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Finkenstedt A, Joannidis M. [Management of acute pancreatitis in the emergency department and the intensive care unit]. DIE ANAESTHESIOLOGIE 2024; 73:490-498. [PMID: 38884779 DOI: 10.1007/s00101-024-01431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.
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Affiliation(s)
- Armin Finkenstedt
- Gemeinsame Einrichtung für Internistische Notfall- und Intensivmedizin, Department für Innere Medizin, Landeskrankenhaus Innsbruck, Innsbruck, Österreich.
| | - Michael Joannidis
- Gemeinsame Einrichtung für Internistische Notfall- und Intensivmedizin, Department für Innere Medizin, Landeskrankenhaus Innsbruck, Innsbruck, Österreich
- Universitätsklinik für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Liu Y, Cheng JP, Zhao XL. The effect of serum triglyceride levels and different lipid-lowering methods on the prognosis of hypertriglyceridemic acute pancreatitis: a single-center 12-year retrospective study by propensity score matching. Scand J Gastroenterol 2024; 59:843-851. [PMID: 38625376 DOI: 10.1080/00365521.2024.2342406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/06/2024] [Indexed: 04/17/2024]
Abstract
AIM To investigate the impact of triglyceride on hypertriglyceridemic acute pancreatitis (HTG-AP) and different lipid-lowering methods on triglyceride-lowering efficiency and HTG-AP. METHODS The patients with HTG-AP from January 2012 to December 2023 in Civil Aviation General Hospital were analyzed, retrospectively. Patients were divided and compared according to whether their triglycerides were below 5.56 mmol/L at 48 and 72 h of admission. The patients were divided into control group, insulin group, and low molecular weight heparin (LMWH)+bezafibrate group based on the different methods of lipid-lowering. Propensity score matching (PSM) was employed to balance the baseline characteristics. RESULTS There was no correlation between the severity of HTG-AP and the triglyceride at admission. The incidence of severity, local complications, and persistent organ failure (POF) were significantly decreased in patients with 48-h and 72-h triglyceride attainment. Following PSM, the incidence of infectious pancreatic necrosis (IPN) (3.3% vs. 13.3%) was significantly reduced in insulin group compared with control group (p < .05). Compared with control group, LMWH + bezafibrate group had higher lipid reduction efficiency, and the incidence of IPN (0.9% vs. 10.1%) and POF (8.3% vs. 19.3%) was significantly decreased (p < .05). There was no significant difference in the efficiency of lipid-lowering, complications, and POF between LMWH + bezafibrate group and insulin group (p > .05). CONCLUSION The severity of HTG-AP is not associated with the triglyceride levels at admission. However, rapid reduction of triglyceride levels can lower the incidence of local complications and respiratory failure. Compared with conservative treatment, insulin and LMWH + bezafibrate can both reduce the incidence of IPN in patients with HTG-AP.
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Affiliation(s)
- Yang Liu
- Department of Gastroenterology, Civil Aviation General Hospital, School of Civil Aviation Clinical Medicine, Peking University, Beijing, China
| | - Jian-Ping Cheng
- Department of Gastroenterology, Civil Aviation General Hospital, School of Civil Aviation Clinical Medicine, Peking University, Beijing, China
| | - Xiao-Lin Zhao
- Department of Gastroenterology, Civil Aviation General Hospital, School of Civil Aviation Clinical Medicine, Peking University, Beijing, China
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Hussein EA. Factors affecting clinical outcomes of continuous and intermittent plasmapheresis in patients with severe hypertriglyceridemia. Ther Apher Dial 2024. [PMID: 38676441 DOI: 10.1111/1744-9987.14134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/08/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Acute hypertriglyceridemia is considered a category III indication for plasmapheresis. The use of plasma as replacement fluid (RF) has been suggested to replace the consumed lipoprotein lipase. Heparin when used as an anticoagulant could possibly release lipoprotein lipase, thereby increasing triglyceride clearance. METHODS The impact of RF (albumin vs fresh frozen plasma (FFP) and anticoagulant (ACD-A vs. heparin) on triglycerides following plasmapheresis in 27 patients with severe hypertriglyceridemia (SHTG) was investigated. A paired study of four patients with recurrent SHTG was conducted, evaluating continuous (Optia) versus intermittent flow plasmapheresis (Haemonetics). RESULTS Shorter procedures positively impacted triglycerides (TG) drop post-sessions p < 0.05. In albumin sessions, patients who used heparin demonstrated significantly greater drop in TG and required less sessions than did those with citrate p < 0.05. In heparin sessions, patients who used albumin demonstrated significantly greater drop in triglycerides and required less sessions than did those with FFP p < 0.05. Three of six patients who used FFP and heparin showed a triglyceride drop of 11.7% following three sessions and a 50% drop with one albumin session. Compared with Haemonetics, Optia removed comparable volumes of plasma in less time, processing smaller blood volumes and using less citrate p < 0.05. Patients demonstrated significantly lower drop in TG and required more sessions with Haemonetics than they did with Optia p < 0.05. CONCLUSION Shorter procedure was the main predictor for effective TG clearance. This can be achieved by continuous apheresis technology, particularly when using albumin as RF. TG removal via Optia seems to be optimized by using heparin.
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Affiliation(s)
- Eiman A Hussein
- Department of Clinical and Chemical Pathology, Division of Transfusion Medicine, Apheresis unit of Kasr Alainy Blood Bank, Faculty of Medicine, Cairo University, Cairo, Egypt
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Finkenstedt A, Joannidis M. [Management of acute pancreatitis in the emergency department and the intensive care unit]. Med Klin Intensivmed Notfmed 2024; 119:156-164. [PMID: 38285193 DOI: 10.1007/s00063-023-01104-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/05/2023] [Accepted: 11/06/2023] [Indexed: 01/30/2024]
Abstract
Acute pancreatitis is a gastrointestinal emergency where diagnosis is based on typical symptoms, increased serum lipase concentration, and abdominal imaging. Local complications and organ failure in severe acute pancreatitis regularly necessitate treatment in the intensive care unit and are associated with increased mortality rates. Only optimal interdisciplinary treatment can improve the prognosis of patients with severe acute pancreatitis. This article gives guidance on the initial diagnostic and etiological examinations as well as on the evaluation of organ failure and the severity assessment according to common classification systems. Furthermore, the endoscopic management of biliary pancreatitis and infected necrosis is discussed and the basics of targeted volume therapy, nutrition, and indications for antibiotic treatment are reviewed.
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Affiliation(s)
- Armin Finkenstedt
- Gemeinsame Einrichtung für Internistische Notfall- und Intensivmedizin, Department für Innere Medizin, Landeskrankenhaus Innsbruck, Innsbruck, Österreich.
