The role of plasmapheresis in the treatment of hypertriglyceridemia-induced acute pancreatitis
American Journal of Emergency Medicine 38 (2020) 1515-1539
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The role of plasmapheresis in the treatment of hypertriglyceridemia-induced acute pancreatitis
Dear Editor,
We have read the article titled “Critical pancreatitis management as- sociated with hypertriglyceridemia in pregnancy in emergency service” published by Satilmis et al. [1] with great interest. We thank the authors for this informative and successful manuscript. We also would like to mention a few important points about plasma exchange therapy (plas- mapheresis/apheresis) in acute pancreatitis.
Standard treatment modalities may be inadequate in the treatment of hypertriglyceridemia-induced acute pancreatitis (HIAP) [2]. In such a case, the primary goal of treatment is to rapidly reduce excessively el- evated triglyceride levels in the blood [2]. The use of plasmapheresis for this purpose has become widespread in recent years. In patients with HIAP, plasmapheresis has been reported to speed up the Healing process not only because it rapidly cleanses excessively high triglyceride levels in the blood, but also reduces Proinflammatory cytokines (such as tumor necrosis factor-? and interleukin-1) [3]. A number of recent studies have shown that the treatment of severe HIAP with plasmaphe- resis significantly improves clinical outcomes [3-5]. Triglyceride levels have been reported to decrease by 54% after a single plasmapheresis session in patients with HIAP. After the second plasmapheresis session, the triglyceride level in the blood has been reported to decrease by 79% [5]. Plasmapheresis has been further reported to significantly reduce the incidence of systemic inflammatory response syndrome and length of hospital stay. According to the findings obtained from these studies, plasmapheresis has been suggested to be effective in the treatment of cases with severe hypertriglyceridemia (N1000-2000 mg/dL) and se- vere HIAP [3,5]. Therefore, it is of great importance to estimate or deter- mine the severity of the disease in the early stage in HIAP cases.
Several scoring systems (e.g. Ranson criteria, revised Atlanta classifi- cation, and Bedside index for the severity of acute pancreatitis) are cur- rently used to detect Severe acute pancreatitis in the early period [6,7]. Ranson criteria, the most commonly used one, consist of 11 parameters. Five of them are evaluated at the time of admission, while the remaining six are evaluated 48 h after admission. A score is given for each positive criterion. The 5 criteria that are evaluated at the initial presentation are: age N55, glucose N200 mg/dL, WBC count N16,000/mm3, serum AST N250 IU/L, and serum LDH N350 IU/L [6]. Similarly, in the study by Satilmis et al. [1], Ranson’s criteria were used to evaluate the severity of acute pancreatitis. The authors have reported that the patient’s Ranson score at the time of admission was 5. However, this caused con- fusion for us because the above-mentioned 5 criteria must be positive to have an initial Ranson score of 5. However, in this article, the patient’s glucose level was reported to be 102 mg/dL at the time of admission to the emergency department. Furthermore, Biochemical parameters
such as AST and LDH gave lipemic stimulation (lactescent serum) and could not be measured. Therefore, the patient’s initial Ranson score can- not be 5. Perhaps this reported Ranson score is the Ranson score mea- sured 48 h after admission, not the one measured at the time of admission.
Financial support
The authors declared that this study has received no financial support.
Declaration of competing interest
No conflict of interest was declared by the authors.
Kamil Kokulu MD? Serdar Ozdemir MD Abdullah Algin MD Serdar Ozdemir MD
Department of Emergency Medicine, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
?Corresponding author at: Umraniye Training and Research Hospital, Department of Emergency Medicine, Elmalikent Mahallesi Adem Yavuz
Cad. No: 1 Umraniye, 34764 Istanbul, Turkey.
E-mail address: drkokulu@gmail.com.
22 November 2019
https://doi.org/10.1016/j.ajem.2020.01.032
References
- Satilmis D, Turkoglu O, Guven R, Cander B. Critical pancreatitis management associ- ated with hypertriglyceridemia in pregnancy in emergency service. Am J Emerg Med 2020;38(7):1516.
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- Gavva C, Sarode R, Agrawal D, Burner J. therapeutic plasma exchange for hypertri- glyceridemia induced pancreatitis: a rapid and practical approach. Transfus Apher Sci Off J World Apher Assoc Off J Eur Soc Haemapheresis 2016;54:99-102. https:// doi.org/10.1016/j.transci.2016.02.001.
- Huang C, Liu J, Lu Y, Fan J, Wang X, Liu J, et al. Clinical features and treatment of hypertriglyceridemia-induced acute pancreatitis during pregnancy: a retrospective study. J Clin Apheresis 2016;31:571-8. https://doi.org/10.1002/jca.21453.
- Kandemir A, Coskun A, Yavasoglu I, Bolaman Z, Unubol M, Yasa MH, et al. Therapeutic plasma exchange for hypertriglyceridemia induced acut pancreatitis: the 33 cases ex- perience from a tertiary reference center in Turkey. Turk J Gastroenterol Off J Turk Soc Gastroenterol 2018;29:676-83. https://doi.org/10.5152/tjg.2018.17627.
- Kuo DC, Rider AC, Estrada P, Kim D, Pillow MT. Acute pancreatitis: what’s the score? J Emerg Med 2015;48:762-70. https://doi.org/10.1016/j.jemermed.2015.02.018.
- Kokulu K, Gunaydin YK, Akilli NB, Koylu R, Sert ET, Koylu O, et al. Relationship be- tween the neutrophil-to-lymphocyte ratio in acute pancreatitis and the severity and systemic complications of the disease. Turk J Gastroenterol Off J Turk Soc Gastroenterol 2018;29:684-91. https://doi.org/10.5152/tjg.2018.17563.
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