Effects of time interval for hemofiltration on the prognosis of severe acute pancreatitis

Intensive management of severe acute pancreatitis

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

Early Gut Barrier Dysfunction in Patients with Severe Acute Pancreatitis: Attenuated by Continuous Blood Purification Treatment

Objectives

The aim of this study was to investigate the effect of continuous blood purification (CBP) on early gut mucosal dysfunction in patients with severe acute pancreatitis (SAP).

Methods

Patients with SAP were randomized to receive 24 hours of continuous veno-venous hemofiltration (CVVH; n=33) or no CVVH (n=30). Blood samples were taken from the patients at 0, 6, 12, and 24 hours during CVVH therapy. Serum diamine oxidase (DAO) and endotoxin, epithelial permeability, transepithelial electrical resistance (TER) and F-actin rearrangement of the epithelial monolayer were used as the markers for the assessment of gut barrier function and the effect of CBP therapy in patients with SAP.

Results

Patients with SAP had increased levels of serum DAO, endotoxin, and epithelial permeability when compared with normal controls, and the increase was more pronounced in patients with organ dysfunction (p<0.01). F-actin rearrangement, loose cell-cell junction, and iNOS mRNA upregulation were found in all patients. After CBP treatment, Acute Physiology and Chronic Health Evaluation II score and SOFA score improved significantly; levels of serum DAO, endotoxin, and epithelial permeability decreased (p<0.05). CBP also significantly attenuated reorganization of actin and downregulated iNOS mRNA expression and NO production (p<0.05).

Conclusions

CBP can not only improve the general conditions but also effectively improve gut barrier dysfunction. The beneficial effect of CBP on gut barrier dysfunction is associated with the improvement of cytoskeletal instability, by downregulating iNOS through the removal of excess proinflammatory factors.

Short-term continuous high-volume hemofiltration on clinical outcomes of severe acute pancreatitis

OBJECTIVES

This study aimed to conduct a single-center prospective trial of short-term continuous high-volume hemofiltration (HVHF) in patients with predicted severe acute pancreatitis (SAP).

METHODS

Patients with acute pancreatitis with Acute Physiology and Chronic Health Evaluation II scores of greater than 15 on admission between January 2008 and December 2010 were allocated to receive either optimal standard therapy or 72 hours of continuous HVHF on an alternate basis, beginning as soon as possible after admission. Biomarkers and clinical outcomes were compared between the 2 groups.

RESULTS

A total of 61 patients received either conventional therapy (n = 29) or HVHF (n = 32). High-volume hemofiltration treatment was associated with a significant reduction in the incidence of renal failure (P = 0.013), infected pancreatic necrosis (P = 0.048), length of hospitalization (P = 0.005), mortality (P = 0.033), as well as duration of renal (P < 0.001), respiratory (P = 0.002), and hepatic failure (P = 0.001). Acute Physiology and Chronic Health Evaluation II score and C-reactive protein and interleukin 6 levels were significantly reduced after the start of HVHF on days 1, 3, and 7 (all, P < 0.05).

CONCLUSIONS

This study suggests that short-term HVHF may reduce local and systemic complications and mortality in patients with SAP with Acute Physiology and Chronic Health Evaluation score of greater than 15.

Therapeutic plasma exchange in patients with severe hypertriglyceridemia: a multicenter study

Extremely high plasma triglyceride (TG) concentration is a recognized risk factor for acute pancreatitis (AP). In order to evaluate the therapeutic efficacy of plasma-exchange plasmapheresis in treating patients with severe hypertriglyceridemia (sHTG), 17 patients who had not responded to conventional medical therapy (fat-free diet plus pharmaceutical interventions) were referred for therapeutic plasma exchange (TPE) in a multicenter frame case series study. Two hundred seventeen TPE sessions were performed, and therapy is ongoing for five (30%) of the patients. After treatment, the mean plasma TG and total cholesterol concentrations were significantly reduced from 1929 and 510 mg/dL, to 762 and 227 mg/dL, respectively (P < or = 0.001 in both cases). In most cases, the interval between treatments was related to the clinical presentation and individual circumstances. The removal of TG-rich lipoproteins prevented relapses of AP. In this case series, TPE is confirmed as a safe and reliable method for treating patients with refractory sHTG when a severe complication, such as AP, is clinically demonstrated or can be actively prevented. Therefore, in cases where standard medical approaches fail to promote the clearance of TGs from plasma and a high risk of first or second hypertriglyceridemic pancreatitis persists, TPE provides a therapeutic option for preventing life-threatening sHTG.

