Plasmapheresis to Treat Hypertriglyceridemia in a Child With Diabetic Ketoacidosis and Pancreatitis

Lutfi, Riad; Huang, Jennifer; Wong, Hector R.

doi:10.1542/peds.2011-0217

Cited by 47 publications

(51 citation statements)

References 10 publications

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“…However, hypertriglyceridemia secondary to diabetic ketoacidosis was the only cause of acute pancreatitis in the majority of patients recently reported by Fulop and Eder [14]. Indeed, no predisposing etiology other than hypertriglyceridemia due to poorly controlled diabetes was discovered in previous case reports of a similar triad of hypertriglyceridemia, diabetic ketoacidosis, and acute pancreatitis [15,16].…”

Section: Discussionmentioning

confidence: 87%

Therapeutic Plasmapheresis in Primary Presentation of Diabetes Mellitus With Diabetic Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis

Gandham

Yousaf

Win

et al. 2014

World J Nephrol Urol

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Severe hypertriglyceridemia (SHTG)-induced acute pancreatitis has been well described. Currently accepted therapeutic options are limited. We report a case of acute pancreatitis associated with hypertriglyceridemia and diabetic ketoacidosis that was safely and effectively managed with plasmapheresis. A 38-year-old female with history of gestational diabetes presented with acute onset of nausea and abdominal pain. She denied alcohol use and was on oral contraceptive pills. On physical exam, she was afebrile, normotensive, and tachycardic with mild abdominal distension and diffuse tenderness. Diagnostic tests revealed a serum glucose of 414 mg/dL, triglycerides > 816 mg/ dL, amylase of 106 U/L, lipase of 272 U/L, anion gap of 23, BUN of 13 mg/dL, creatinine of 0.3 mg/dL, sodium of 120 mmol/L, HCO 3 of 14 mmol/L, and positive urine ketones. Computed tomography (CT) findings were consistent with severe acute pancreatitis. The patient was managed conservatively on day 1. Due to persistence of symptoms, plasma exchange using NxStage plasmafilter was performed on day 2 and day 3, which resulted in significant reduction of the triglyceride level and resolution of abdominal pain. Patient was discharged home with gemfibrozil and glyburide as maintenance therapy. The exact mechanism of hypertriglyceridemia-induced pancreatitis is not clear. It has been postulated that hyperviscosity of blood due to lipid particles causes ischemia in the pancreas, releasing inflammatory mediators and leading to pancreatic necrosis and inflammation. The advantage of plasmapheresis over conservative management is the removal of lipid particles in a relatively short period of time and clearance of triglyceridemia-associated pro-inflammatory agents.

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Section: Discussionmentioning

confidence: 87%

Therapeutic Plasmapheresis in Primary Presentation of Diabetes Mellitus With Diabetic Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis

Gandham

Yousaf

Win

et al. 2014

World J Nephrol Urol

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“…Insulin is considered to be the drug of choice in severe hyperlipidemia-induced pancreatitis with concomitant hyperglycemia as well, but plasmapheresis and heparin administration as emergency treatment can also be used. Continuous fibrate therapy is needed in order to prevent the recurrence of pancreatitis [5], however if severe lipid disorders are present or lipid lowering drugs are insufficient, nutraceuticals could also be adopted. The lipid lowering drugs combined with fish oil supplementation or berberine, were found to be more effective in lowering LDL cholesterol and triglyceride levels, than the monotherapy [14].…”

Section: Discussionmentioning

confidence: 99%

“…The pathomechanism is not fully understood; the discussion of previous reported cases resulted in many different hypotheses explaining the most likely sequence of events [1]. All previous reports on children suggest that DKA occurring in type 1 diabetes (T1D) as a "first" symptom can cause HL and consequent AP [2][3][4][5][6]. Here, we report another sequence of events for the first time in an adolescent, where hyperlipidemia preceded the onset of diabetic ketoacidosis and led to an acute necrotizing pancreatitis which provoked DKA as the first manifestation of type 2 diabetes (T2D).…”

Section: Introductionmentioning

confidence: 99%

Primary Hyperlipidemia, Acute Pancreatitis and ketoacidosis in an Adolescent with Type 2 Diabetes

