(292) Plasma Exchange for Hypertriglyceridemic Pancreatitis: Is There a Benefit?

Introduction: Hypertriglyceridemic pancreatitis (HP) is the third most common cause of pancreatitis in the United States with rates between 5-22%. HP incidence has increased parallel to rising obesity and diabetes mellitus. Plasma exchange (PLEX) has been described as a treatment for HP, however, there is scant literature supporting its use. In this report, we describe a severe case of HP and review PLEX HP treatment efficacy.

Description: A patient with prior mild HP episodes was admitted to the floor with his typical HP symptoms. He decompensated with lactic acidosis, hypocalcemia, acute kidney injury, a triglyceride (TG) level of 5136 mg/dL, and pancreatic necrosis on computed tomography. He was started on an insulin infusion and fluid resuscitated. He was transferred to the intensive care unit (ICU) and rapidly worsened with multiorgan failure requiring intubation, renal replacement, and multiple vasopressors. He received two PLEX treatments for his worsening condition, ultimately, he recovered and was discharged home.

Discussion: HP develops when TG levels, typically over 1000 mg/dL, overwhelm the adipocyte storage system and directly injure the pancreas. PLEX pulls TG from circulation, removing the damaging substrate, making it an appealing modality. Studies have investigated PLEX as an HP treatment, but most are small case series or retrospective studies. Often PLEX is compared to insulin infusion therapy, which promotes TG storage as its treatment mechanism. PLEX reliably decreases TG levels by 50-75%, reducing TG levels quicker than insulin, however, no study to date has shown a mortality benefit with PLEX over insulin. Currently, guidelines do not endorse routine PLEX in HP. Investigations have focused on specific populations potentially benefiting from PLEX therapy: early PLEX recipients, very high TG level, and severe HP. None of these subpopulations gained a mortality benefit. PLEX is not without potential harm. It involves invasive catheter placement, may require transferring an unstable patient to a PLEX capable facility, and carries anaphylaxis or transfusion reaction risk. Well designed, rigorous studies to identify candidates potentially deriving benefit from PLEX are needed as HP incidence increases, and this difficult treatment consideration becomes increasingly common in the ICU.