Conservative approach in the management of severe acute pancreatitis: eight-year experience in a single institution

INTRODUCTION

Recognition of severe acute pancreatitis (SAP), intensive care, shifting away from early surgical treatment, and monitoring of the intra-abdominal pressure (IAP) is important in the management of SAP. The aim of our study was retrospective evaluation and critical assessment of the experience with SAP management protocol involving new strategy in the university hospital.

METHODS

Protocols of 274 SAP patients treated in our institution during the last eight years were reassessed. APACHE II, CRP and SOFA score, IAP, pulmonary complications, ventilatory support and infection rate were evaluated. The success of the conservative treatment, surgical interventions and mortality was analysed comparing period 1 from 1999 to 2002 and period 2 from 2003 to 2006.

RESULTS

More patients with necrotising SAP were treated in period 2. The average CRP and SOFA score was higher in period 2, p=0.018; p=0.011. A total of 139 patients underwent continuous veno-venous haemofiltration (CVVH) as a component of fluid resuscitation and IAP control. Application of CVVH increased in period 2, p<0.005. Only 5-8% of patients were managed with ventilatory support. The overall infection rate decreased in period 2 comprising 21%, p<0.005. Success rate of the conservative therapy reached 69% in period 2, p<0.01. Surgical treatment was performed in 41% of patients in period 1 vs. 19% in period 2, p<0.001. Overall mortality was 19%, with a reduction to 12% in year 2006.

CONCLUSION

The conservative protocol-based approach is a rational treatment strategy for the management of SAP and can be successfully implemented in the setting of the university hospital.

Cost-effectiveness analysis of early veno-venous hemofiltration for severe acute pancreatitis in China

AIM: To determine the most cost-effective hemofiltration modality for early management of severe acute pancreatitis (SAP) in China.

METHODS: We carried out a search of Pub-Medline and Chinese Biomedical Disk database. Controlled clinical trials on Chinese population were included in the analysis. The four decision branches that were analyzed were: continuous or long-term veno-venous hemofiltration (CVVH/LVVH), short-term veno-venous hemofiltration (SVVH), SVVH plus peritoneal dialysis (PD), and non-hemofiltration control group. The effectiveness of the technique was determined by survival rate, complications prevention and surgery preservation. The total cost of hospitalization was also assessed.

RESULTS: The SVVH only technique was the least costly modality, $5809 (44 449 RMB), and was selected as the baseline treatment modality. SVVH only arm achieved the lowest C/E ratio in terms of overall survival, complications prevention and surgery preservation. In incremental cost-effectiveness analysis, the CVVH/LVVH only and the control arms were inferior to other techniques. Sensitivity analysis showed SVVH only and SVVH plus PD arms overlapped in C/survival ratio.

CONCLUSION: The role of early veno-venous hemofiltration as an alternative therapy for SAP remains controversial. However, we propose that early use of short-term high-volume veno-venous hemofiltration would have a beneficial impact on the management of SAP.

Organ failure associated with acute pancreatitis in African-American and Hispanic patients

OBJECTIVE

We studied the relationship between acute pancreatitis and organ failure in African-American and Hispanic patients.

METHODS

The medical records of 760 (417 African-American and 343 Hispanic) patients aged 19-85 years diagnosed with acute pancreatitis over 15 years were reviewed retrospectively. We abstracted and analyzed data related to demographics, etiology, type of pancreatitis, organ failure and mortality.

