulin Alone in the Treatment of Hypertriglyceridemic Pancreatitis (LIHTGP Trial): Study Protocol for a Multicenter, Prospective, Single-Blind, Randomized Controlled Trial

OBJECTIVE

Currently, insulin and/or heparin/low-molecular-weight heparin (LMWH) serve as an early lipid-lowering treatment for hypertriglyceridemic pancreatitis (HTGP). However, whether the clinical prognosis of combining LMWH with insulin is superior to using insulin alone remains unknown. This trial will compare the clinical outcomes of LMWH with insulin and an insulin regimen for emergency lipid-lowering treatment in HTGP patients.

METHODS

In total, 476 eligible participants will be recruited from 18 hospitals throughout China. Participants in the LMWH group will receive LMWH combined with insulin, whereas insulin alone will be administered to those in the insulin group. The patients will be followed up at 3 and 6 months after discharge. Adverse reactions will be evaluated by the safety monitoring committee. Safety outcomes and adverse events will also be recorded.

RESULTS

The study is registered in the Chinese Clinical Trial Registry (No: ChiCTR1900023640). Recruitment will begin in August 2019 and will be completed in December 2021 (http://www.chictr.org.cn/index.aspx). No data are available now.

CONCLUSIONS

The trial will investigate the efficacy of using LMWH combined with insulin as an emergency lipid-lowering treatment in reducing new organ failure, mortality, hospital stays, and expenses compared using with insulin alone for patients with HTGP.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Effect of different degrees of hypertriglyceridemia on severity of acute pancreatitis

BACKGROUND

Too much free fatty acids in the body can damage pancreatic acinar cells and result in the generation of a large number of inflammatory factors, leading to multiple organ dysfunction. By observing the influence of different degrees of hypertriglyceridemia (HTG) on the severity of acute pancreatitis, this study confirmed that the risk of severe pancreatitis increases with the increase of blood lipid level.

AIM

To investigate the effect of different degrees of HTG at the early onset stage on the severity of hyperlipidemic acute pancreatitis (HLAP).

METHODS

Eighty-seven patients with HLAP treated from June 2016 to December 2019 at our hospital were retrospectively analyzed. According to the levels of serum triglyceride (TG) on admission, they were divided into three groups: (1) Moderate HTG group (TG: 5.65-11.30 mmol/L); (2) severe HTG group (TG: 11.3-22.3 mmol/L); and (3) very severe HTG group (TG: ≥ 22.4 mmol/L). The changes in biochemical indicators, the modified CT severity index (MCTSI) score, and disease severity were observed.

RESULTS

Compared with the moderate HTG group, MCTSI scores, the levels of C-reactive protein (CRP), and the incidence of moderately severe acute pancreatitis/severe acute pancreatitis were significantly higher in the severe HTG group and very severe HTG group, but there was no significant difference in MCTSI or CRP between the severe HTG group and very severe HTG group.

CONCLUSION

The level of TG within 24 h after onset has an effect on HLAP severity, and the severity of acute pancreatitis induced by moderate HTG is mild and the risk of severe pancreatitis is low. Severe/very severe HTG may be associated with a high risk of severe HLAP.

Bacterial staphylokinase as a promising third-generation drug in the treatment for vascular occlusion

Vascular occlusion is one of the major causes of mortality and morbidity. Blood vessel blockage can lead to thrombotic complications such as myocardial infarction, stroke, deep venous thrombosis, peripheral occlusive disease, and pulmonary embolism. Thrombolytic therapy currently aims to rectify this through the administration of recombinant tissue plasminogen activator. Research is underway to design an ideal thrombolytic drug with the lowest risk. Despite the potent clot lysis achievable using approved thrombolytic drugs such as alteplase, reteplase, streptokinase, tenecteplase, and some other fibrinolytic agents, there are some drawbacks, such as high production cost, systemic bleeding, intracranial hemorrhage, vessel re-occlusion by platelet-rich and retracted secondary clots, and non-fibrin specificity. In comparison, bacterial staphylokinase, is a new, small-size plasminogen activator, unlike bacterial streptokinase, it hinders the systemic degradation of fibrinogen and reduces the risk of severe hemorrhage. A fibrin-bound plasmin-staphylokinase complex shows high resistance to a₂-antiplasmin-related inhibition. Staphylokinase has the potential to be considered as a promising thrombolytic agent with properties of cost-effective production and the least side effects.