| | - Michael Joannidis
- Gemeinsame Einrichtung für Internistische Notfall- und Intensivmedizin, Department für Innere Medizin, Landeskrankenhaus Innsbruck, Innsbruck, Österreich
- Universitätsklinik für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Danielewski M, Rapak A, Kruszyńska A, Małodobra-Mazur M, Oleszkiewicz P, Dzimira S, Kucharska AZ, Słupski W, Matuszewska A, Nowak B, Szeląg A, Piórecki N, Zaleska-Dorobisz U, Sozański T. Cornelian Cherry ( Cornus mas L.) Fruit Extract Lowers SREBP-1c and C/EBPα in Liver and Alters Various PPAR-α, PPAR-γ, LXR-α Target Genes in Cholesterol-Rich Diet Rabbit Model. Int J Mol Sci 2024; 25:1199. [PMID: 38256272 PMCID: PMC10816641 DOI: 10.3390/ijms25021199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Cornelian cherry (Cornus mas L.) fruits, abundant in iridoids and anthocyanins, are natural products with proven beneficial impacts on the functions of the cardiovascular system and the liver. This study aims to assess and compare whether and to what extent two different doses of resin-purified cornelian cherry extract (10 mg/kg b.w. or 50 mg/kg b.w.) applied in a cholesterol-rich diet rabbit model affect the levels of sterol regulatory element-binding protein 1c (SREBP-1c) and CCAAT/enhancer binding protein α (C/EBPα), and various liver X receptor-α (LXR-α), peroxisome proliferator-activated receptor-α (PPAR-α), and peroxisome proliferator-activated receptor-γ (PPAR-γ) target genes. Moreover, the aim is to evaluate the resistive index (RI) of common carotid arteries (CCAs) and aortas, and histopathological changes in CCAs. For this purpose, the levels of SREBP-1c, C/EBPα, ATP-binding cassette transporter A1 (ABCA1), ATP-binding cassette transporter G1 (ABCG1), fatty acid synthase (FAS), endothelial lipase (LIPG), carnitine palmitoyltransferase 1A (CPT1A), and adiponectin receptor 2 (AdipoR2) in liver tissue were measured. Also, the levels of lipoprotein lipase (LPL), visceral adipose tissue-derived serine protease inhibitor (Vaspin), and retinol-binding protein 4 (RBP4) in visceral adipose tissue were measured. The RI of CCAs and aortas, and histopathological changes in CCAs, were indicated. The oral administration of the cornelian cherry extract decreased the SREBP-1c and C/EBPα in both doses. The dose of 10 mg/kg b.w. increased ABCA1 and decreased FAS, CPT1A, and RBP4, and the dose of 50 mg/kg b.w. enhanced ABCG1 and AdipoR2. Mitigations in atheromatous changes in rabbits' CCAs were also observed. The obtained outcomes were compared to the results of our previous works. The beneficial results confirm that cornelian cherry fruit extract may constitute a potentially effective product in the prevention and treatment of obesity-related disorders.
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Affiliation(s)
- Maciej Danielewski
- Department of Pharmacology, Wroclaw Medical University, J. Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland; (W.S.); (A.M.); (B.N.); (A.S.)
| | - Andrzej Rapak
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigla 12, 53-114 Wroclaw, Poland; (A.R.); (A.K.)
| | - Angelika Kruszyńska
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigla 12, 53-114 Wroclaw, Poland; (A.R.); (A.K.)
| | - Małgorzata Małodobra-Mazur
- Department of Forensic Medicine, Division of Molecular Techniques, Wroclaw Medical University, M. Sklodowskiej-Curie 52, 50-369 Wroclaw, Poland;
| | - Paweł Oleszkiewicz
- Department of Radiology and Imaging Diagnostics II, Lower Silesian Center of Oncology, Pulmonology and Hematology, Grabiszynska 105, 53-439 Wroclaw, Poland;
| | - Stanisław Dzimira
- Department of Pathology, Wroclaw University of Environmental and Life Sciences, C. K. Norwida 31, 50-375 Wroclaw, Poland;
| | - Alicja Z. Kucharska
- Department of Fruit, Vegetable, and Plant Nutraceutical Technology, Wroclaw University of Environmental and Life Sciences, J. Chelmonskiego 37, 51-630 Wroclaw, Poland;
| | - Wojciech Słupski
- Department of Pharmacology, Wroclaw Medical University, J. Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland; (W.S.); (A.M.); (B.N.); (A.S.)
| | - Agnieszka Matuszewska
- Department of Pharmacology, Wroclaw Medical University, J. Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland; (W.S.); (A.M.); (B.N.); (A.S.)
| | - Beata Nowak
- Department of Pharmacology, Wroclaw Medical University, J. Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland; (W.S.); (A.M.); (B.N.); (A.S.)
| | - Adam Szeląg
- Department of Pharmacology, Wroclaw Medical University, J. Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland; (W.S.); (A.M.); (B.N.); (A.S.)
| | - Narcyz Piórecki
- Bolestraszyce Arboretum and Institute of Physiography, Bolestraszyce 130, 37-722 Wyszatyce, Poland;
- Institute of Physical Culture Sciences, Medical College, University of Rzeszow, Cicha 2A, 35-326 Rzeszow, Poland
| | - Urszula Zaleska-Dorobisz
- Department of General and Pediatric Radiology, Wroclaw Medical University, M. Sklodowskiej-Curie 50/52, 50-369 Wroclaw, Poland;
| | - Tomasz Sozański
- Department of Preclinical Sciences, Pharmacology and Medical Diagnostics, Faculty of Medicine, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370 Wroclaw, Poland;
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Majumdar SK. Triglyceride Clearance in Hypertriglyceridemic Pancreatitis: Time Course and Its Implications for Management. Endocr Pract 2023; 29:971-979. [PMID: 37714331 DOI: 10.1016/j.eprac.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
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.
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Affiliation(s)
- Sachin K Majumdar
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut; Departments of Endocrinology and Internal Medicine, Bridgeport Hospital, Yale New Haven Health System, Bridgeport, Connecticut.
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Cao W, Ni X, Gan M, Xie B, Xie Y, Wang Q, Meng L, He C, Chen J, Wang X. Treatment and diagnosis of hyperlipidemia acute pancreatitis in pregnancy associated with pre‑pregnancy obesity and diabetes: A case report. Exp Ther Med 2023; 26:573. [PMID: 38023361 PMCID: PMC10652241 DOI: 10.3892/etm.2023.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023] Open
Abstract
Hyperlipidemia acute pancreatitis (HLAP) is a specific type of pancreatitis mainly caused by elevated serum triglyceride (TG) levels. Therefore, knowledge of patients' medical history is crucial to the identification of those at high risk of HLAP. Diabetes and obesity are associated with high levels of triglycerides, a risk factor for the development of HLAP, which should be controlled before pregnancy. Moreover, HLAP is associated with additional diagnostic and management challenges related to hyperlipidemia (HL) and pregnancy. HLAP during pregnancy has a rapid onset and rapid progression, and complications are more likely to damage the function of multiple organs. HLAP is more common after 28 weeks of pregnancy, the cause is mostly high TG and the serum TG of the patient is often >1,000 mg/d1. Clinicians should be alert to the occurrence of server acute pancreatitis (AP). Therefore, clinicians need to identify and implement effective treatment in a timely manner to control the progression of HLAP during pregnancy and improve pregnancy outcomes. The present study reported the case of a 26-year-old pregnant patient who was hospitalized for epigastric pain at 35 weeks and 2 days of gestation. Medical and family history reported previous diagnoses of diabetes and obesity (weight before pregnancy, 103 kg; BMI, 36.40 kg/m2). Laboratory tests demonstrated high levels of lipase and amylase, a notable systemic inflammatory response, HL, coagulopathy, hypoproteinemia and hyperglycemia. Abdominal ultrasonography demonstrated a hypoechoic pancreatic head. A clinical diagnosis of AP was confirmed using CT scanning. Initial interventions for HLAP included aggressive intravenous hydration, bowel rest, pain control and a combination of heparin and insulin. Lipid-lowering agents were administered to reduce serum lipid levels. Hemoperfusion and continuous renal replacement therapy were also used to rapidly counteract the elevated lipid levels. Antibiotics were administered in the present case because inflammatory markers such as leukocytes, neutrophils and C-reactive protein were elevated. The patient and newborn were discharged 11 days after hospitalization, with an improvement in maternal clinical health and the infant was healthy. When evaluating pregnant patients with pre-obesity and diabetes presenting with abdominal pain, obstetricians should consider HLAP. Timely diagnosis and multi-team precision treatment are effective for good outcomes for mother and baby.
