Factors Affecting Outcome in Acute Hypertriglyceridemic Pancreatitis Treated with Plasma Exchange: An Observational Cohort Study

Abstract

ObjectivesThe optimal therapy for hypertriglyceridemic acute pancreatitis, especially the role of plasma exchange (PE), is not entirely clear. The aim of our large, single-center, observational, cohort study was to analyze the factors affecting outcome in hypertriglyceridemic pancreatitis treated with PE.MethodsWe included 111 episodes of hypertriglyceridemic pancreatitis treated with PE, which occurred in 103 different patients. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, triglycerides, delay to first PE, and PE treatment details were retrospectively obtained from the patients’ records. The main outcome measures were length of hospitalization and in-hospital mortality.ResultsThe patients were 47±9 years old and the median APACHE II score at first PE was 4 (inter-quartile range (IQR) 2–7). There was a seasonal variation in the incidence of hypertriglyceridemic pancreatitis, and the recurrence rate was 1.6% per year. Triglycerides at presentation did not correlate with APACHE II or influence the outcome. The mean reduction in triglycerides during PE was 59% (from 44±31 to 18±15 mmol/l), which was twice the reduction observed during conservative treatment (27% daily). The median hospital stay was 16 days (IQR 10–24) and in-hospital mortality was 5%. The median delay to first PE was 35 hours (IQR 24–52), and there was no difference in mortality in the early and late PE groups (7% vs. 6%, p = 0.79). The group with citrate anticoagulation during PE had a significantly lower mortality than the group with heparin anticoagulation (1% vs. 11%, p = 0.04), and citrate was an independent predictor also in the multivariate model (p = 0.049).ConclusionsPE effectively reduced serum triglycerides faster than could be expected with conservative treatment. The delay in PE therapy did not influence survival. We found that citrate anticoagulation during PE was associated with reduced mortality, which should be confirmed in a randomized study.

Plasmapheresis in the Management of Acute Pancreatitis due to Severe Hypertriglyceridemia—Reporting New Cases

“…This review is consistent with the findings of Chen and Gubensek (19) and reported the absence of randomized controlled trials about the effectiveness of the technique (9,22). However, there has been an increasing number of successful cases described.…”

“…Ramirez et al (17) described 11 patients submitted to PFin eight patients, a single plasma exchange was sufficient to reduce TG <1000 mg/dl. Only three patients died, all with the worst severity indexes and who experienced most delay before the procedure (19). The Clinical Practice Guidelines recommend daily PF for 1-3 days depending on the patient course and TG level (15,20).…”

“…The goal is to achieve TG concentrations lower than 500-1000 mg/dl. Heparin use as anticoagulant for the procedure may have advantages considering its ability to release LPL, enhancing TG reduction (19).…”

Up-Regulation Mttp and Apob Gene Expression in Rat Liver is Related to Post-Lipectomy Hypertriglyceridemia

“…Furthermore, some studies documented a post-liposuction increase in serum TAG concentration [8]. Since an increase in serum TAG concentration was shown to be associated with elevated risk of myocardial infarction, ischemic stroke, preterm death [9,10,11] and acute pancreatitis [12], the post-lipectomy changes in serum TAG concentration require further study.…”

High-volume hemofiltration is not preferred for hypertriglyceridemia-induced pancreatitis

“…Three of the case reports used insulin and heparin therapy, two used plasma exchange therapy, and one used a combination of fish oil, insulin, and gemfibrozil. An observational cohort study 8 referenced on UpToDate® examined the differences between heparin and citrate use in plasmapheresis therapy and found that heparin was associated with a higher mortality.…”