Dynamic Detection of Monocyte Subsets in Peripheral Blood of Patients with Acute Hypertriglyceridemic Pancreatitis

Aim

Monocytes play an important role in acute pancreatitis (AP). Hypertriglyceridemic pancreatitis (HTGP) is always more severe than normal lipid-AP, whether the mechanism of aggravation involves monocyte subsets remains unknown though. The present study was aimed to analyze changes of peripheral blood M1 and M2 monocytes in HTGP patients.

Methods

A total of 90 subjects were enrolled, among which 16 diagnosed with HTGP, 34 with acute biliary pancreatitis (ABP), 20 with hypertriglyceridemia (HTG), and 20 healthy controls (HC). Peripheral blood CD14+CD86+ M1 and CD14+CD206+ M2 monocytes were examined by flow cytometry on days 1, 3, and 7 after admission.

Results

We found a marked increase in total and M1 monocyte count in AP patients (P < 0.05). In HTGP, the percentage of M1 monocytes in white blood cells was significantly higher on days 1, 3, and 7, while M2 monocyte percentage was decreased on day 3, compared with ABP (P < 0.05). In mild HTGP, M1 monocyte count and percentage gradually decreased, while M2 monocyte percentage gradually increased from day 1 to 7. In severe HTGP, M1 monocyte count and percentage rose to the highest point while M2 were the lowest on day 3. Additionally, the level of M1 monocytes showed a positive correlation with plasma triglyceride and Ranson score of HTGP patients.

Conclusions

Peripheral blood M1 and M2 monocytes showed different dynamic changes in mild and severe HTGP. A more dominant role of CD14+CD86+ M1 monocytes may be involved in the pathogenesis of HTGP.

Severe Hypertriglyceridemia-Related Pancreatitis: Characteristics and Predictors of Recurrence

OBJECTIVES

The diagnosis of severe hypertriglyceridemia (HTG) as a cause for acute pancreatitis is often delayed with limited data on the characteristics and predictors of recurrent pancreatitis in this population.

METHODS

A regional database of severe HTG level of 1000 mg/dL or greater was analyzed to identify subjects with acute pancreatitis. Factors associated with recurrent pancreatitis during long-term follow-up were investigated.

RESULTS

Severe HTG-associated pancreatitis was evident in 171 patients (75% diabetics). Recurrent pancreatitis was observed in 16%; this was associated with younger age, alcohol abuse, and an increase in triglyceride levels. In multivariable analysis, peak triglycerides level of greater than 3000 mg/dL (hazard ratio, 2.92; 95% confidence interval, 1.28-6.64; P = 0.011) and most recent triglycerides level of greater than 500 mg/dL (hazard ratio, 3.72; 95% confidence interval, 1.60-8.66; P = 0.002) remained independently associated with recurrent pancreatitis. These lipid measures as well as alcohol abuse were additionally correlated with a stepwise increase in the number of pancreatitis episodes.

CONCLUSIONS

Severe HTG-related pancreatitis was closely associated with diabetes. Extreme HTG and a lack of attainment of lower triglyceride levels were independent long-term predictors of recurrent pancreatitis. These findings emphasize the importance of early identification and successful treatment of severe HTG and its underlying disorders to reduce the burden of recurrent pancreatitis.

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.

Lipid profile associated with the systemic inflammatory response syndrome and sepsis in critically ill patients

OBJECTIVES

Changes in lipid profiles occur in systemic inflammatory response syndrome (SIRS), whether due to sepsis or another cause. Hypocholesterolemia associated with hypertriacylglycerolemia can lead to disease severity and higher mortality. The aim of this systematic review was to describe the principal alterations in markers that participate in the alteration of the lipid profile.

METHODS

We reviewed articles focused on alterations in the lipid profile in SIRS, sepsis, or both that were indexed in the Scientific Electronic Library Online from 2000 to 2017. The descriptors used were SIRS; sepsis; lipid profile; and lipoproteins. We focused in particular on the relationships among SIRS, sepsis, and lipid profiles.