Lukács¹,

Barkai²

2016

J Diabetes Metab

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A case is presented of a 15-year-old boy with a past medical history of hyperlipidemia and hypertension. He attended the emergency department with a 3-day history of vomiting, acute abdominal pain, and altered mental status. Laboratory data on admission revealed metabolic acidosis (pH: 7.12, BE: -20.8 mmol/L), high blood glucose level (32.1 mmol/L) and significant hyperlipidemia (cholesterol: 16.3 mmol/L, triglycerides: 21.1 mmol/L). Treatment with electrolytes and volume replacement and intravenous insulin successfully resolved the ketoacidosis, but the abdominal pain and hyperlipidemia remained. Abdominal US and CT scan showed severe necrotizing pancreatitis with a pseudocyst. The laboratory studies showed a Frederickson type V pattern hyperlipidemia. HbA 1c was 14.3% (133 mmol/mol), indicating the presence of chronic glucose elevation. Based on the lack of islet cell antibodies and the normal fasting serum C-peptide level, type 2 diabetes was diagnosed. His HLA DQB1 genotype is associated with neutral autoimmune diabetes risk. The rare and enigmatic triad of diabetic ketoacidosis, hyperlipidemia and acute pancreatitis has been reported in a few adult and childhood cases. The pathomechanism is not clear and the association among the members of the triad may have four different explanations. All previous reports in children, suggest that ketoacidosis occurring in type 1 diabetes as first symptom can cause hyperlipidemia, and consequent acute pancreatitis. However, to the best of our knowledge, this is the first report of a pediatric patient presenting with primary hyperlipidemia-induced acute necrotizing pancreatitis complicated by diabetic ketoacidosis at the onset of non-autoimmune diabetes.

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“…In some instances, TPE for hypertriglyceridemic pancreatitis resulted in improvements in clinical and laboratory findings and patient outcomes. TPE has been effective in acute management of patients with hypertriglyceridemic pancreatitis and acute respiratory distress syndrome, 30 recurrent acute pancreatitis, 29 diabetes-associated severe hypertriglyceridemia, 31 gestational hypertriglyceridemia, 32 and familial hyperlipidemias. 33 In one case, 31 plasmapheresis was used successfully in a child with hypertriglyceridemia, diabetic ketoacidosis, pancreatitis, and acute kidney injury.…”

Section: Discussionmentioning

confidence: 99%

“…TPE has been effective in acute management of patients with hypertriglyceridemic pancreatitis and acute respiratory distress syndrome, 30 recurrent acute pancreatitis, 29 diabetes-associated severe hypertriglyceridemia, 31 gestational hypertriglyceridemia, 32 and familial hyperlipidemias. 33 In one case, 31 plasmapheresis was used successfully in a child with hypertriglyceridemia, diabetic ketoacidosis, pancreatitis, and acute kidney injury. TPE is also an effective treatment in hypertriglyceridemia associated with ritonavir 34 and with asparaginase chemotherapy for acute lymphocytic anemia in adults and children.…”

Section: Discussionmentioning

confidence: 99%

Plasmapheresis in the Management of Severe Hypertriglyceridemia

Seda

Meyer

Amundson

et al. 2013

Critical Care Nurse

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P lasmapheresis is an advanced and established extracorporeal therapy in critical care, a process in which plasma, the fluid part of the blood, is separated from blood cells by a device known as a cell separator. In critically ill patients, plasmapheresis is used to remove toxins, medications, destructive antibodies, and clotting factors from the peripheral circulation. During plasmapheresis, a nurse uses a cell separator that either spins the blood to separate the cells from the fluid or filters the blood through a membrane with extremely small pores that allow only the fluid part to pass through. Although in current practice the terms plasmapheresis and therapeutic plasma exchange (TPE) are often used interchangeably, TPE This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:1. Describe use of plasmapheresis for the management of severe hypertriglyceridemia 2. Identify conventional therapeutic modalities used for management of hypertriglyceridemia 3. Discuss effects of hypertriglyceridemia on clinical laboratory tests CNE Continuing Nursing Education CoverPlasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis. (Critical Care Nurse. 2013;33[4]:18-24) 18 CriticalCareNurse Vol 33, No. 4, AUGUST 2013 www.ccnonline.org by AACN on May 9, 2018 http://ccn.aacnjournals.org/ Downloaded from takes the actual plasmapheresis procedure a step further: Plasma is separated from whole blood and discarded, and then a volume of replacement fluid equal to the volume of the discarded plasma is infused. Usually a patient has a needle or a catheter inserted into a vein in each arm, allowing the blood to be taken from one arm and circulated through the cell separator to remove the plasma. The aspiration device on the machine is adjusted to remove the undesirable blood components and then return the rest...

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Plasmapheresis to Treat Hypertriglyceridemia in a Child With Diabetic Ketoacidosis and Pancreatitis

Cited by 47 publications

References 10 publications

Therapeutic Plasmapheresis in Primary Presentation of Diabetes Mellitus With Diabetic Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis

Therapeutic Plasmapheresis in Primary Presentation of Diabetes Mellitus With Diabetic Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis

Primary Hyperlipidemia, Acute Pancreatitis and ketoacidosis in an Adolescent with Type 2 Diabetes

Plasmapheresis in the Management of Severe Hypertriglyceridemia

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