Long-Term Plasma Exchange for Severe Refractory Hypertriglyceridemia: A Decade of Experience Demonstrates Safety and Efficacy Michal Schaap-Fogler, 1 Daniel Schurr, 2 Tova Schaap, 3 Eran Leitersdorf, 2 and Deborah Rund 3 * 1 Faculty of Medicine, Hadassah University Hospital, Jerusalem, Israel 2 Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah University Hospital, Jerusalem, Israel 3 Plasmapheresis Unit, Hematology Department, Hadassah University Hospital, Jerusalem, Israel Hypertriglyceridemia (hyperTG) is a common form of dyslipidemia and is frequently associated with premature coronary disease, and when severe, recurrent events of pancreatitis may occur. The management of hyperTG is generally medical (life style modification, medications). Plasma exchange (PE) has been reported to be useful in emergency situations particularly when acute pancreatitis results from extreme hyperTG. To our knowledge, there is only one report on long-term use of PE for hyperTG. We here report our results of long-term treatment of hyperTG in 6 patients with Frederickson Type V hyperlipidemia who had recurrent attacks of pancreatitis due to hyperTG refractory to medical therapy. PE was performed from one to eight times a month, mostly using a Cobe Spectra apparatus. In total, our center has performed a total of 1,593 PE sessions for hyperTG. There were no safety issues associated with PE for hyperTG other than occasional access problems (clotted fistula, IV access problems). Determination of plasma TG levels before and after PE demonstrated high efficiency of TG removal (42% to 58% reduction). There was marked clinical improvement in recurrent pancreatitis; patients had a major decrease in episodes (39% to 100%) while on regular PE, as long as they adhered to the treatment schedule. We conclude that long-term PE for hyperTG, while costly, is feasible and safe and may reduce recurrent attacks of pancreatitis. J. Clin. Apheresis 24:254–258, 2009. V V C 2009 Wiley-Liss, Inc. Key words: plasmapheresis; hyperlipidemia; acute pancreatitis INTRODUCTION Hypertriglyceridemia (hyperTG) is a common form of dyslipidemia. The prevalence of hyperTG, defined as triglyceride (TG) levels >150 mg/dl [1], in United States adults age 20 years and older is estimated at 25% to 35% [2]. Some studies suggest that high serum TG levels are an independent risk factor for cardiovascular disease, after controlling for low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol [3,4]. Patients with serum TG levels of >200 mg/dl are at increased risk of developing an acute episode of pancreatitis [5–7]. Elevated serum TG levels are most often observed in persons with the metabolic syndrome. Less than 5% of cases of hyperTG have a known molecular basis. Factors contributing to elevated levels of TG include obesity and overweight, physical inactivity, cigarette smoking, excess alcohol intake, high-carbohydrate diets, pregnancy, sev- eral diseases (non-insulin dependent diabetes mellitus (NIDDM), chronic renal failure, nephrotic syndrome), drugs (corticosteroids, estrogens, retinoids), and genetic disorders (familial combined hyperlipidemia, familial hyperTG, familial dysbetalipoproteinemia) [8–12]. HyperTG can be categorized by the Fredrickson classification, based on the type of lipoprotein elevated [13]. According to this classification, all but one of the hyperlipidemias, Type IIa, are characterized by ele- vated triglycerides: Types I, IIb, III, IV, and V. In Type V, the lipoproteins increased are VLDL and chylomicrons. Serum total cholesterol levels are also elevated, whereas LDL cholesterol levels are normal. The management of hyperTG is generally medical (life style modification combined with medications). Acute pancreatitis, a major complication in patients with hyperTG, is an inflammation of the pancreas, resulting in a sudden onset of unrelenting upper abdominal pain. Treatment, which is mainly conserva- tive (bowel rest, volume resuscitation, analgesia, antibi- otics), requires hospitalization with close medical observation. Patients with severe or necrotizing pancre- atitis may need surgical intervention and admission to intensive care units. Mortality in hospitalized patients is estimated at 2% to 22% [14]. *Correspondence to: Deborah Rund, Hadassah University Hospital, Jerusalem, Israel, POB 12000, Jerusalem, Israel IL-91120. E-mail: rund@cc.huji.ac.il Received 24 July 2009; Accepted 3 November 2009 Published online 19 November 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jca.20224 V V C 2009 Wiley-Liss, Inc. Journal of Clinical Apheresis 24:254–258 (2009)