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Affiliation(s)
- Weiping Cao
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Xia Ni
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Mengwen Gan
- Department of Nursing, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Bing Xie
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Yurong Xie
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Qin Wang
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Lishi Meng
- Department of Computed Tomography, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Chao He
- Central Laboratory of Medicine, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Juan Chen
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
- Department of Obstetrics, Shanghai Changning District Maternal and Children Health Hospital, Shanghai 200050, P.R. China
| | - Xinzhi Wang
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, Jiangsu 210009, P.R. China
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Wang J, Xia Y, Cao Y, Cai X, Jiang S, Liao Y, Shi M, Luo H, Wang D. Evaluating the efficacy and timing of blood purification modalities in early-stage hyperlipidemic acute pancreatitis treatment. Lipids Health Dis 2023; 22:208. [PMID: 38031159 PMCID: PMC10685498 DOI: 10.1186/s12944-023-01968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023] Open
Abstract
Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is characterized by a violent cytokine storm-driven inflammation and is associated with a predisposition to severe disease. The treatment strategy for HTG-AP consists mainly of conventional symptomatic and lipid-lowering treatments. For early-stage HTG-AP, blood purification (BP) can rapidly and effectively reduce serum triglyceride and inflammatory cytokine levels, block the development of systemic inflammatory response syndrome, and improve patient outcomes. Currently, the primary modalities for BP in patients with HTG-AP include plasma exchange, hemoperfusion, and hemofiltration. When using BP to treat patients with HTG-AP, a comprehensive analysis incorporating the elevated lipid levels and severity of the patient's condition contributes to the selection of different treatment modes. Moreover, the timing of the treatment is also imperative. Early intervention is associated with a better prognosis for patients with HTG-AP requiring lipid-lowering treatment.
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Affiliation(s)
- Jianjun Wang
- Department of Hepatobiliary Surgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yang Xia
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yuan Cao
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Xianfu Cai
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Shichun Jiang
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yougang Liao
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Mingsong Shi
- Nuclear Medicine Laboratory, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Huiwen Luo
- Nuclear Medicine Laboratory, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China.
| | - Decai Wang
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China.
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Anbessie ZM, Gebremeskel YB. Hypertriglyceridemic pancreatitis managed with heparin and insulin: a case report. J Med Case Rep 2023; 17:256. [PMID: 37337255 DOI: 10.1186/s13256-023-03995-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/21/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Alcohol and gall stones are common causes of pancreatitis. Other causes of pancreatitis include hypertriglyceridemia, trauma, congenital anomalies, and medications. Hypertriglyceridemic pancreatitis is distinguished, as it is more severe and complicated. The management of hypertriglyceridemic pancreatitis, other than the basic care given to other pancreatitis patients, is to decrease the serum triglyceride level to less than 500 mg/dl as soon as possible. Plasmapheresis, hemofiltration, and other modalities have been proven effective therapies, but, are expensive and not easily accessible. Insulin and heparin which are cheaper alternatives for treatment, have been reported in case reports along with one randomized controlled trial. The number of patients in these reports was small, so, the therapy is not well established. For most African countries like ours, the only option for management is heparin and insulin. Despite this fact, there has not been any publication regarding this issue on our continent. CASE REPORT We report the case of a 24 years old Ethiopian male who presented with severe central abdominal pain, easy fatiguability, and vomiting of one-day duration. He was tachycardic and tachypneic with diffuse abdominal tenderness, and had tendon xanthomas. His plasma was lactescent with a serum triglyceride level of 4775 mg/dl. His abdominal CT scan showed diffuse pancreatic swelling with a peripancreatic fluid collection, and his serum lipase was elevated. With a diagnosis of hypertriglyceridemic pancreatitis, he was managed with intravenous insulin infusion along with subcutaneous heparin. His random blood sugar was checked hourly with three episodes of hypoglycemia during therapy. His serum triglyceride level dropped to less than 500 mg/dl in three days, and he was discharged with no complications. CONCLUSION Since our findings are consistent with a prior randomized controlled trial and compilation of case reports, it would strengthen the evidence for safety and efficacy of insulin and heparin therapy. This therapy, which is the only available therapy in most countries of our continent, would decrease most of the complications of hypertriglyceridemic pancreatitis that we face. We believe, our report would be a wake-up call for researchers and clinicians in our continent to change their practice and strengthen the evidence for the treatment.
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Perez V, Faust AC, Taburyanskaya M, Patil RA, Ortegon A. Effectiveness of an Intravenous Insulin-Based Treatment Protocol for the Management of Hypertriglyceridemia-Associated Acute Pancreatitis. J Pharm Technol 2023; 39:55-61. [PMID: 37051280 PMCID: PMC10084412 DOI: 10.1177/87551225231151570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Background There is burgeoning interest in intravenous insulin for hypertriglyceridemia-induced acute pancreatitis (HTG-AP) as a less invasive alternative to plasmapheresis; however, there are few published descriptions of disease-specific insulin protocols. Objective To compare the efficacy and safety of an insulin infusion-based protocol with nonstandardized medical therapy for HTG-AP. Methods This is a retrospective analysis before and after creation of an HTG-AP-specific insulin infusion treatment protocol. Inclusion criteria were age ≥18 years, an initial triglyceride level >1000 mg/dL, and a diagnosis of AP. The primary outcome of the study was time to a triglyceride level ≤1000 mg/dL. Results Sixty-seven patients were included in this study (26 pre-protocol and 41 in the HTG-AP insulin protocol group). Baseline characteristics between the groups were similar, with median initial triglyceride levels >3500 mg/dL. There was a trend toward patients treated with the HTG-AP-specific infusion reaching a triglyceride level ≤1000 mg/dL faster (43.3 [24.9-72.1] vs 26.9 [17.7-51.1] hours; P = 0.07). Those treated to ≤500 mg/dL achieved this faster with the disease-specific infusion (49.2 [29.4-67.8] vs 70.9 [36.3-107.2] hours, P = 0.04). Hypoglycemia was numerically lower in the HTG-AP-specific insulin infusion group despite higher insulin infusion rates (7.3% vs 19.2%). No patient in the HTG-AP-specific protocol group required plasmapheresis. Conclusions The use of an HTG-AP-specific insulin infusion protocol, compared with antecedent nonstandardized care, resulted in prompter achievement of a triglyceride level ≤500 mg/dL and a strong trend toward faster achievement of ≤1000 mg/dL without an increased risk of hypoglycemia. While intravenous insulin may be considered the initial medical therapy for HTG-AP, further studies are needed to determine the optimal dosing.
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Affiliation(s)
- Valeria Perez
- Department of Pharmacy, Texas Health
Presbyterian Hospital Dallas, Dallas, TX, USA
- School of Pharmacy, Texas Tech
University Health Sciences Center, Dallas, TX, USA
| | - Andrew C. Faust
- Department of Pharmacy, Texas Health
Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | | | - Anthony Ortegon
- Sound Physicians Pulmonary Critical
Care/Southwest Pulmonary Associates, Dallas, TX, USA
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Hidalgo NJ, Pando E, Alberti P, Mata R, Fernandes N, Adell M, Villasante S, Blanco L, Balsells J, Charco R. The role of high serum triglyceride levels on pancreatic necrosis development and related complications. BMC Gastroenterol 2023; 23:51. [PMID: 36829113 PMCID: PMC9955530 DOI: 10.1186/s12876-023-02684-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis. METHODS We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150-199 mg/dL), High TG (200-499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis. RESULTS A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis (OR: 3.27, 95% CI - 6.27, p < 0.001). CONCLUSIONS An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.
