Obesity correlates with early hyperglycemia in patients with acute pancreatitis who developed organ failure

TSPO in pancreatic beta cells and its possible involvement in type 2 diabetes

Amyloidosis forms a large family of pathologies associated with amyloid deposit generated by the formation of amyloid fibrils or plaques. The amyloidogenic proteins and peptides involved in these processes are targeted against almost all organs. In brain they are associated with neurodegenerative disease, and the Translocator Protein (TSPO), overexpressed in these inflammatory conditions, is one of the target for the diagnostic. Moreover, TSPO ligands have been described as promising therapeutic drugs for neurodegenerative diseases. Type 2 diabetes, another amyloidosis, is due to a beta cell mass decrease that has been linked to hIAPP (human islet amyloid polypeptide) fibril formation, leading to the reduction of insulin production. In the present study, in a first approach, we link overexpression of TSPO and inflammation in potentially prediabetic patients. In a second approach, we observed that TSPO deficient rats have higher level of insulin secretion in basal conditions and more IAPP fibrils formation compared with wild type animals. In a third approach, we show that diabetogenic conditions also increase TSPO overexpression and IAPP fibril formation in rat beta pancreatic cell line (INS-1E). These data open the way for further studies in the field of type 2 diabetes treatment or prevention.

Elevated serum HbA1c level, rather than previous history of diabetes, predicts the disease severity and clinical outcomes of acute pancreatitis

INTRODUCTION

The aim of our study is to explore the value of serum glycosylated hemoglobin A1c (HbA1c) in disease severity and clinical outcomes of acute pancreatitis (AP).

RESEARCH DESIGN AND METHODS

Patients with AP were included from January 2013 to December 2020, retrospectively, dividing into normal serum HbA1c level (N-HbA1c) group and high serum HbA1c level (H-HbA1c) group according to the criteria HbA1c <6.5%. We compared patient characteristics, biochemical parameters, disease severity, and clinical outcomes of patients with AP in two groups. Besides, we evaluated the efficacy of serum HbA1c to predict organ failure (OF) in AP patients by receiver operating curve (ROC).

RESULTS

We included 441 patients with AP, including 247 patients in N-HbA1c group and 194 patients in H-HbA1c group. Serum HbA1c level was positively correlated with Atlanta classification, systemic inflammatory response syndrome, local complication, and OF (all p<0.05). Ranson, BISAP (bedside index of severity in acute pancreatitis), and CT severity index scores in patients with H-HbA1c were markedly higher than those in patients with N-HbA1c (all p<0.01). ROC showed that the best critical point for predicting the development of OF in AP with serum HbA1c is 7.05% (area under the ROC curve=0.79). Logistic regression analysis showed H-HbA1c was the independent risk factor for the development of OF in AP. Interestingly, in patients with presence history of diabetes and HbA1c <6.5%, the severity of AP was significantly lower than that in H-HbA1c group. Besides, there was no significant difference between with and without history of diabetes in N-HbA1c group.

CONCLUSIONS

Generally known, diabetes is closely related to the development of AP, and strict control of blood glucose can improve the related complications. Thus, the level of glycemic control before the onset of AP (HbA1c as an indicator) is the key to poor prognosis of AP, rather than basic history of diabetes. Elevated serum HbA1c level can become the potential indicator for predicting the disease severity of AP.

Preexisting diabetes, serum calcium and D-dimer levels as predictable risk factors for pancreatic necrosis of patients with acute pancreatitis: a retrospective study

BACKGROUND

Some individuals with acute pancreatitis (AP) suffer from pancreatic necrosis. Diabetes affects the severity of AP, but whether diabetes influences pancreatic necrosis is unclear. This study aims to investigate the clinical characteristics of AP patients with and without diabetes as well as analyze the risk factors of pancreatic necrosis.

RESEARCH DESIGN AND METHODS

A total of 625 AP patients participated in the study. Clinical and laboratory data were retrieved. Multivariate logistic regression analysis was used to identify the risk factors for pancreatic necrosis. ROC curves assess the accuracy of indicators for predicting pancreatic necrosis in AP.

RESULTS

AP patients with diabetes had high BMI, CTSI scores, pancreatitis severity, WBC, neutrophil, CRP, triacylglycerols and glucose levels. Diabetes, serum calcium and D-dimer were independent risk factors for pancreatic necrosis. Pancreatic necrosis in diabetes patients is also associated with sex and age. D-dimer is a better predictor of pancreatic necrosis in AP patients than serum calcium.

CONCLUSIONS

Diabetic patients are more likely to suffer severe AP. Serum calcium and D-dimer are independent predictors for pancreatic necrosis. Furthermore, low serum calcium, high D-dimer levels, younger age and female sex are independent risk factors for pancreatic necrosis in AP patients with diabetes.

