Objectives: Interleukin (IL)-21 is a cytokine associated with tissue inflammation, autoimmune and infectious diseases. Organ dysfunction and death can occur in patients with acute pancreatitis in two distinct clinical phases. Initially, a systemic inflammatory response syndrome which may be followed by systemic sepsis from infected pancreatic necrosis, known as the 'second hit'. The expression and possible role of IL-21 in acute pancreatitis has not been established. Methods: Thirty-six patients with mild, moderate and severe acute pancreatitis were enrolled. Peripheral blood samples of patients were drawn on days 7, 9, 11, and 13. Reverse transcription polymerase chain reaction and enzyme-linked immunosorbent assay were performed to determine the expression and concentration of IL-21. Results: Interleukin-21 mRNA levels increased significantly at day 9 in severe (P = 0.002) pancreatitis compared to both the mild and control patient groups. At the protein level, IL-21 was elevated in severe acute pancreatitis patients compared to mild, although this was not significant. Furthermore, day 9 IL-21 was elevated in septic severe acute pancreatitis patients and patients with pancreatic necrosis. Conclusions: Interleukin-21 is transiently elevated in severe acute pancreatitis compared to the mild/moderate group and hence IL-21 may contribute to the immune imbalance that occurs in acute pancreatitis.