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Affiliation(s)
- Nils Jimmy Hidalgo
- grid.7080.f0000 0001 2296 0625Universitat Autonoma de Barcelona, Bellaterra, Spain ,grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Elizabeth Pando
- Universitat Autonoma de Barcelona, Bellaterra, Spain. .,Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d'Hebron, 119 Passeig de la Vall d'Hebron, 08035, Barcelona, Spain.
| | - Piero Alberti
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Rodrigo Mata
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Nair Fernandes
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Montse Adell
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Sara Villasante
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Laia Blanco
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Joaquim Balsells
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Ramon Charco
- grid.411083.f0000 0001 0675 8654Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d’Hebron, 119 Passeig de la Vall d’Hebron, 08035 Barcelona, Spain
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Kozlov A, Becher MU, Schlecker S. [Hypertriglyceridemic pancreatitis and cardiac tamponade in a 26-year-old woman]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:88-92. [PMID: 36418500 DOI: 10.1007/s00108-022-01434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 11/25/2022]
Abstract
A 26-year-old woman with type 2 diabetes mellitus and discontinued intensive conventional insulin therapy was admitted to the authors' hospital with acute upper abdominal pain. Severe hypertriglyceridemia and acute pancreatitis were diagnosed. Treatment included insulin administration and plasmapheresis. On day 3, the patient developed sudden haemodynamic instability and in-hospital cardiopulmonary arrest. Focused echocardiography showed pericardial effusion with right ventricular collapse. Pericardiocentesis was performed, leading to a return of spontaneous circulation.
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Affiliation(s)
- A Kozlov
- Zentrum für Innere Medizin, Medizinische Klinik II für Kardiologie, Rhythmologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum Solingen, Gotenstr. 1, 42653, Solingen, Deutschland.
| | - M U Becher
- Zentrum für Innere Medizin, Medizinische Klinik II für Kardiologie, Rhythmologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum Solingen, Gotenstr. 1, 42653, Solingen, Deutschland
| | - S Schlecker
- Zentrum für Innere Medizin, Medizinische Klinik II für Kardiologie, Rhythmologie, Pneumologie und Internistische Intensivmedizin, Städtisches Klinikum Solingen, Gotenstr. 1, 42653, Solingen, Deutschland
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13
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Yazan CD, Yavuz DG. EFFICACY OF DOUBLE FILTRATION PLASMAPHERESIS TREATMENT IN ACUTE PANCREATITIS ASSOCIATED WITH SEVERE HYPERTRIGLYCERIDEMIA. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2023; 19:125-130. [PMID: 37601712 PMCID: PMC10439322 DOI: 10.4183/aeb.2023.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Background and aim Hypertriglyceridemia is one of the leading causes of acute pancreatitis and is associated with increased morbidity and mortality. Today the recommended treatment options are fasting, hydration, if necessary antibiotics and there is not a standard recommendation to decrease triglycerides rapidly. Double Fıltratıon Plasmapheresis (DFPP) may be an option to decrease triglycerides rapidly but its effect on the disease course is unknown. Method In the present study, we present results of four acute pancreatitis cases associated with hypertriglyceridemia treated with DFPP. All of the patients were diagnosed as acute pancreatitis at emergency room and no complications were observed in sessions. A 76.3% reduction in triglyceride levels was observed in one or two treatment sessions. Results and conclusion DFPP is an effective and safe option to decrease triglyceride levels rapidly but further research is needed to show the effect on mortality and morbidity.
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Affiliation(s)
- C. Dincer Yazan
- Marmara University Faculty of Medicine, Endocrinology and Metabolism, Istanbul, Turkey
| | - D. Gogas Yavuz
- Marmara University Faculty of Medicine, Endocrinology and Metabolism, Istanbul, Turkey
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14
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Use of insulin and heparin in the management of severe hypertriglyceridemia in a critically ill patient. Med Clin (Barc) 2022; 159:e81-e82. [PMID: 36049973 PMCID: PMC9421491 DOI: 10.1016/j.medcli.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 01/13/2023]
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15
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, Jong AD. Pancréatite aiguë grave du patient adulte en soins critiques 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Safety and Efficacy of Insulin and Heparin in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Patient without Diabetes: A Case Report. Case Rep Endocrinol 2022; 2022:7905552. [PMID: 36203643 PMCID: PMC9532158 DOI: 10.1155/2022/7905552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/24/2022] [Indexed: 11/30/2022] Open
Abstract
Acute pancreatitis (AP) leads to a variety of complications, such as local or systemic inflammatory responses as well as organ failure. While choledocholithiasis and alcohol abuse are two of the most common causes of AP, hypertriglyceridemia causes AP with an incidence rate between 2 and 5%. The management of hypertriglyceridemia-induced pancreatitis (HTGIP) is focused on the lowering of triglyceride (TG) levels, and the efficacy of therapies for the management of HTGIP may vary based on the hypertriglyceridemia etiology. The aim of this article is to report a case of a 43-year-old female with a history of familial hypertriglyceridemia and without diabetes who was admitted for acute pancreatitis with a TG level elevated to 4,435 mg/dL. The patient was treated with a combination of insulin, heparin, atorvastatin, and omega-3-acid ethyl esters, and her TG level was reduced to 880 mg/dL after 9 days of therapy. Despite the successful treatment of the patient, standardization of the approach for the treatment of HTGIP is needed. Future research should aim to identify the appropriateness of insulin therapy specifically in patients without diabetes presenting with hypertriglyceridemia and the dosing associated with optimal safety.
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17
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Jaber S, Garnier M, Asehnoune K, Bounes F, Buscail L, Chevaux JB, Dahyot-Fizelier C, Darrivere L, Jabaudon M, Joannes-Boyau O, Launey Y, Levesque E, Levy P, Montravers P, Muller L, Rimmelé T, Roger C, Savoye-Collet C, Seguin P, Tasu JP, Thibault R, Vanbiervliet G, Weiss E, De Jong A. Guidelines for the management of patients with severe acute pancreatitis, 2021. Anaesth Crit Care Pain Med 2022; 41:101060. [PMID: 35636304 DOI: 10.1016/j.accpm.2022.101060] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide guidelines for the management of the intensive care patient with severe acute pancreatitis. DESIGN A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations. CONCLUSIONS There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.
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Affiliation(s)
- Samir Jaber
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France.
| | - Marc Garnier
- Sorbonne Université, GRC 29, DMU DREAM, Service d'Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
| | - Karim Asehnoune
- Service d'Anesthésie, Réanimation chirurgicale, Hôtel Dieu/HME, CHU Nantes, Nantes cedex 1, France; Inserm, UMR 1064 CR2TI, team 6, France
| | - Fanny Bounes
- Toulouse University Hospital, Anaesthesia Critical Care and Perioperative Medicine Department, Toulouse, France; Équipe INSERM Pr Payrastre, I2MC, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology & Pancreatology, University of Toulouse, Rangueil Hospital, Toulouse, France
| | | | - Claire Dahyot-Fizelier
- Anaesthesiology and Intensive Care Department, University hospital of Poitiers, Poitiers, France; INSERM U1070, University of Poitiers, Poitiers, France
| | - Lucie Darrivere
- Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, CHU de Bordeaux, Hôpital Magellan, Bordeaux, France
| | - Yoann Launey
- Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, University Hospital of Rennes, Rennes, France
| | - Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care, AP-HP, Henri Mondor Hospital, Créteil, France; Université Paris-Est Creteil, EnvA, DYNAMiC, Faculté de Santé de Créteil, Creteil, France
| | - Philippe Levy
- Service de Pancréatologie et d'Oncologie Digestive, DMU DIGEST, Université de Paris, Hôpital Beaujon, APHP, Clichy, France
| | - Philippe Montravers
- Université de Paris Cité, INSERM UMR 1152 - PHERE, Paris, France; Département d'Anesthésie-Réanimation, APHP, CHU Bichat-Claude Bernard, DMU PARABOL, APHP, Paris, France
| | - Laurent Muller
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France
| | - Thomas Rimmelé
- Département d'anesthésie-réanimation, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France; EA 7426: Pathophysiology of Injury-induced Immunosuppression, Pi3, Hospices Civils de Lyon-Biomérieux-Université Claude Bernard Lyon 1, Lyon, France
| | - Claire Roger
- Réanimations et surveillance continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Montpellier, France; Department of Intensive care medicine, Division of Anaesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Savoye-Collet
- Department of Radiology, Normandie University, UNIROUEN, Quantif-LITIS EA 4108, Rouen University Hospital-Charles Nicolle, Rouen, France
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, Réanimation chirurgicale, CHU de Rennes, Rennes, France
| | - Jean-Pierre Tasu
- Service de radiologie diagnostique et interventionnelle, CHU de Poitiers, Poitiers, France; LaTim, UBO and INSERM 1101, University of Brest, Brest, France
| | - Ronan Thibault
- Service Endocrinologie-Diabétologie-Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, NuMeCan, Nutrition Metabolisms Cancer, Rennes, France
| | - Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France; University of Paris, Paris, France; Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care (DAR B), University Hospital Center Saint Eloi Hospital, Montpellier, France; PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
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18
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Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early. World J Surg 2022; 46:1758-1767. [PMID: 35355100 PMCID: PMC9174303 DOI: 10.1007/s00268-022-06533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/23/2022]
Abstract
Background The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP. Methods The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected. Results From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05). Conclusions In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06533-w.