RESULTS

Of the 760 patients, 24% had organ failure. Of the 182 patients with organ failure, 125 patients (69%) had multiple organ failure, whereas 57 patients (31%) had single type. Cardiovascular system failure was the common organ dysfunction (28%). Of the 760 patients, 14% died. Patients with organ failure had a higher mortality (40%) compared with those without it (6%) (OR=9.6, 95% CI: 6.0-15.3) (P=0.001). Mortality was higher among those with multiple organ failure (46%) compared with those with single type (25%). Mortality was highest among those with pulmonary failure (57%).

CONCLUSION

The prevalence of organ failure in our study was slightly higher than the general population (20%). Mortality from single type was higher than that reported in previous studies (8-11%), especially mortality from pulmonary failure (18%). Prevention, early diagnosis and prompt treatment of organ failure may improve the clinical outcome.

Treatment of severe acute pancreatitis by different administration route: a comparative analysis

AIM: To compare the efficacy of rude rhubarb in the treatment of severe acute pancreatitis (SAP) by nasogastric or nasojejunal feeding.

METHODS: SAP patients were divided into group A (n = 20) and B (n = 23) randomly. Based on comprehensive treatment, the patients in group A were given rude rhubarb by nasogastric feeding, while those in group B were given rude rhubarb by nasojejunal feeding. The APACHE-Ⅱ score and Balthazar CT score on the 7th and 14th day were observed, and the level of serum C-reactive protein (CRP) and amylase and the intestinal function were also detected.

RESULTS: On day 7, the APACHE-Ⅱ score in group B was significantly lower than that in group A (3.76 ± 2.82 vs 4.58 ± 2.07, P < 0.05), but Balthazar CT score had no marked difference between the two groups (P > 0.05). On day 14, both the APACHE-Ⅱ score and Balthazar CT score were not notably different between group A and B (P > 0.05). The recovery time of CRP and intestinal function had significant differences between group B and A (8.3 ± 1.7 vs 9.1 ± 3.6, P < 0.05; 6.2 ± 2.9 vs 8.5 ± 2.3, P < 0.01).

CONCLUSION: Application of rude rhubarb by nasojejunal feeding can more effectively control the systemic inflammation in SAP and shorten the course of disease.

Continuous veno-venous haemofiltration in the treatment of severe acute pancreatitis: 6-year experience

BACKGROUND

Continuous veno-venous haemofiltration (CVVH) could be reasonable for attenuation of systemic complications in severe acute pancreatitis (SAP). The aim of the study was implementation and feasibility assessment of the CVVH in the treatment protocol of SAP.

PATIENTS AND METHODS

CVVH was applied to 111 SAP patients during 2000-2005. APACHE II, systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), serum lipase, C-reactive protein (CRP), complication rate and main outcomes were analysed comparing two periods.

RESULTS

Overall, 39 patients corresponded to Balthazar grade E SAP and 72 patients to necrotizing SAP (NSAP), with an average APACHE II score of 7 and 8.5, respectively, on admission. CVVH was started within 48 h in 82% of patients. Duration of CVVH was significantly augmented in NSAP patients during the routine period, comprising 92 h (p=0.006). The clinical presentation of SIRS and MODS was similar in both periods, with more initial pulmonary dysfunctions in NSAP (p=0.048). Peripancreatic infection decreased in the routine period; surgical interventions were performed in 34.8% vs 72.4% of patients. Hospital stay comprised on average 15.9 days for grade E SAP and 29.4 days for NSAP in the routine period, with overall mortality of 10.26% and 30.5%, respectively.

DISCUSSION

Application of CVVH in the treatment protocol of SAP is obscure due to relative invasiveness, a poorly understood mechanism of action and scarce clinical experience. We conclude that early pre-emptive application of CVVH is safe and feasible in the treatment of SAP. Duration of the procedure seems to be essential. Randomized clinical trials are justified. Our results are in favour of clinical application of CVVH in the treatment of SAP.