RESULTS

We included 29 studies that discussed decreased high-density lipoprotein (HDL), total cholesterol, and low-density lipoprotein, and elevated triacylglycerols concentrations in patients with SIRS, sepsis, or both. The variation in the lipid profile was proportional to the level of inflammation as evaluated by inflammatory markers, including C-reactive protein, interleukin-6 and interleukin-8, lipopolysaccharide-binding protein, and tumor necrosis factor. Additionally, there was a change in the composition of lipoproteins, especially HDL, triacylglycerols, and very low-density lipoprotein. HDL appears to be an inflammatory marker, as reduction of its levels reflects the intensity of the underlying inflammatory process.

CONCLUSION

Critically ill patients with SIRS, sepsis, or both presented with alterations in lipid metabolism.

Predictive value of apolipoprotein B and A-I ratio in severe acute pancreatitis

BACKGROUND AND AIM

Severe acute pancreatitis (SAP) has considerable mortality and morbidity rates. Although many indices have been developed to classify the severity of acute pancreatitis (AP), an optimal method for predicting SAP has not been identified. The ratio of apolipoprotein B to A-I (apoB/A-I) is associated with metabolic syndrome and inflammatory status. This study investigated the association between severity of AP and serum apoB/A-I ratio.

METHODS

Patients with AP were prospectively enrolled at Yonsei University Wonju College of Medicine from March 2015 to August 2016. The severity of AP was assessed according to the revised Atlanta classification criteria (Atlanta 2012).

RESULTS

Of 191 patients with AP, 134 (70.2%) had mild AP, 42 (22%) had moderately severe AP, and 15 (7.9%) had SAP; apoB/A-I ratio was highest in patients with SAP (P = 0.001). The apoB/A-I ratio was positively correlated with Atlanta classification, computed tomography severity index, and Bedside index for severity of AP. The apoB/A-I ratio showed the highest predictive value for SAP in patients with AP compared with apolipoprotein B or apolipoprotein A-I alone.

CONCLUSION

Serum apoB/A-I ratio appears to have value for predicting SAP in patients with AP.

Elevated Serum Triglycerides in the Prognostic Assessment of Acute Pancreatitis: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Hypertriglyceridemia has been positively associated with the risk of acute pancreatitis (AP), but whether increased triglyceride (TG) levels are associated with the severity of AP remains unknown. To this, a meta-analysis was conducted to assess the effect of elevated serum TG on the prognosis of AP.

METHODS

We searched PubMed, EMBASE, and the Cochrane library to identify all eligible studies (up to September 2016). We pooled the odds ratios (ORs) or standardized mean difference from individual studies using a random-effects model to investigate associations between levels of TG and the prognosis of AP.

RESULTS

A total of 15 studies were included in the meta-analysis, including a total of 1564 patients with triglyceride-related acute pancreatitis (TGAP) and 5721 patients with nontriglyceride-related acute pancreatitis (NTGAP). The occurrence of renal failure [OR=3.18; 95% confidence interval (CI): 1.92, 5.27; P<0.00001], respiratory failure (OR=2.88; 95% CI: 1.61, 5.13; P<0.0001), and shock (OR=3.78; 95% CI: 1.69, 8.44; P<0.0001) was statistically significantly higher in TGAP group than in NTGAP group. Furthermore, mortality (OR=1.90; 95% CI: 1.05, 3.45; P<0.01), systemic inflammatory response syndrome (OR=2.03; 95% CI: 1.49, 2.75; P<0.00001), and Acute Physiology and Chronic Health Evaluation (APACHE-II) scores (standardized mean difference=2.72; 95% CI: 1.00, 4.45; P<0.001) were also statistically significantly higher in TGAP group than in NTGAP group.

CONCLUSION

Elevated serum TGs are related to a worse prognosis of AP.