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Marić N, Mačković M, Bakula M, Mucić K, Udiljak N, Marušić M. Hypertriglyceridemia-induced pancreatitis treated with continuous insulin infusion-Case series. Clin Endocrinol (Oxf) 2022; 96:139-143. [PMID: 34263462 DOI: 10.1111/cen.14554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/27/2021] [Accepted: 06/30/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE There are no definitive treatment guidelines for hypertriglyceridemia (HTG)-induced acute pancreatitis (AP). The aim of this retrospective study was to evaluate the efficacy of insulin in decreasing triglyceride (TG) levels in patients with HTG-induced AP. DESIGN We included 17 cases of HTG-induced AP treated with continuous insulin aspart for 4 days. PATIENTS Fifteen patients were male, two were female. The mean TG level at admission was 56.53 ± 25.29 mmol/L. The mean APACHE II score was 10.2 ± 5.7, Ranson 4.2 ± 1.7 and Balthazar 6.5 ± 2.6, implying a severe form of the disease. METHODS In an 8-year period, 17 patients with a diagnosis of HTG-induced AP were treated with a continuous infusion of 5% dextrose and insulin aspart in an attempt to lower TG levels. TG levels were assessed on admission, the second and fourth day of therapy. The patient outcome, complications and recurrence of AP were monitored. RESULTS A significant reduction of TG levels was observed in all patients on Day 4. All patients survived, with one forming a giant pseudocyst as a disease complication, one needing haemodialyses treatment due to an acute kidney injury, and one developing acute respiratory distress syndrome that required mechanical ventilation for 4 days. All patients recovered completely. CONCLUSION Our study showed that continuous insulin aspart infusion decreases TG levels in HTG-induced AP from a mean TG level of 56.53 mmol/L on Day 1 to 21.75 mmol/L on Day 2 and finally to 6.86 mmol/L on Day 4. We consider this therapy very efficient, safe, simple to administer and monitor.
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Affiliation(s)
- Nikolina Marić
- Department of Intensive Care, Department of Internal Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
| | - Maja Mačković
- Department of Intensive Care, Department of Internal Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
| | - Miro Bakula
- Department of Endocrinology, Diabetes and Metabolic Diseases, Department of Internal Medicine, Clinical Hospital Sveti Duh, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Katarina Mucić
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nikola Udiljak
- Department of Intensive Care, Department of Internal Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
| | - Marinko Marušić
- Department of Gastroenterology and Hepatology, Department of Internal Medicine, Clinical Hospital Sveti Duh, Zagreb, Croatia
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20
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Yu XQ, Li WQ. Progress in research of hyperlipidemic acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2021; 29:804-808. [DOI: 10.11569/wcjd.v29.i14.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the continuous change of dietary structure and other factors, the incidence of hyperlipidemic acute pancreatitis (HLAP) has increased year by year. In particular, HLAP is different from other types of acute pancreatitis in its mechanism, so its clinical diagnosis and treatment have its own particularity. In this paper, we review the progress in the research of HLAP.
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Affiliation(s)
- Xian-Qiang Yu
- Medical College of Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Wei-Qin Li
- Medical College of Southeast University, Nanjing 210009, Jiangsu Province, China,Department of Critical Care Medicine, Jinling Hospital, Affiliated to Southeast University, General Hospital of Eastern Theater Command, Nanjing 210002, Jiangsu Province, China
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21
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Thomas CM, Vicent M, Moore S, Ali F, Wooten L, Louzon PR. Treatment of Severe Hypertriglyceridemia With Insulin Infusions in Severe COVID-19: A Case Series. J Pharm Pract 2021; 35:1044-1048. [PMID: 33882724 DOI: 10.1177/08971900211010473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Rapid onset of severe hypertriglyceridemia was quickly recognized in critical COVID-19 patients. Associated causes have been due to secondary hemophagocytic lymphohystiocytosis (HLH) syndrome, medication-induced, or acute liver failure. Statins, omega-3 polyunsaturated acids, niacin, and fibrates are common oral lipid lowering therapy options in patients at risk for hypertriglyceridemia. The severity of hypertriglyceridemia in COVID-19 patients with triglyceride values reaching greater than 1,000 mg/dL put them at a heightened risk of pancreatitis and therefore an essential need to acutely lower their levels. We present a case series of 5 patients who achieved rapid triglyceride lowering through continuous insulin infusion therapy. METHODS A retrospective chart review of 48 critical COVID-19 patients who were admitted from March 22 to April 15, 2020 was conducted. Inclusion criteria consisted of mechanical ventilation and continuous insulin infusion to treat severe hypertriglyceridemia resulting with 5 eligible patients in this case report. RESULTS AND CONCLUSION In addition to standard oral lipid lowering therapies, continuous insulin infusion successfully treated severe hypertriglyceridemia in critically ill COVID-19 patients. None of the patients experienced pancreatitis or hypoglycemia necessitating cessation of insulin. Further studies are needed to show the optimum dose and duration of insulin infusion as monotherapy and in combination with oral therapies.
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Affiliation(s)
| | - Martie Vicent
- Department of Pharmacy, AdventHealth Orlando, FL, USA
| | - Shawn Moore
- Department of Surgery, AdventHealth Orlando, FL, USA
| | - Fahd Ali
- Department of Surgery, AdventHealth Orlando, FL, USA.,Department of Critical Care, AdventHealth Orlando, FL, USA
| | - Leslie Wooten
- Department of Pharmacy, AdventHealth Orlando, FL, USA
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22
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Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient. Mayo Clin Proc Innov Qual Outcomes 2021; 5:520-524. [PMID: 33997648 PMCID: PMC8105512 DOI: 10.1016/j.mayocpiqo.2020.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Treatment strategies for hypertriglyceridemia-induced acute pancreatitis are not well defined in the current literature or guidelines. One therapeutic option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic woman treated with a reduced-dose insulin infusion that was complicated by hypoglycemic episodes requiring dextrose infusion titrations. Empirical initiation of a higher dextrose concentration infusion with glucose level titrations should be considered to avoid hypoglycemia for nondiabetic patients treated with an insulin infusion to lower triglyceride levels. In this case, clinical pharmacy assistance was imperative for successful treatment with a reduced-dose insulin infusion and titrated dextrose infusion in the management of hypertriglyceridemia-induced acute pancreatitis.