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Effects of antioxidant on NF-κB and iNOS in rats with acute necrotizing pancreatitis

AIM: To observe the influence of antioxidant N-acetylcysteine (NAC) on nuclear factor-kappa B (NF-κB) and inducible nitric oxide synthase (iNOS) in pancreatic tissue of rats with acute necrotizing pancreatitis (ANP).

METHODS: A total of 95 Spraque-Dawley (SD) male rats were randomly divided into control group (group C, n = 25), acute pancreatitis group (group A, n = 35) and NAC intervention group (group N, n = 35). In group A, SD rats were injected twice intraperitoneally with 8 g/L L-arginine (2×1.2 mg/g) in an interval of 1 hour for ANP. In group C, SD rats received the same amount of saline at the same time. In group N, 0.5 mol/L NAC (0.05 mg/g) was administered intraperitoneally 1 hour before the start of L-arginine injection. Animals were killed at 6, 12, 24, 36, and 48 hours after the first L-arginine injection. The concentration of NF-κB and the activity of iNOS in rat's pancreatic tissue of each group were assayed.

RESULTS: The concentration of NF-κB in pancreatic tissue in group N significantly decreased in earlier period than that in group A (10.4±2.3 vs 89.7±6.4, 6.8±3.2 vs 21.5±3.5, 7.9±3.4 vs 32.5±4.5, 5.4±2.7 vs 14.7±5.2, and 5.0±3.7 vs 11.1±2.3, P < 0.05 or P < 0.01). iNOS activity increased in group A, whereas it significantly decreased in group N (15.2± 4.0 vs 24.2±3.8, 28.3±8.0 vs 36.8±6.0, 25.2±3.8 vs 30.5±3.5 , 21.2±3.7 vs 28.7±7.2, and 18.8±5.5 vs 28.2±4.2, P < 0.05 or P < 0.01).

CONCLUSION: Antioxidants may decrease the activity of iNOS through the inhibition of NF-κB activation.

Formalized therapeutic guideline for hyperlipidemic severe acute pancreatitis

AIM: To investigate a formalized therapeutic guideline for hyperlipidemic severe acute pancreatitis (HL-SAP).

METHODS: Thirty-two consecutive patients with severe acute pancreatitis were included in the clinical trial. All of them met the following five criteria for admission to the study, namely the Atlanta classification and stratification system for the clinical diagnosis of SAP, APACHEII score more than 8, time interval for therapeutic intervention less than 72 h after onset of the disease, serum triglyceride (TG) level 6.8 mmol/L or over, and exclusion of other etiologies. They were divided into severe acute pancreatitis group (SAP, 22 patients) and fulminant severe acute pancreatitis group (FSAP, 10 patients). Besides the conventional therapeutic measures, Penta-association therapy was also applied in the two groups, which consisted of blood purification (adsorption of triglyceride and hemofiltration), antihyperlipidemic agents (fluvastatin or lipanthyl), low molecular weight heparin (fragmin), insulin, topical application of Pixiao (a traditional Chinese medicine) over the whole abdomen. Serum triglyceride, pro-inflammatory cytokines and anti-inflammatory cytokines were determined before blood purification (PF), at the end of blood purification (AFE) and on the 7^th day after onset of the disease (AF7) respectively. Simultaneously, severity of the diseases was assessed by the APACHE II system. Prognosis was evaluated by non-operation cure rate, absorption rate of pseudocyst, time interval pseudocyst absorption, hospital stay and survival rate.

