Apheresis in acute pancreatitis due to severe Hyper-TG

 Q: 57 year old male is admitted to ICU with severe abdominal pain and hypotension. Patient is diagnosed with acute pancreatitis secondary to severe hypertriglyceridemia. When apheresis is indicated?

Answer: There are two main modes of treatment in patients who present with severe hypertriglyceridemia-induced pancreatitis (HTGP), apheresis, and intravenous insulin infusion. Either treatment is effective but apheresis should be selected in patients with "the presence of worrisome clinical features". Also, if bedside clinicians feel that the severity of acute pancreatitis is high enough to require therapeutic plasma exchange (TPE)/apheresis. Just on a side note, Heparin has also been described as a treatment in HTGP (see our pearl @ https://bit.ly/3iPGcws)

Worrisome features include 

●Signs of hypocalcemia 

●Lactic acidosis 

 ●Two  or more signs of worsening systemic inflammation i.e., 

• temperature either more than 38.5°C or less than 35.0°C, 
• heart rate more than 90 beats/min, 
• a respiratory rate more than 20 breaths/min or PaCO2 of less than 32 mmHg, 
• WBC count of more than 12,000 cells/mL, less than 4000 cells/mL, or >10 percent immature (band) forms. 

●Signs of worsening organ dysfunction or multi-organ failure as defined by the Modified Marshall scoring system for organ dysfunction.

#gastro-enterology

#endocrinology 

References:

1. Alagözlü H, Cindoruk M, Karakan T, Unal S. Heparin and insulin in the treatment of hypertriglyceridemia-induced severe acute pancreatitis. Dig Dis Sci 2006; 51:931. 

2.  Jabbar MA, Zuhri-Yafi MI, Larrea J. Insulin therapy for a non-diabetic patient with severe hypertriglyceridemia. J Am Coll Nutr 1998; 17:458. 

3. Mikhail N, Trivedi K, Page C, et al. Treatment of severe hypertriglyceridemia in nondiabetic patients with insulin. Am J Emerg Med 2005; 23:415. 

4. Betteridge DJ, Bakowski M, Taylor KG, et al. Treatment of severe diabetic hypertriglyceridaemia by plasma exchange. Lancet 1978; 1:1368. 

5. Ipe TS, Pham HP, Williams LA 3rd. Critical updates in the 7th edition of the American Society for Apheresis guidelines. J Clin Apher 2018; 33:78.