Free Fatty Acid Increases the Expression of NLRP3-Caspase1 in Adipose Tissue Macrophages in Obese Severe Acute Pancreatitis

BACKGROUND AND AIMS

Obesity is an important risk factor for severe acute pancreatitis. The necrosis of epididymal adipose tissue occurs in severe acute pancreatitis. Adipose tissue macrophages play an important role in metabolic related inflammation. Therefore, we explored the potential mechanisms between adipose tissue macrophages and obesity-related severe acute pancreatitis.

METHODS

Severe acute pancreatitis mice model was induced by caerulein with lipopolysaccharide. The severity of severe acute pancreatitis was evaluated according to the morphological, general, and biochemical change. We assessed the injury of epididymal white adipose tissue, pancreas, and adipose tissue macrophages in obese mice and lean mice with severe acute pancreatitis. Outcomes of caerulein-induced severe acute pancreatitis were studied in lean and obese mice with or without lipase inhibitor orlistat.

RESULTS

Fat necrosis and pancreatic injury increased in the SAP groups. High levels of serum free fatty acid and triglyceride were increased significantly in the SAP group. The NLRP3-caspase1 inflammasome signal pathway in adipose tissue macrophages markedly enhanced in the SAP groups compared with control group. Free fatty acid can trigger macrophages inflammation through NLRP3-caspase1. Lipase inhibited by orlistat remarkably decreased in adipose tissue necrosis, and the levels of serum lipase, amylase, and pancreatic tissue damage decreased in the orlistat group compared with the SAP group. The NLRP3-caspase1 inflammasome pathway in adipose tissue macrophages markedly decreased in the orlistat groups compared with SAP group. The levels of serum free fatty acid and triglyceride were decreased significantly in the orlistat group.

CONCLUSIONS

Inflammation increases in adipose tissue macrophages of obese mice with severe acute pancreatitis. Free fatty acid generated via adipocyte lipolysis worsens inflammation in adipose tissue macrophages and the outcome of severe acute pancreatitis in obese mice through the NLRP3-caspase1 inflammasome pathway.

Inhibition of Notch activity suppresses hyperglycemia-augmented polarization of macrophages to the M1 phenotype and alleviates acute pancreatitis

Acute pancreatitis (AP) is an acute inflammatory disorder characterized by acinar cell death and inflammation. Multiple factors cause hyperglycemia after AP. Macrophage polarization is involved in tissue injury and repair, and is regulated by Notch signaling during certain inflammatory diseases. The present study explores the relationship among hyperglycemia, macrophage polarization, and Notch signaling during AP and the related mechanisms. A cerulein-induced AP model was established in FVB/N mice, and AP with hyperglycemia was initiated by injection of 50% concentration glucose. Tissue damage, Notch activity, and macrophage polarization were assessed in pancreatic tissues. The role of Notch signaling in macrophage polarization during AP was also assessed in vitro by co-culturing primary macrophages and pancreatic acinar cells, and establishing a lipopolysaccharide (LPS)-induced inflammatory model in RAW264.7 cells. Pancreatic acinar cells were damaged and proinflammatory factor levels were increased in pancreatic tissues during AP. The hyperglycemic conditions aggravated pancreatic injury, increased macrophage infiltration, promoted macrophage polarization towards an M1 phenotype, and led to excessive up-regulation of Notch activity. Inhibition of Notch signaling by DAPT or Notch1 knockdown decreased the proportion of M1 macrophages and reduced the production of proinflammatory factors, thus mitigating pancreatic injury. These findings suggest that hyperglycemia induces excessive Notch signaling after AP and further aggravates AP by promoting pancreatic macrophage polarization towards the M1 phenotype. The Notch signaling pathway is a potential target for the prevention and treatment of AP.

Global Loss of Core 1-Derived O-Glycans in Mice Leads to High Mortality Due to Acute Kidney Failure and Gastric Ulcers

The core 1 structure is the major constituent of mucin-type O-glycans, which are added via glycosylation—a posttranslational modification present on membrane-bound and secretory proteins. Core 1 β1,3-galactosyltransferase (C1galt1), an enzyme that synthesizes the core 1 structure, requires Cosmc, a C1galt1-specific molecular chaperone, for its enzymatic activity. Since Cosmc-knockout mice exhibit embryonic lethality, the biological role of core 1-derived O-glycans in the adult stage is not fully understood. We generated ubiquitous and inducible CAGCre-ER^TM/Cosmc-knockout (iCAG-Cos) mice to investigate the physiological function of core 1-derived O-glycans. The iCAG-Cos mice exhibited a global loss of core 1-derived O-glycans, high mortality, and showed a drastic reduction in weights of the thymus, adipose tissue, and pancreas 10 days after Cosmc deletion. They also exhibited leukocytopenia, thrombocytopenia, severe acute pancreatitis, and atrophy of white and brown adipose tissue, as well as spontaneous gastric ulcers and severe renal dysfunction, which were considered the causes underlying the high mortality of the iCAG-Cos mice. Serological analysis indicated the iCAG-Cos mice have lower blood glucose and total blood protein levels and higher triglyceride, high-density lipoprotein, and total cholesterol levels than the controls. These data demonstrate the importance of core 1-derived O-glycans for homeostatic maintenance in adult mice.