RESULTS: Serum triglyceride level (mmol/L), TNFα (U/mL) concentration and APACHE II score were significantly decreased (P < 0.05) at AFE and AF7, as compared with PF. However, serum IL-10 concentration (pg/mL) was increased significantly (P < 0.001) at AFE, and decreased significantly (P < 0.05) at AF7 when compared with PF. Operations: The First surgical intervention time was 55.8 ± 42.6 d in SAP group (5 patients) and 12.2 ± 6.6 d in FSAP group (7 patients), there was a significant difference between the two groups (P = 0.02). The number of operations in the two groups was 1.33 ± 0.5 vs 3.5 ± 1.2 (P = 0.0037), respectively. Prognosis: Non-operation cure rate, absorption rate of pseudocyst, hospital stay and survival rate in SAP group and FSAP group were 100% (22/22) vs 11.1% (1/9), 77.3% (17/22) vs 11.1% (1/9), 54.2 ± 35.9 vs 99.1 ± 49.5 d (P = 0.008) and 100% (22/22) vs 66.7% (6/9) (P = 0.0044). The time for absorption of pseudocyst was 135.1 ± 137.5 d in SAP group.

CONCLUSION: Penta-association therapy is an effective guideline in the treatment of hyperlipidemic severe acute pancreatitis at its early stage (within 72 h).

Organ failure associated with severe acute pancreatitis

AIM: To investigate the relationship between severe acute pancreatitis (SAP) and organ failure.

METHODS: Clinical data of 74 cases of SAP from Jan. 1993 to Dec. 2002 were retrospectively reviewed, and the relationship between organ failure and age, gender, etiology, extent of necrosis, infection of necrosis and mortality was analyzed.

RESULTS: A total of 47 patients (63.5%) showed organ failure, 20 patients (27.0%) multiple organ failure, whereas 27 patients (36.5%) with dysfunction of a single organ system. Pulmonary failure was the most common organ dysfunction (23.0%) among single organ failures. There were no significant differences in age, gender and gallstone pancreatitis among patients with or without organ failure (P > 0.05). The incidence of organ failure in infected necrosis was not higher compared with sterile necrosis, and patients with increased amount of necrosis did not have an increased prevalence of organ failure (P > 0.05). Patients with organ failure had a higher mortality rate compared with those without organ failure (P < 0.05). The death of SAP was associated with multiple organ failure (P < 0.005), pulmonary failure (P < 0.005), cardiovascular dysfunction (P < 0.05) and gastrointestinal dysfunction (P < 0.05).

CONCLUSION: Organ failure is common in patients with SAP, and patients with multiple organ failure and pulmonary failure have a higher mortality rate. Prevention and active treatment of organ failure can improve the outcome of patients with SAP.

Clinical study on nutrition support in patients with severe acute pancreatitis

AIM: To investigate the effect of nutritional support therapy on severe acute pancreatitis (SAP).

METHODS: A total of 96 patients with severe acute pancreatitis were divided randomly into control and treatment groups. The former group received total parenteral nutrition (TPN) via central venous infusion, while parenteral nutrition (PN) and enteral nutrition (EN) therapies were applied in different phases for the latter group. The nutrition status, acute phase responses, pancreas lesions, enteric mucosa penetrability and immune functions were monitored.

RESULTS: Body weight and prealbumin concentration were increased in treatment group, compared to those in the control group, but albumin concentration did not change significantly. Acute physiology and chronic health evaluation II (APACHE II) scores decreased after 7 d of treatment, whereas the scores of the control group decreased on the 11^th day. Concentrations of tumor necrosis factor-α (TNF-α), interleukine-6 (IL-6) and serum C reactive protein (CRP) dropped earlier in the treatment group (on the 4^th day) than that in the control group (on the 7^th day). No difference was observed in pancreatic lesions between the control and treatment groups. Concentration of endotoxin and lactulose/manicol (L:M) ratio of urine did not change in treatment group, but those in the control group were elevated markedly. Compared with the treatment group, CD4:CD8 T cells ratio and immunoglobulin G (IgG) concentration in the control group decreased significantly.

CONCLUSION: Compared to TPN, the combined therapy of EN and PN could improve the nutrition status and moderate the acute phase response obviously. Moreover, the integrity of enteric mucosa and immune function were protected more effectively in treatment group than in the control one. On the other hand, EN did not simulate the excretion of pancreas and avoid exaggerating the inflammation of pancreas. Thus, appropriate application of PN and EN appears to be more effective for patients with SAP.