Therapeutic plasmapheresis for hypertriglyceridemia-associated acute pancreatitis: case series and review of the literature

Abstract

Background: Severe hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (AP) in the United States. The current standard of care includes management of HTG using pharmacological therapy. More recently, plasmapheresis has been proposed as a therapeutic tool for decreasing triglyceride (TG) levels, especially in critically ill patients. Few studies are available to ascertain overall benefits of plasmapheresis over traditional management. Objective: To analyze the outcomes of patients treated with plasmapheresis for severe HTGassociated pancreatitis. Methods: We conducted a retrospective chart review of three patients with severe HTGassociated (TGs greater than 1000 mg/dl; 11.29 mmol/l) AP at the Methodist University Hospital. All the patients underwent plasmapheresis as part of their treatment. Results: The average TG level before plasmapheresis was 3532 mg/dl (range: 2524-4562 mg/ dl; 39.9 mmol/l; range: 28.5-51.6 mmol/l). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 1.3 (range 1-2), and mean TG level after plasmapheresis was 1051 mg/dl (range: 509-1771 mg/dl; 11.9 mmol/l; range: 5.8-20 mmol/l). After the first session, the average reduction of TG level was 2481 mg/dl (range 753-3750 mg/dl; 28 mmol/l; range: 8.5-42.4 mmol/l) or approximately 70%. None of the patients developed complications related to plasmapheresis. Conclusions: Plasmapheresis can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.

Conservative management in hypertriglyceridemia‐associated pancreatitis

“…This case series highlights the natural trajectory of serum TG in patients managed conservatively with fasting, hydration, pain management and alleviation of underlying contributing factors. The 22 episodes of HTG-associated pancreatitis in our series had a calculated fall in serum TG of 69.8% by 48 h. This rate of decline is similar to those reported in plasmapheresis case series, which demonstrated 49-80% reductions in serum TG after a single session [2, 5,6,20,30,33,34,36,39,48,53,54,[58][59][60]. These findings are also consistent with other observational reports that showed no difference in the rate of TG decline between patients managed with or without plasmapheresis [47].…”

“…Heparin and/or insulin infusions have been successfully used in cases of HTG‐related pancreatitis, especially when hyperglycaemia was present . Uncontrolled and retrospective case reports and series showed reduced TG levels following plasmapheresis , but minimal outcome data. A systematic review of apheresis used in HTG‐associated pancreatitis could not determine benefit for morbidity, mortality or pancreatitis severity .…”

Apolipoprotein C-II: New findings related to genetics, biochemistry, and role in triglyceride metabolism

“…This can also be implemented as a prophylactic therapy to rapidly lower TG if needed 125 . The recent development of an apoC-II mimetic peptide, which incorporates the third helix of apoC-II, has shown some promise as potential future therapy.…”

Emodin in Severe Acute Pancreatitis Treatment

“…There is no significant association between the level of blood triacylglycerol and the severity of severe acute pancreatitis. Control of blood triacylglycerol levels can prevent the recurrence of acute pancreatitis [16].…”