Excess Body Weight and Pancreatic Disease

Background

Excess body weight (EBW) is a risk factor for various acute and chronic conditions. Conversely, the "obesity paradox" suggests a protective effect of higher body weight on some disease outcomes. This article discusses the role of EBW along the disease continuum of pancreatitis and pancreatic cancer (PC) in terms of incidence and outcome.

Summary

Comparison of findings is hampered by the use of different methods to assess EBW. Nevertheless, in acute pancreatitis (AP) and PC, EBW, especially visceral obesity, presents a distinct risk factor and predictor of a negative outcome. Findings of a protective effect likely result from nonconsideration of fat distribution or other confounders. Regarding chronic pancreatitis (CP), few studies indicate lower incidence and a better outcome with higher body mass. However, there is insufficient evidence to confirm the existence of an obesity paradox. The precise mechanisms of how EBW affects the disease continuum require further elucidation but both common and disease-specific effects seem involved.

Key Messages

EBW is associated with higher incidence and a negative outcome in AP and PC. The association with CP is less conclusive. Thus, maintaining normal weight is advisable at any stage of the disease continuum.

Fatal Acute Pancreatitis in an Adolescent: A Case Report

Acute pancreatitis is uncommon in children and adolescents, and when it does occur, it is rarely fatal. The cause of death may be misdiagnosed as a death due to diabetic ketoacidosis or an infectious disease if an autopsy is not performed. Because these deaths are often unexpected and may occur before medical care, the forensic pathologist may be contacted to determine the cause of death. Even deaths that occur after hospitalization may be referred to the medical examiner because of the concern for drug involvement, the unusual age of the decedent, or the decreased availability for a hospital autopsy. We report a fatal case of acute pancreatitis in a 14-year-old adolescent girl who was brought unresponsive to the emergency room of a university hospital and died after unsuccessful resuscitation efforts.

Triglyceride and glucose (TyG) index is an effective biomarker to identify severe acute pancreatitis

BACKGROUND

Early diagnosis of severe acute pancreatitis (AP) is important to reduce morbidity and mortality. We investigated the association between the triglyceride and glucose index (TyG index) and the prognosis of severe AP (SAP).

METHODS

The TyG index was calculated as: ln [fasting triglycerides (mg/dL) x fasting plasma glucose (mg/dL)]/2. Multivariable logistic regression analyses were used to investigate the independent association between the TyG index and the severity of AP.

RESULTS

In this study, 373 patients with AP were recruited from three hospitals. The TyG index was higher in the SAP group than in the non-SAP group. Further, the TyG index was higher than in patients admitted to an intensive care unit and those who died of AP. The TyG index was an independent predictive factor for SAP (odds ratio 7.14, 95% confidence interval 2.80-18.19). The area under the curve increased significantly, from 0.738 to 0.830, after adding the TyG index to a predictive SAP model.

CONCLUSIONS

Our findings suggest that the TyG index is an independent prognostic factor in patients with AP and could be used as a simple prognostic indicator for SAP.

Intensive management of severe acute pancreatitis

To investigate an optimal management bundle to improve the survival rate of severe acute pancreatitis (SAP). We constructed a treatment bundle based on our clinical investigation, literature, and empirical practice. Intensive management during the acute response stage and infection stage comprised eight main issues: etiology, diagnosis, fluid resuscitation, support of organ function, abdominal compartment syndrome (ACS), enteral nutrition, intestinal function, and antibiotics. The intensive management plan included a time-dependent plan for the eight main issues and goal-directed therapy. The plan must be started within the prescribed time (time-dependent endeavors) and must involve the right strategies, right sequence, and right ward for each individual. Effective goal-directed therapy and essential treatment measures must be performed within a specified period of time, and treatment efficacy should be regularly assessed. In 2010, intensive management was initiated in China. Intensive management has significant effects on SAP. This strategy was adopted by 36 hospitals in China, resulting in significant improvements in prognoses. Some criteria of intensive management were adopted by the International Association of Pancreatology (IAP)/American Pancreatic Association Working Group Acute Pancreatitis Guidelines in 2013. Intensive management is an important efficacy-based treatment strategy that can significantly ameliorate prognoses.