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23
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Reed JM, Hogan BM, Nasser-Ghodsi N, Loftus CG. Management of Hypertriglyceridemia-Induced Acute Pancreatitis in a Nondiabetic Patient. Mayo Clin Proc Innov Qual Outcomes 2021; 5:230-235. [PMID: 33718798 PMCID: PMC7930755 DOI: 10.1016/j.mayocpiqo.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Hypertriglyceridemia-induced acute pancreatitis treatment strategies are not well defined in current literature or guidelines. One therapy option is an insulin infusion accompanied by a dextrose infusion to avoid hypoglycemia. The purpose of this case report is to highlight dosing considerations for dextrose infusions in nondiabetic patients. We describe a case of hypertriglyceridemia-induced acute pancreatitis in a 34-year-old nondiabetic female patient treated with a reduced-dose insulin infusion, complicated by hypoglycemic episodes requiring dextrose infusion titrations. Empirical initiation of a higher dextrose concentration infusion with glucose level titrations should be considered to avoid hypoglycemia for nondiabetic patients treated with an insulin infusion to lower triglyceride levels. In this case, clinical pharmacy assistance was imperative for successful treatment with a reduced-dose insulin infusion and titrated dextrose infusion in the management of hypertriglyceridemia-induced acute pancreatitis.
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Affiliation(s)
- Jamie M. Reed
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Pharmacy, Indiana University Health, Indianapolis
- Correspondence: Address to Jamie M. Reed, PharmD, BCPS, 550 N University Blvd, Indianapolis, IN 46202.
| | | | | | - Conor G. Loftus
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Huang Z, Xu Z, Xu R, Huang L, Xu X, Lai X. Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis. J Diabetes 2021; 13:200-210. [PMID: 32734598 DOI: 10.1111/1753-0407.13100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/05/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This study aimed to analyze the genetics and treatments of the patients with the triad of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis (AP). METHODS We conducted a retrospective study of six patients with the triad of AP, hypertriglyceridemia, and DKA at our hospital. All patients underwent plasmapheresis as part of their treatment. The clinical characteristics of the patients were obtained from the hospital information system and analyzed. Whole exome sequencing was performed using samples of one patient (case 6) and his family members. RESULTS The average triglyceride level before plasmapheresis was 3282.17 ± 2975.43 mg/dL (range: 1646-9332 mg/dL). The triglyceride levels dropped by approximately 80% after plasmapheresis. None of the patients developed complications related from plasmapheresis. During follow-up, patients 5 and 6 developed recurrent pancreatitis for several times and showed the formation of pancreatic pseudocysts. We identified three novel heterozygous missense mutations in the family of patient 6, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD. CONCLUSIONS Three novel heterozygous missense mutations, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD were first identified in a patient with the triad of DKA, hypertriglyceridemia, and AP. The combination of plasmapheresis, hydration, and insulin therapy may have the greatest clinical benefits for these patients.
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Affiliation(s)
- Zixi Huang
- Department of General Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyan Xu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruoqing Xu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Huang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiang Xu
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoyang Lai
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Shirolkar A, Yadav A, Mandal TK, Dabur R. Intervention of Ayurvedic drug Tinospora cordifolia attenuates the metabolic alterations in hypertriglyceridemia: a pilot clinical trial. J Diabetes Metab Disord 2021; 19:1367-1379. [PMID: 33520840 DOI: 10.1007/s40200-020-00657-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022]
Abstract
Purpose Hypertriglyceridemia (HG) is an independent risk factor with more prevalence than hypercholesterolemia and its attributes to cardiovascular disease (CVD) and pancreatitis. Hence, it becomes imperative to search for new triglyceride (TG) lowering agents. Tinospora cordifolia (TC) is a well-known Ayurvedic drug and a rich source of protoberberine alkaloids hence can contribute to TG lowering without side effects. Hence, to explore the therapeutic efficacy of T. cordifolia and its effects on biochemistry and metabolome in the patients of hyper-triglyceridemia, clinical trials were conducted. Methods Patients (n = 24) with hypertriglyceridemia were randomized into two groups to receive T. cordifolia extract (TCE) (3.0 g/per day) and metformin (850 mg/day) for 14 days having >300 mg/dl triglyceride level and cholesterol in the range of 130-230 mg/dl. Lipid profiles of blood samples were analyzed. Urine samples were subjected to HPLC-QTOF-MS to quantify oxidative damage and abnormal metabolic regulation. Results Intervention with TCE reduced the triglyceride, LDL, and VLDL levels to 380.45 ± 17.44, 133.25 ± 3.18, and 31.85 ± 5.88 mg/dL and increased the HDL to 47.50 ± 9.05 mg/dL significantly (p < 0.05) in the HG patients after 14 days treatment. TCE dosage potently suppressed the inflammatory and oxidative stress marker's i.e. levels of isoprostanes significantly (p < 0.01). Qualitative metabolomics approach i.e. PCA and PLS-DA showed significant alterations (p < 0.05) in the levels of 40 metabolites in the urine samples from different groups. Conclusion TCE administration depleted the levels of markers of HG i.e. VLDL, TG, and LDL significantly. Metabolomics studies established that the anti-HG activity of TCE was due to its antioxidative potential and modulation of the biopterin, butanoate, amino acid, and vitamin metabolism. Clinical trials registry India (CTRI) registration no. CTRI- 2016-08-007187.
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Affiliation(s)
- Amey Shirolkar
- Department of Biochemistry, National Research Institute of Basic Ayurvedic Sciences (NRIBAS), Kothrud, Pune, Maharashtra 411038 India
| | - Aarti Yadav
- Clinical Biochemistry Laboratory, Department of Biochemistry, Maharishi Dayanand University, Rohtak, Haryana 124001 India
| | - T K Mandal
- Department of Biochemistry, National Research Institute of Basic Ayurvedic Sciences (NRIBAS), Kothrud, Pune, Maharashtra 411038 India
| | - Rajesh Dabur
- Department of Biochemistry, National Research Institute of Basic Ayurvedic Sciences (NRIBAS), Kothrud, Pune, Maharashtra 411038 India.,Clinical Biochemistry Laboratory, Department of Biochemistry, Maharishi Dayanand University, Rohtak, Haryana 124001 India
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Dai J, Jiang M, Hu Y, Xiao J, Hu B, Xu J, Han X, Shen S, Li B, Wu Z, He Y, Ren Y, Wen L, Wang X, Hu G. Dysregulated SREBP1c/miR-153 signaling induced by hypertriglyceridemia worsens acute pancreatitis and delays tissue repair. JCI Insight 2021; 6:138584. [PMID: 33491670 PMCID: PMC7934861 DOI: 10.1172/jci.insight.138584] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 12/02/2020] [Indexed: 01/01/2023] Open
Abstract
Severe acute pancreatitis (AP) is a life-threatening disease with up to 30% mortality. Therefore, prevention of AP aggravation and promotion of pancreatic regeneration are critical during the course and treatment of AP. Hypertriglyceridemia (HTG) is an established aggravating factor for AP that hinders pancreatic regeneration; however, its exact mechanism remains unclear. Using miRNA sequencing and further verification, we found that miRNA-153 (miR-153) was upregulated in the pancreas of HTG animal models and in the plasma of patients with HTG-AP. Increased miR-153 aggravated HTG-AP and delayed pancreatic repair via targeting TRAF3. Furthermore, miR-153 was transcriptionally suppressed by sterol regulatory element-binding transcription factor 1c (SREBP1c), which was suppressed by lipoprotein lipase malfunction-induced HTG. Overexpressing SREBP1c suppressed miR-153 expression, alleviated the severity of AP, and facilitated tissue regeneration in vivo. Finally, therapeutic administration of insulin also protected against HTG-AP via upregulating SREBP1c. Collectively, our results not only provide evidence that HTG leads to the development of more severe AP and hinders pancreatic regeneration via inducing persistent dysregulation of SREBP1c/miR-153 signaling, but also demonstrate that SREBP1c activators, including insulin, might be used to treat HTG-AP in patients.
