Treatment of Hyperlipidemic Acute Pancreatitis With Plasma Exchange: A Single‐Center Experience

Abstract

Of the cases of acute pancreatitis, 1-7% are caused by severe hypertriglyceridemia and can be treated with plasma exchange (PE). We report on a large series of patients with acute hyperlipidemic pancreatitis (HLP) treated with PE. In the 1992-2008 period, 50 patients (45 +/- 8 years old, 92% male) with acute HLP were treated with PE, during which 1-2 plasma volumes were exchanged. Heparin was used as anticoagulant in 85% of the procedures, and citrate in the rest. Cholesterol and triglycerides were measured before and after PE. In the 2003-2008 cohort of 40 patients, we retrospectively recorded an Acute Physiology and Chronic Health Evaluation II (APACHE II) score at the first PE session, hospital mortality, and length of hospital stay. A total of 79 PE treatments were done, 1-5 per patient. The volume exchanged was 4890 +/- 1300 mL over a duration of 3.5 +/- 2 h. During the first PE, the triglycerides were lowered from 58.9 +/- 40.8 to 10.8 +/- 10.8 mmol/L, and the total cholesterol was lowered from 20.0 +/- 7.6 to 5.7 +/- 4.3 mmol/L. In 10% of the procedures the plasmafilter was replaced, and in 3% the filter was clotted. Hypotension occurred in 3% of PE and there was one case of gastrointestinal bleeding after PE with heparin anticoagulation. In the 2003-2008 cohort, the median APACHE II score was 5 (range 0-15), the median overall hospital stay was 18 days (range 3-142 days) and the hospital mortality was 15%. To conclude, in acute hyperlipidemic pancreatitis, one to two plasma exchanges effectively reduce the serum triglyceride level. There is a low rate of procedure-related complications. A mortality rate of 15% is considerable.

Lipoprotein apheresis

“…The greatest reduction was observed when a centrifugal cell separator was used and it was noted that most patients' abdominal pain was relieved within 30 min of commencing the procedure [21]. A similar reduction in triglyceride was reported using membrane filtration; however, the plasma separator had to be replaced in 10% of the procedures because of an increase in transmembrane pressure and in 3% because of clot in the filter [24 ].…”

Current knowledge of hypertriglyceridemic pancreatitis

“…In some centers, plasmapheresis is only used in severe AP [63], but other centers even treat patients with low APACHE II scores [66,70]. The only paper comparing subjects with conservative managements vs. plasma exchange, showed no benefits in terms of mortality [64].…”

“…Table 1 summarizes main demographic data, comorbidities, type of replacement, serum TG before plasma exchange is done, the percentage of reduction and the in-hospital mortality for those papers published including more than five patients [63][64][65][66][67][68][69][70][71]. One single session of plasma exchange is able to reduce serum TG from 49 to 80%, although few patients need two or more sessions to reach a TG level below 1000 mg/dL.…”

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

“…In addition to eliminating oral intake, hydration and analgesia, which constitute the standard therapy of pancreatitis of any etiology, specific therapies have been used to reduce triglyceride levels, including heparin and insulin [8], [14], as well as plasma exchange [15]–[19]. Heparin stimulates the release of endothelial lipoprotein lipase into circulation, while insulin activates lipoprotein lipase, therefore increasing the clearance of chylomicrons from plasma.…”