Incidence of New Onset Diabetes Mellitus Secondary to Acute Pancreatitis: A Systematic Review and Meta-Analysis

Background and Aims: Patients who have an episode of acute pancreatitis (AP) frequently develop diabetes mellitus (DM) over time. The reported incidence of DM after AP varies depending on the severity, etiology and the extent of pancreatic necrosis during AP. We performed a systematic review to determine the incidence of new-onset DM after AP episode (s), and compared the rate of DM in AP patients based upon different disease characteristics. Methods: A total of 31 relevant studies with 13894 subjects were collected from Medline, Embase, and Web of Science. Stata 15 software was used for data analyses in the meta-analysis. Results: The random-effects pooled incidence was 23.0% for DM (95% CI 16.0-31.0%) and 15.0% (95% CI 9.0-23.0%) for DM treated with insulin. We noted substantial heterogeneity in incidence estimates for DM and DM treated with insulin (I 2 = 95.61 and 71.78%; both p < 0·001). The DM incidence was higher in the populations that had a severe AP (SAP) episode than in those with mild acute pancreatitis (MAP) (39 vs. 14%). Patients that displayed pancreatic necrosis during the AP attack(s) had a higher frequency of DM than those without necrosis (37 vs. 11%). In addition, the pooled incidence of DM was higher after alcoholic compared to biliary AP (28 vs. 12%). The incidence of insulin use after SAP and alcoholic AP was 21 and 18%, respectively, with very low heterogeneities. According to duration of follow-up, the pooled rate of DM and insulin use within 5 years after AP was 20 and 14%, while the rate associated with follow-up duration of more than 5 years was elevated to 37 and 25%, respectively. On meta-regression, year of publication, male proportion, age at DM test, and duration of follow-up were neither positively nor negatively associated with the incidence of DM and DM treated with insulin in patients who had a prior AP attack. Conclusion: Patients with AP developed DM after discharge from hospital with a frequency of about 23%. SAP, alcoholic AP and acute necrotizing pancreatitis (ANP) were associated with increased incidence of DM. Assessments of severity, etiology, and pancreatic necrosis are critical for predicting DM development after AP.

β cells can be generated from cytokeratin 5-positive cells after cerulein-induced pancreatitis in adult mice

Clinical studies have revealed that some patients will develop glucose tolerance dysfunction after recovering from acute pancreatitis (AP), which indicated the importance of investigating the potential therapies for restoration of islet β cell function. Cytokeratin 5 (Krt5)-positive cells are considered to function as stem or progenitor cells in the regeneration of lung and salivary gland following injury. In the present study, AP was induced by six hourly intraperitoneal injections of 100 μg/kg cerulein for 4 consecutive days in adult mice, in order to determine the role of Krt5-positive cells in pancreatic regeneration, especially in the restoration of β cell function and the underlying mechanisms. Results showed that glucose homeostasis were deteriorated partly during the recovery process after AP. Furthermore, clusters of Krt5-positive cells were significantly increased in the damaged pancreas marked by inflammatory cells infiltration and acinar cell eradication. In addition, cells co-labelling insulin and Krt5 were found in the injured region after cerulein administration, part of these cells were immunopositive for GLUT2. Taken together, our data demonstrated that Krt5-expressing cells could be involved in the natural pancreas self-healing process and the renewal of β cells after AP in adult mice. It is promising that promoting conversion of Krt5-expressing cells into functional β cells may be a novel method to mitigate the development of diabetes mellitus after AP in vivo.

Endocrine and exocrine pancreatic insufficiency after acute pancreatitis: long-term follow-up study

BACKGROUND

Patients could develop endocrine and exocrine pancreatic insufficiency after acute pancreatitis (AP), but the morbidity, risk factors and outcome remain unclear. The aim of the present study was to evaluate the incidence of endocrine and exocrine pancreatic insufficiency after AP and the risk factors of endocrine pancreatic insufficiency through a long-term follow-up investigation.

METHODS

Follow-up assessment of the endocrine and exocrine function was conducted for the discharged patients with AP episodes. Oral Glucose Tolerance Test (OGTT) and faecal elastase-1(FE-1) test were used as primary parameters. Fasting blood-glucose (FBG), fasting insulin (FINS), glycosylated hemoglobin HBA1c, 2-h postprandial blood glucose (2hPG), Homa beta cell function index (HOMA-β), homeostasis model assessment of insulin resistance (HOMA-IR) and FE-1 were collected. Abdominal contrast-enhanced computed tomography (CECT) was performed to investigate the pancreatic morphology and the other related data during hospitalization was also collected.