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Affiliation(s)
- Juanjuan Dai
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mingjie Jiang
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yangyang Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jingbo Xiao
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiyao Xu
- Department of Emergency, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Han
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuangjun Shen
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bin Li
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zengkai Wu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan He
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yingchun Ren
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li Wen
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingpeng Wang
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoyong Hu
- Department of Gastroenterology and.,Shanghai Key Laboratory of Pancreatic Diseases, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Sun Y. Progress in diagnosis and treatment of hypertriglyceridemic acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2020; 28:1223-1228. [DOI: 10.11569/wcjd.v28.i24.1223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
At present, the incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) is on the rise, the age of onset tends to be younger, and severe HTG-AP is more common. HTG has become the second major cause of acute pancreatitis (AP) in China. Previous studies have demonstrated that the severity of hypertriglyceridemia correlates with the severity of AP. However, the pathogeneses of HTG and HTG-AP are still unknown. The treatments for HTG-AP include low-calorie diet, insulin, heparin, lipid-lowering drugs, and blood purification. Although these treatments, especially blood purification measures represented by plasma exchange, have been proven to reduce blood lipid levels, they still need to be confirmed by high-quality randomized controlled trials to improve the prognosis of HTG-AP. The value of gene diagnosis and therapy in the diagnosis and treatment of HTG-AP has attracted more and more attention, which may be an important direction of HTG-AP research in the future.
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Affiliation(s)
- Yun Sun
- Department of Critical Care Medicine, the Second Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China
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28
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Hypertriglyceridemia and acute pancreatitis. Pancreatology 2020; 20:795-800. [PMID: 32571534 DOI: 10.1016/j.pan.2020.06.005] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/21/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023]
Abstract
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.
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Alakel N, Heuschkel S, Balaian E, Röllig C, Bornhäuser M. Treatment of Pegylated Asparaginase-Induced Hypertriglyceridemia with Continuous Intravenous Infusion of Insulin and Heparin: A Case Report. Chemotherapy 2020; 64:210-214. [PMID: 32045924 DOI: 10.1159/000505773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/06/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pegylated asparaginase may induce prolonged hypertriglyceridemia. To date, there is no standard management of this complication. Here, we present a case report of pegylated asparaginase-induced hypertriglyceridemia and hepatotoxicity successfully treated with continuous intravenous infusion of insulin and heparin. CASE PRESENTATION A 51-year-old male patient with lymphoid blast crisis of chronic myelogenous leukemia was treated with pegylated asparaginase. The patient developed severe hypertriglyceridemia. Supportive therapy with low-fat diet, fibric acids, and omega-3 fatty acids was not successful, and later, the patient developed high-grade hepatotoxicity. Like hypertriglyceridemia-induced pancreatitis, continuous intravenous infusion of insulin and heparin was initiated. The level of triglyceride and cholesterol decreased rapidly within 4 days. CONCLUSION In case of severe pegylated asparaginase-induced hypertriglyceridemia, continuous intravenous infusion of insulin and heparin can reduce rapidly and safely the triglyceride level. Controlled trials are needed to address this important issue.
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Affiliation(s)
- Nael Alakel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany,
| | - Sandra Heuschkel
- Klinik-Apotheke, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Ekaterina Balaian
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany
| | - Christoph Röllig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany
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Agarwal T, Lyngdoh T, Dudbridge F, Chandak GR, Kinra S, Prabhakaran D, Reddy KS, Relton CL, Davey Smith G, Ebrahim S, Gupta V, Walia GK. Causal relationships between lipid and glycemic levels in an Indian population: A bidirectional Mendelian randomization approach. PLoS One 2020; 15:e0228269. [PMID: 31995593 PMCID: PMC6988960 DOI: 10.1371/journal.pone.0228269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/12/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Dyslipidemia and abnormal glycemic traits are leading causes of morbidity and mortality. Although the association between the two traits is well established, there still exists a gap in the evidence for the direction of causality. OBJECTIVE This study aimed to examine the direction of the causal relationship between lipids and glycemic traits in an Indian population using bidirectional Mendelian randomization (BMR). METHODS The BMR analysis was conducted on 4900 individuals (2450 sib-pairs) from the Indian Migration Study. Instrument variables were generated for each lipid and glycemic trait (fasting insulin, fasting glucose, HOMA-IR, HOMA-β, LDL-cholesterol, HDL-cholesterol, total cholesterol and triglycerides) to examine the causal relationship by applying two-stage least squares (2SLS) regression in both directions. RESULTS Lipid and glycemic traits were found to be associated observationally, however, results from 2SLS showed that only triglycerides, defined by weighted genetic risk score (wGRS) of 3 SNPs (rs662799 at APOAV, rs780094 at GCKR and rs4420638 at APOE/C1/C4), were observed to be causally effecting 1.15% variation in HOMA-IR (SE = 0.22, P = 0.010), 1.53% in HOMA- β (SE = 0.21, P = 0.001) and 1.18% in fasting insulin (SE = 0.23, P = 0.009). No evidence for a causal effect was observed in the reverse direction or between any other lipid and glycemic traits. CONCLUSION The study findings suggest that triglycerides may causally impact various glycemic traits. However, the findings need to be replicated in larger studies.
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Affiliation(s)
- Tripti Agarwal
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | - Tanica Lyngdoh
- Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, India
| | - Frank Dudbridge
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Sanjay Kinra
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Caroline L. Relton
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - George Davey Smith
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Shah Ebrahim
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vipin Gupta
- Department of Anthropology, University of Delhi, Delhi, India
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Ozcelik S, Baş S, Ozcelik M, Sarıaydın M, Celik M, Gözü H. EFFICACY OF INSULIN, HEPARIN AND FENOFIBRATE COMBINATION TREATMENT IN SEVERE HYPERTRIGLYCERIDEMIA: DOUBLE CENTER EXPERIENCE. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2019; 15:460-465. [PMID: 32377243 PMCID: PMC7200120 DOI: 10.4183/aeb.2019.460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT Severe hypertriglyceridemia (SH), which calls for a triglyceride (TG) level above 1000 mg/dL, remains an important health issue. While some data exist to offer combination of heparin, insulin and fenofibrate as a reasonable treatment option, safety and benefits of this therapy have not been accurately weighted, largely due to the limited sample size of the relevant studies. AIM Assess the efficacy and safety of the heparin, insulin and fenofibrate combination in the treatment of patients with SH. PATIENTS - METHODS Patients aged ≥18 years with TG level above 1000 mg/dL and adequate organ function were included. Triglyceride levels were measured immediately before the treatment and on the 3rd and 6th days of the treatment. Treatment dosage, duration, response and side effects were assessed. Patients with hypertriglyceridemia presenting with acute pancreatitis were treated additionally with lipid apheresis. RESULTS A total of 42 patients were included. Of these, 85.8% came to medical attention with some kind of secondary hypertriglyceridemia causes. The baseline median TG value of the cases was 2141.0 mg/ dL (1026-12250). There were 6 patients (14.3%) with acute pancreatitis at presentation. In patients without pancreatitis, with administration of insulin infusion, unfractionated heparin infusion and fenofibrate capsule, median TG values decreased to 921 mg/ dL (190-6400) on the 3rd day and to 437 mg/ dL (112-1950) on the 6th day of the treatment (p<0.0001, Friedman test). Potential toxicities related to insulin, heparin and fenofibrate combination treatment including hypoglycemia, hemorrhage, rise in creatine kinase levels, hepato - and nephrotoxicity were not observed. CONCLUSION In this trial involving patients with SH, our data suggest that insulin, heparin and fenofibrate combination therapy was safe and effective.
