Treatment of Hyperlipidemic Acute Pancreatitis With Plasma Exchange: A Single-Center Experience Jakob Gubenšek, Jadranka Buturovic ´-Ponikvar, Andreja Marn-Pernat, Janko Kovac ˇ, Bojan Knap, Vladimir Premru, and Rafael Ponikvar Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia 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 Evalu- ation 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 plasmafil- ter was replaced, and in 3% the filter was clotted. Hypoten- sion occurred in 3% of PE and there was one case of gastrointestinal bleeding after PE with heparin anticoagu- lation. 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. Key Words: Hypertriglyceridemia, Pancreatitis, Plasma exchange, Total cholesterol. Acute hyperlipidemic pancreatitis (HLP) is an acute pancreatitis occurring in the presence of severe hypertriglyceridemia and in the absence of other causes (1). While mild hyperlipidemia is common in acute pancreatitis of any etiology (2,3), severe hyper- triglyceridemia, on the other hand, is recognized as the underlying cause in 1–7% of all cases of acute pancreatitis (4,5). The risk of HLP is believed to increase rapidly when triglycerides are above approximately 10–20 mmol/L (1,6), which is the level at which chylomicrons begin to form.To achieve such a high triglyceride level, a patient usually has an underlying lipid abnormality and a secondary factor (e.g. uncontrolled diabetes, alcohol intake, or medica- tion) (2). The exact pathophysiology of HLP is uncertain. It is known that chylomicrons impair blood flow in the capillary beds, thereby causing ischemia within the pancreas. Ischemia probably causes pancreatic lipase to hydrolyze triglycerides into free fatty acids, which are toxic to acinar cells and the vascular endothelium (7). In this way, inflammation can be started and amplified within the pancreas. The proposed mecha- nism is partially supported by animal studies showing that hyperlipidemia intensifies the course of pancre- atitis in rats (8), although in humans no difference was observed in the clinical course of HLP and pan- creatitis from other causes (4). Plasma exchange (PE) was shown to rapidly lower the triglyceride level and ameliorate the course of HLP (9–11), but this treatment is not accepted and applied universally. In this single-center retrospective cohort observational study, we report our experience with PE in the setting of acute HLP. Received May 2009. Address correspondence and reprint requests to Dr Jakob Gubenšek, Klinic ˇni oddelek za nefrologijo, Univerzitetni klinic ˇni center Ljubljana, Zaloška cesta 7, SI-1000 Ljubljana, Slovenia. Email: jakob.gubensek@kclj.si Conflict of interest statement: None to declare. Therapeutic Apheresis and Dialysis 13(4):314–317 doi: 10.1111/j.1744-9987.2009.00731.x © 2009 The Authors Journal compilation © 2009 International Society for Apheresis 314