RESULTS

One hundred thirteen patients were included in this study and 34 of whom (30.1%) developed diabetes mellitus (DM), 33 (29.2%) suffered impaired glucose tolerance (IGT). Moreover, 33 patients (29.2%) developed mild to moderate exocrine pancreatic insufficiency with 100μg/g

CONCLUSION

The integrated morbidity of DM and IGT after AP was 59.25%, which was higher than exocrine pancreatic insufficiency. 6.2% and 29.2% of patients developed severe and mild to moderate exocrine pancreatic insufficiency, respectively. The extent of pancreatic necrosis>50%, WON and insulin resistance were the independent risk factors of new onset diabetes after AP.

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Key Words

• Acute pancreatitis
• Endocrine pancreatic insufficiency
• Exocrine pancreatic insufficiency
• Follow-up study
• Insulin resistance
• Pancreatic necrosis

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MESH Headings

• Acute Disease
• Diabetes Complications
• Exocrine Pancreatic Insufficiency/etiology
• Female
• Follow-Up Studies
• Glucose Intolerance/complications
• Humans
• Male
• Middle Aged
• Pancreatitis/complications
• Regression Analysis
• Risk Factors

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Grants

• National Natural Science Foundation of China
• Science and Technology Foundation of Zhejiang Province

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Affiliation(s)

Jianfeng Tu Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Shangtang road 158#, Hangzhou, 310014 China
Jingzhu Zhang Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Lu Ke Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Yue Yang Hangzhou Medical College, Binwen road 481#, Hangzhou, 310053 China
Qi Yang Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Guotao Lu Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Baiqiang Li Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Zhihui Tong Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Weiqin Li Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China
Jieshou Li Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210002 China

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Risk Factors of Hyperglycemia in Patients After a First Episode of Acute Pancreatitis: A Retrospective Cohort

OBJECTIVES

The aim of this study was to evaluate the risk factors for hyperglycemia development after a first episode of acute pancreatitis (AP).

METHODS

Three hundred and ten patients treated for AP were retrospectively evaluated. Hyperglycemia was determined by fasting blood glucose. All data were collected from the medical records room database and a follow-up telephone call.

RESULTS

The incidence rate of hyperglycemia was obviously increased 5 years after the event. Hazard ratios (HRs) of developing hyperglycemia in patients with hyperlipidemia, fatty liver, and hypertension were 2.52 (P < 0.001), 1.87 (P = 0.01), and 1.78 (P = 0.017), respectively. Patients of biliary origin that underwent endoscopic retrograde cholangiopancreatography presented a 4.62-fold greater risk than those managed conservatively. Other risk factors were random blood glucose greater than 8.33 mmol/L (HR, 4.19; P < 0.001), lactate dehydrogenase greater than 350 U/L (HR, 1.99; P = 0.017), calcium less than 1.75 mmol/L (HR, 3.86; P = 0.004), and elevated creatine kinase (HR, 2.74; P = 0.001). Patients with AB blood type showed 2.92-fold greater risk compared with those with O blood type. Among them, hyperlipidemia and hyperglycemia on admission were the only independent risk factors (both P < 0.05).

CONCLUSIONS

Hyperlipidemia, fatty liver, hypertension, endoscopic retrograde cholangiopancreatography treatment, acute hyperglycemia, elevated lactate dehydrogenase and creatine kinase, decreased calcium, and AB blood type were risk factors for hyperglycemia development after AP.

Diabetes increases pancreatic fibrosis during chronic inflammation

Diabetes and fibrosis can be concurrent processes in several diseases such as cystic fibrosis or chronic pancreatitis. To evaluate whether diabetes can influence fibrosis and thus aggravate the pathological process, the progression of chronic pancreatitis was assessed in diabetic and non diabetic mice. For this purpose, insulin producing beta-cells in C57Bl/6J mice were selectively impaired by administration of streptozotocin. Chronic pancreatitis was then induced by repetitive administration of cerulein in normoglycaemic and hyperglycaemic mice. Diabetes caused enhanced collagen I deposition within three weeks of the onset of chronic pancreatitis and increased the proliferation of interstitial cells. This was accompanied by an increased number of interlobular fibroblasts, which expressed S100A4 (fibroblast-specific protein-1) and stimulation of α-smooth muscle actin expression of pancreatic stellate cells. In addition, the observed aggravation of chronic pancreatitis by diabetes also led to a significantly enhanced atrophy of the pancreas, increased infiltration of inflammatory chloracetate esterase positive cells and enhanced acinar cell death. We conclude that diabetes has a detrimental influence on the progression of chronic pancreatitis by aggravating fibrosis, inflammation and pancreatic atrophy.