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Affiliation(s)
- S. Ozcelik
- Adıyaman University Training and Research Hospital - Department of Endocrinology and Metabolism, Istanbul, Turkey
| | - S. Baş
- Adıyaman University Training and Research Hospital - Haydarpaşa Numune Training and Research Hospital, Department of Internal Diseases, Istanbul, Turkey
| | - M. Ozcelik
- University of Health Sciences Umraniye Training and Research Hospital - Department of Internal Diseases, Istanbul, Turkey
| | - M. Sarıaydın
- Adıyaman University Training and Research Hospital - Department of Internal Diseases, Adıyaman, Istanbul, Turkey
| | - M. Celik
- Adıyaman University Training and Research Hospital - Haydarpaşa Numune Training and Research Hospital, Department of Internal Diseases, Istanbul, Turkey
| | - H. Gözü
- Marmara University Medical School - Department of Endocrinology and Metabolism, Istanbul, Turkey
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32
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Song YX, Zhu HY, Du YQ. Advances in research of pathogenesis and treatment of hyperlipidemic acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2019; 27:112-116. [DOI: 10.11569/wcjd.v27.i2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the incidence of hyperlipidemic acute pancreatitis has increased year by year. At present, the exact pathogenesis is still unclear. It may be related to the increase of free fatty acids due to increased triglyceride (TG), which leads to toxicity to the pancreas, pancreatic microcirculation disorder, and calcium overload. The key to treatment is to reduce TG rapidly. Lifestyle changes and weight loss are the key to preventing recurrence.
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Affiliation(s)
- Ying-Xiao Song
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
| | - Hui-Yun Zhu
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
| | - Yi-Qi Du
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
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Pseudohyponatremia in Hypertriglyceridemia-Induced Acute Pancreatitis: A Tool for Diagnosis Rather Than Merely a Laboratory Error? Pancreas 2019; 48:126-130. [PMID: 30540682 DOI: 10.1097/mpa.0000000000001192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The relative rarity of hypertriglyceridemia (HTG) as the etiology for acute pancreatitis (AP) delays the final diagnosis of hypertriglyceridemia-induced AP (HTG-AP). This study aimed to explore the diagnostic and prognostic value of pseudohyponatremia in this clinical entity. METHODS We retrospectively compared 140 patients with HTG-AP and 266 patients of AP of other etiologies. The correlation of presenting hyponatremia and a final diagnosis of HTG-AP is evaluated. RESULTS Presenting hyponatremia had an area under curve of 0.926 for predicting the diagnosis of HTG-AP. After dichotomization by the optimal cutoff value of 130 mEq/dL, patients with hyponatremia had a higher prevalence of acute kidney injury (61.9% vs 38.1%, P < 0.001), systemic inflammatory response syndrome (52.2% vs 47.8%, P < 0.001), a higher Ranson criteria (3.0 vs 1.4, P < 0.001), and a higher Bedside Index for Severity of Acute Pancreatitis score (0.69 vs 0.55, P = 0.011). CONCLUSIONS Presenting hyponatremia is highly efficient in differentiating hypertriglyceridemia from other etiologies of AP. It also demonstrated promising prognostic values in both AP and HTG-AP patients. Therefore, initial serum sodium could potentially provide the first clue of HTG-AP, as well as facilitate risk-stratifying patients to determine treatment allocation.
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Waller A, Long B, Koyfman A, Gottlieb M. Acute Pancreatitis: Updates for Emergency Clinicians. J Emerg Med 2018; 55:769-779. [PMID: 30268599 DOI: 10.1016/j.jemermed.2018.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis. OBJECTIVE This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis. DISCUSSION Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe. CONCLUSIONS Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.
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Affiliation(s)
- Anna Waller
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Moderate Hypertriglyceridemia Causing Recurrent Pancreatitis: A Case Report and the Literature Review. Case Rep Gastrointest Med 2018; 2018:8714390. [PMID: 30345124 PMCID: PMC6174808 DOI: 10.1155/2018/8714390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/19/2018] [Accepted: 09/09/2018] [Indexed: 12/27/2022] Open
Abstract
Recurrent acute pancreatitis secondary to hypertriglyceridemia (HTG) with levels below 1000 mg/dL has been rarely reported in the literature. HTG is the third most common cause of acute pancreatitis and has been established in the literature as a risk factor when levels are greater than 1000 mg/dL. A 43-year-old patient presented to the hospital with severe epigastric abdominal pain. Initial laboratory investigations were significant for a lipase level of 4143 U/L and a triglyceride level of 600 mg/dL. Computed tomography (CT) of the abdomen showed diffuse enlargement of the pancreas consistent with pancreatitis. A diagnosis of severe acute pancreatitis secondary to high triglycerides was made based on the revised Atlanta classification 2012. The patient was initially managed with intravenous boluses of normal saline followed by continuous insulin infusion. Diabetic Ketoacidosis (DKA) was ruled out due to a past medical history of diabetes. Her clinical course was complicated by acute respiratory distress syndrome requiring intubation and mechanical ventilation. During the course, she improved symptomatically and was extubated. She was started on nasogastric feeding initially and subsequently switched to oral diet as tolerated. After initial management of HTG with insulin infusion, oral gemfibrozil was started for long-term treatment of HTG. Emerging literature implicates HTG as an independent indicator of poor prognosis in acute pancreatitis (AP). Despite the paucity of data, the risk of developing AP must be considered even at triglyceride levels lower than 1000 mg/dL.
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Rawla P, Sunkara T, Thandra KC, Gaduputi V. Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies. Clin J Gastroenterol 2018; 11:441-448. [PMID: 29923163 DOI: 10.1007/s12328-018-0881-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/14/2018] [Indexed: 12/22/2022]
Abstract
Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.
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Affiliation(s)
- Prashanth Rawla
- Department of Internal Medicine/Hospitalist, SOVAH Health, 320 Hospital Dr, Martinsville, VA, 24115, USA.
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, New York, NY, 11201, USA
| | | | - Vinaya Gaduputi
- Division of Gastroenterology, SBH Health System, Bronx, NY, 19457, USA
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He PP, Jiang T, OuYang XP, Liang YQ, Zou JQ, Wang Y, Shen QQ, Liao L, Zheng XL. Lipoprotein lipase: Biosynthesis, regulatory factors, and its role in atherosclerosis and other diseases. Clin Chim Acta 2018; 480:126-137. [DOI: 10.1016/j.cca.2018.02.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 01/20/2023]
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Abstract
PURPOSE OF REVIEW We provide an overview of current evidence about the independent role of high triglyceride levels for cardiovascular risk and for acute pancreatitis. RECENT FINDINGS Natural experiments of Mendelian randomization have given us a deeper understanding about the molecular pathways involved in triglyceride metabolism. Individuals with low-triglyceride levels generally have lower rates of cardiovascular disease (CVD). There has been a significant growth in the development of new agents that modulate enzymes involved in a variety of aspects of triglyceride packaging into VLDL or chylomicron particles, and triglyceride catabolism. Antisense inhibitors of apolipoprotein CIII are being tested, as are a variety of agents designed to increase lipoprotein lipase activity. Large-scale trials are underway with purified fatty acid (FA) formulations in over 20 000 individuals in aggregate. A large study of a new fibrate is underway. SUMMARY A focus on patients with elevated triglyceride levels is a new paradigm not previously the focus of large trials. Clinical outcome data on cardiovascular risk reductions remains sparse. Some drugs are already approved for use in rare inherited disorders predisposing to severe hypertriglyceridaemia and acute pancreatitis. Safety and costs issues are critical.
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Affiliation(s)
- Anthony C Keech
- aNHMRC Clinical Trials Centre, The University of Sydney bDepartment of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales cDepartment of Diabetes and Endocrinology, St. Vincents Health, Melbourne, Victoria, Australia
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