Development of a novel model of hypertriglyceridemic acute pancreatitis in mice

The morbidity rate of hypertriglyceridemic acute pancreatitis (HTG-AP) increased rapidly over the last decade. However an appropriate animal model was lacking to recapitulate this complicated human disease. We established a novel mice model of HTG-AP by poloxamer 407 (P-407) combined with caerulein (Cae). In our study, serum triglyceride levels of P-407 induced mice were elevated in a dose-dependent manner, and the pancreatic and pulmonary injuries were much severer in HTG mice than normal mice when injected with conventional dose Cae (50 ug/kg), what's more, the severity of AP was positively correlative with duration and extent of HTG. In addition, we found that a low dose Cae (5 ug/kg) could induce pancreatic injury in HTG mice while there was no obvious pathological injury in normal mice. Finally, we observed that HTG leaded to the increased infiltrations of macrophages and neutrophils in mice pancreatic tissues. In conclusion, we have developed a novel animal model of HTG-AP that can mimic physiological, histological, clinical features of human HTG-AP and it could promote the development of therapeutic strategies and advance the mechanism research on HTG-AP.

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.

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.

Prospective evaluation of the cause of acute pancreatitis, with special attention to medicines

AIM: To investigate the cause of acute pancreatitis (AP) by conducting a thorough investigation of drugs and their possible etiological role.

METHODS: We investigated the cause of AP in a large retrospective cohort of 613 adult patients admitted with AP at the Akershus University Hospital, Norway, from 2000 until 2009, who were evaluated with standard ward investigations. This group was compared with a prospectively evaluated group (n = 57) admitted from January 2010 until September 2010 who investigated more extensively using medical history and radiological assessment.

RESULTS: The groups were comparable with regards to gender, age, comorbidity and severity. The most common etiology was bile stones and alcohol, occurring in 60% in both groups. The prospective group was examined more thoroughly with regards to the use of alcohol and medicines. An increased number of radiological investigations during hospital stay and at follow-up were also performed. A more extensive use of radiological evaluation did not increase the detection frequency of bile stones. In the prospective group, more than half of the patients had two or more possible causes of pancreatitis, being mostly a combination of bile stones and drugs. No possible cause was found in only 3.5% of these patients, compared with 29.7% in the retrospective group.

CONCLUSION: A detailed medical history and extensive radiological evaluation may determine a possible etiology in almost all cases of AP. Many patients have several possible risk factors, and uncertainty remains in establishing the definitive etiology.

Therapeutic effects of quercetin on early inflammation in hypertriglyceridemia-related acute pancreatitis and its mechanism

OBJECTIVE

To investigate the therapeutic effects of quercetin on early-stage inflammation in hypertriglyceridemia (HTG)-related acute pancreatitis (AP) both in vivo and in vitro, and its possible mechanism.

METHODS

In vivo, rats were fed a high-fat diet to induce HTG, and AP was induced by intraperitoneal injection of cerulein (50 μg/kg × 2). Quercetin (100, 150 and 200 mg/kg) was administered by intraperitoneal injection after AP induction. In vitro, rat exocrine acinar cells were preincubated with palmitic acid (PA, 0.1 mmol/L, 6 h) with quercetin (5, 10, 20 and 40 μM) prior to a cholecystokinin analog CCK-8 (20pM). Injury of the pancreas was assessed by amylase secretion and pancreatic histological evaluation. Inflammation was estimated by measuring IL-1β, IL-6, TNFα and NF-kB expression. Dynamic expression of IRE1α, sXBP1, C/EBPα and C/EBPβ was monitored by real-time PCR, immunofluorescence (IF) and western blot (WB).

RESULTS

Quercetin intervention reduced plasma amylase level (P < 0.001) in a dose-dependent manner, attenuated pancreatic histopathological damage (P < 0.05), and reduced the mRNA and protein expression of NF-kB, IL-1β, IL-6, TNFα (P < 0.05) more significantly in HTG-related AP rats than in normal-lipid AP rats. Quercetin also down-regulated gene and protein expression levels of IRE1α, sXBP1, C/EBPα and C/EBPβ in a dose-dependent manner.

CONCLUSIONS

Quercetin attenuates early-stage inflammation in HTG-related AP, probably by reducing IRE1α, sXBP1, C/EBPα and C/EBPβ expression.

Chemometrics strategy coupled with high resolution mass spectrometry for analyzing and interpreting comprehensive metabolomic characterization of hyperlipemia

Hyperlipidemia (HLP) is a metabolic disorder which is characterized by a disturbance in lipid metabolism and is a primary risk factor for cardiovascular disease and atherosclerosis.