Diabetes increases pancreatitis induced systemic inflammation but has little effect on inflammation and cell death in the lung

Acute pancreatitis (AP) can lead to a systemic inflammatory response that often results in acute lung injury and single or multiple organ failure. In a previous study we demonstrated that diabetes aggravates the local pathophysiological process during AP. In this study we explore, if diabetes also increases pancreatitis induced systemic inflammation and causes lung injury. Acute pancreatitis was induced in untreated and streptozotocin-treated diabetic mice by injection of cerulein. Systemic inflammation was studied by IL-6 ELISA in blood plasma and white blood cell count. Lung inflammation and lung injury were quantified by chloroacetate esterase staining, evaluation of the alveolar cellularity index and cleaved caspase-3 immunohistochemistry. In normoglycaemic mice AP increased the IL-6 concentration in plasma and caused lymphocytopenia. Diabetes significantly increased the IL-6 concentration in plasma and further reduced the number of lymphocytes during AP, whereas diabetes had little effect on these parameters in the absence of pancreatitis. However, diabetes only marginally increased lung inflammation and did not lead to cell death of the lung epithelium during AP. We conclude that diabetes increases parameters of systemic inflammation during AP, but that this increase is insufficient to cause lung injury.

The clinical relevance of obesity in acute pancreatitis: targeted systematic reviews

BACKGROUND

With the rising prevalence of obesity, its impact on the severity and outcome of acute pancreatitis remains an important consideration when managing obese patients with acute pancreatitis.

OBJECTIVE

To determine the clinical relevance of obesity in acute pancreatitis.

METHODS

A series of clinically relevant questions were framed which formed the basis of our literature search using PubMed and EMBASE databases. These related to acute pancreatitis severity, systemic inflammatory response, mortality, local and systemic complications. The search was restricted to human studies. Studies were classified according to the Oxford Centre for Evidence Based Medicine levels of evidence 1 for prognostic studies. Obesity was defined according to the guidelines of the World Health Organization. In keeping with studies included the binary classification (mild and severe) of acute pancreatitis was used.

RESULTS

Obesity is associated with an amplified systemic inflammatory response in acute pancreatitis and is a prognostic factor for mortality, local, systemic complications and severity in acute pancreatitis. Obesity was not found to be an independent prognostic factor for mortality and organ failure in patients with acute pancreatitis. It was evident that further studies are required to determine whether incorporating obesity into existing scoring systems improves severity prediction. Emerging evidence suggests that an obesity paradox is present in patients with acute pancreatitis.

CONCLUSION

This review demonstrates that obesity has a clinically relevant impact on the course and outcome of acute pancreatitis.

Insulin protects pancreatic acinar cells from palmitoleic acid-induced cellular injury

Acute pancreatitis is a serious and sometimes fatal inflammatory disease where the pancreas digests itself. The non-oxidative ethanol metabolites palmitoleic acid (POA) and POA-ethylester (POAEE) are reported to induce pancreatitis caused by impaired mitochondrial metabolism, cytosolic Ca²⁺ ([Ca²⁺]_i) overload and necrosis of pancreatic acinar cells. Metabolism and [Ca²⁺]_i are linked critically by the ATP-driven plasma membrane Ca²⁺-ATPase (PMCA) important for maintaining low resting [Ca²⁺]_i. The aim of the current study was to test the protective effects of insulin on cellular injury induced by the pancreatitis-inducing agents, ethanol, POA, and POAEE. Rat pancreatic acinar cells were isolated by collagenase digestion and [Ca²⁺]_i was measured by fura-2 imaging. An in situ [Ca²⁺]_i clearance assay was used to assess PMCA activity. Magnesium green (MgGreen) and a luciferase-based ATP kit were used to assess cellular ATP depletion. Ethanol (100 mm) and POAEE (100 μm) induced a small but irreversible Ca²⁺ overload response but had no significant effect on PMCA activity. POA (50–100 μm) induced a robust Ca²⁺ overload, ATP depletion, inhibited PMCA activity, and consequently induced necrosis. Insulin pretreatment (100 nm for 30 min) prevented the POA-induced Ca²⁺ overload, ATP depletion, inhibition of the PMCA, and necrosis. Moreover, the insulin-mediated protection of the POA-induced Ca²⁺ overload was partially prevented by the phosphoinositide-3-kinase (PI3K) inhibitor, LY294002. These data provide the first evidence that insulin directly protects pancreatic acinar cell injury induced by bona fide pancreatitis-inducing agents, such as POA. This may have important therapeutic implications for the treatment of pancreatitis.

Newly diagnosed diabetes mellitus after acute pancreatitis: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) is common in the general population and it poses a heavy burden to society in the form of long-term disability, healthcare use and costs. The pancreas is a key player in glucose homeostasis, but the occurrence of newly diagnosed DM after acute pancreatitis (AP), the most frequent disease of the pancreas, has never been assessed systematically. The aim of this study was to conduct a systematic literature review to determine the prevalence and time course of DM and related conditions after the first attack of AP as well as the impact of covariates.

METHODS

Relevant literature cited in three electronic databases (Scopus, EMBASE and MEDLINE) was reviewed independently by two authors. The main outcome measures studied were newly diagnosed prediabetes, DM, or DM treated with insulin. Pooled prevalence and 95% CIs were calculated for all outcomes.

RESULTS

A total of 24 prospective clinical studies, involving 1102 patients with first episode of AP, met all the eligibility criteria. Prediabetes and/or DM was observed in 37% (95% CI 30% to 45%) individuals after AP. The pooled prevalence of prediabetes, DM and treatment with insulin after AP was 16% (95% CI 9% to 24%), 23% (95% CI 16% to 31%), and 15% (95% CI 9% to 21%), respectively. Newly diagnosed DM developed in 15% of individuals within 12 months after first episode of AP and the risk increased significantly at 5 years (relative risk 2.7 (95% CI 1.9 to 3.8)). A similar trend was observed with regard to treatment with insulin. The severity of AP, its aetiology, individuals' age and gender had minimal effect on the studied outcomes.

CONCLUSIONS

Patients with AP often develop prediabetes and/or DM after discharge from hospital, and have a greater than twofold increased risk of DM over 5 years. Further studies are warranted to determine the optimal strategy for its detection and whether the risk of developing DM after AP can be reduced.

An increased level of haemoglobin A1C predicts a poorer clinical outcome in patients with acute pancreatitis

OBJECTIVE

To compare the clinical features of acute pancreatitis (AP) in patients with and without diabetes.

DESIGN, PATIENTS AND MEASUREMENTS

We retrospectively collected 318 patients with AP in two clinical centres from January 2009 to October 2010. Patients with a previous history of diabetes or with glycosylated haemoglobin A1c (HbA1c) higher than 6·5% were identified as having acute pancreatitis with diabetes (APD), while patients without a history of diabetes and in whom the HbA1c was not higher than 6·5% were considered as AP only. The clinical characteristics and prognosis data of these patients were analysed. Survival curves were plotted according to the Kaplan-Meier method. Cox proportional hazard regression was used to test the association between the clinical prognostic factors and mortality in patients with AP.

RESULTS

In total, 318 patients with AP were enrolled. Among them, 40 had APD and 278 had AP; thus, in this study, the prevalence of diabetes in AP was 12·6% (40/318). Twenty-five per cent (10/40) of the APD cases were indentified using HbA1c. The mortality rate was significantly higher in the APD group (15·0%, 6/40) than that in the AP group (1·1%, 3/278). Survival curves showed that there was a significant survival difference between the APD group and AP group via the log-rank test. Multivariate Cox regression analysis showed that sex, age, diastolic blood pressure, body mass index (BMI) and C-peptide were significantly associated with mortality. Compared with AP patients, subjects with APD had significantly longer time from initial symptoms to admission [1·6 (95% CI: 0·5-3·2) vs 0·9 (95% CI: 0·1-2·2) days], older age of onset (57·2 ± 11·0 vs 44·3 ± 7·8 years), higher levels of glucose (13·9 ± 8·2 vs 7·3 ± 4·1 mm), higher levels of HbA1c [8·5 (95% CI: 6·6-11·4)%vs 5·9 (95% CI: 4·9-6·4)%], lower levels of C-peptide (0·882 ± 0·337 vs 2·621 ± 0·526 ng/ml) and longer duration of hospitalization (18·3 ± 4·6 vs 13·2 ± 5·1 day). Electrocardiograms showed that APD patients had a significantly higher risk of heart ischaemia than AP patients (22/40 vs 20/278).

CONCLUSIONS

HbA1c may be a useful marker to identify unrecognised diabetes in patients with acute pancreatitis; this group of patients has a higher in hospital mortality.

Diabetes aggravates acute pancreatitis and inhibits pancreas regeneration in mice

AIMS/HYPOTHESIS

It is well established that acute pancreatitis often causes diabetes and that a high blood glucose level associated with pancreatitis is a marker of poor prognosis. The aim of this study was to evaluate if diabetes merely reflects the severity of pancreatitis or whether it can also aggravate the progression of this disease in a vicious circle.

METHODS

Reversible acute oedematous pancreatitis was induced in untreated and streptozotocin-treated diabetic mice by injection of cerulein. Progression of pancreatitis was studied by immunohistochemistry, ELISA and various other enzyme assays. The production of regenerating islet-derived 3β (REG3β) was determined by western blot and immunohistochemistry.

RESULTS

While cerulein treatment in non-diabetic mice resulted in acute pancreatitis followed by regeneration of the pancreas within 7 days, diabetes aggravated pancreatitis, inhibited the regeneration of the exocrine tissue and led to strong atrophy of the pancreas. The aggravation of pancreatitis by diabetes was characterised by decreased production of the anti-inflammatory protein REG3β, increased inflammation, augmented oedema formation and increased cell death during the acute phase of pancreatitis (p < 0.05). During the regenerative phase, diabetes augmented inflammation, increased cell death, reduced acinar cell expansion and increased the expansion of duct as well as interstitial cells, resulting in the formation of tubular complexes (p < 0.05). Administration of insulin reversed the observed phenotype in diabetic mice.

CONCLUSIONS/INTERPRETATION

Diabetes aggravates acute pancreatitis and suppresses regeneration of the exocrine tissue. Thus, diabetes is not just a concomitant phenomenon of pancreatitis, but can have a fundamental influence on the progression of acute pancreatitis.

The complex exocrine-endocrine relationship and secondary diabetes in exocrine pancreatic disorders

The pancreas is a dual organ with exocrine and endocrine functions. The interrelationship of the endocrine-exocrine parts of the pancreas is a complex one, but recent clinical and experimental studies have expanded our knowledge. Many disorders primarily of the exocrine pancreas, often solely in the clinical realm of gastroenterologists are associated with diabetes mellitus (DM). Although, the DM becoming disorders are often grouped with type 2 diabetes, the pathogenesis, clinical manifestations and management differ. We review here data on the association of exocrine-endocrine pancreas, the many hormones of the pancreas and their possible effects on the exocrine functions followed by data on the epidemiology, pathogenesis, and management of DM in chronic pancreatitis, cystic fibrosis, pancreatic cancer, and clinical states after pancreatic surgery.

Hyperglycemia and diabetes mellitus in children with pancreatitis

OBJECTIVE

To assess the risk factors for developing hyperglycemia and diabetes mellitus (DM) in children with pancreatitis.

STUDY DESIGN

Patients (from infants to age 21 years) hospitalized with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis were studied retrospectively. Subjects with known DM or cystic fibrosis before presentation with pancreatitis were excluded.

RESULTS

A total of 176 patients met the study criteria. Of these, 140 had AP, 29 had ARP, and 7 had chronic pancreatitis. Severe pancreatitis was associated with hyperglycemia; 41% of the patients with hyperglycemia required insulin, and 8 patients (4.5%) developed DM requiring insulin by the time of discharge. These 8 patients with postpancreatitis DM were more likely to be overweight. Five of the 8 patients had a seizure disorder, and 4 had another comorbidity, such as mental retardation or cerebral palsy. Seven of the 8 patients who developed DM had a single episode of AP, and one patient had ARP.

CONCLUSIONS

Our findings indicate that hyperglycemia and DM can occur with pancreatitis. In some cases, postpancreatitis DM was associated with mental retardation, seizure disorder, and use of antiseizure medication. As opposed to adults who develop DM after chronic pancreatitis, children can develop DM due to a single episode of AP.

Simplified Early Predictors of Severe Acute Pancreatitis: A Prospective Study

Background

To propose simple tests for the prediction of severe acute pancreatitis (SAP), which are accurate and could be performed at emergency departments and outpatient clinics.

Methods

A prospective study was performed on 149 patients admitted with acute pancreatitis. Body mass index (BMI), plain chest radiograph, blood biochemical data were obtained at the time of admission; white cell, lymphocyte and platelet counts, hematocrit level, prothrombin time, PaO₂, creatinine, calcium, blood sugar, total protein, aspartate aminotransferase, total bilirubin, amylase, lipase and C-reaction protein were determined. Patients were graded into severe and mild acute pancreatitis based on CT Balthazar grading system.

Results

Twenty-seven patients were diagnosed to have SAP and 122 patients considered mild acute pancreatitis. Comparing parameters between both groups; significant factors (P < 0.05) were blood sugar level, haematocrit level, BMI and presence of pleural effusion in chest X-ray. The hematocrit at admission and at approximately 24 hours was significantly higher among patients with SAP. Twenty-two of 27 cases of severe disease and only 10 of 122 cases of mild acute pancreatitis diagnosed to have pleural effusion (P < 0.001).

Conclusion

BMI, blood glucose ≥ 190 mg/dL, hematocrit level ≥ 43 % and pleural effusion detected by plain chest radiograph are simple tests and provide significant predictive power for clinical decision-making.