Plasmapheresis Hypertriglyceridemic Pancreatitis

## Plasmapheresis for Hypertriglyceridemic Pancreatitis with Intra-Abdominal Infection: Clinical Outcomes **Conclusion**: Current evidence does not support routine use of plasmapheresis for hypertriglyceridemia-associated acute pancreatitis (HTGP), even in the setting of intra-abdominal infection, as available data show no improvement in organ failure or mortality, with potential harm including prolonged ICU stay. ### Clinical Evidence Summary | Outcome Domain | Evidence from Retrieved Sources | Key Findings | |----------------|-------------------------------|--------------| | **Mortality** | Systematic review & prospective cohort [1][2] | No mortality benefit demonstrated; single prospective study (60 vs 34 patients) showed no survival advantage over conservative management | | **Organ Failure** | Multicenter prospective cohort (Cao et al., JAMA Netw Open 2023) [1] | Plasmapheresis did **not** reduce incidence or duration of organ failure | | **ICU Stay** | Same multicenter cohort [1] | **Increased** ICU length of stay associated with plasmapheresis | | **Triglyceride Reduction** | Case series [1][2] | Effective at acutely lowering serum TG (50-80% per single session), but this does not translate to improved clinical outcomes | | **Intra-abdominal Infection** | No specific data in retrieved evidence | No retrieved studies address plasmapheresis outcomes specifically in HTGP complicated by intra-abdominal infection | ### Safety and Practical Considerations | Factor | Detail | |--------|--------| | **Adverse Events** | Requires central venous access; risk of infection, allergic reactions, bleeding [2] | | **Cost** | High cost, limited availability [1][2] | | **Temporizing Effect** | TG reduction is transient without addressing underlying etiology [4] | ### Guideline Recommendations | Source | Recommendation | Strength | |--------|---------------|----------| | **IAP Revised Guidelines 2025** [1] | Plasmapheresis should be used **selectively** in HTGP; due to high cost, invasive approach, unclear benefits, and risk of adverse events | Strong recommendation; low-quality evidence | | **American Society of Apheresis** [2] | Approved for **severe** HTGP with worsening organ dysfunction/multi-organ failure, worsening systemic inflammation, or lactic acidosis — **only after insulin failure** | Conditional | | **Endocrine Society Guideline** [4] | Consider only in patients who do **not** respond to conventional methods or with extraordinarily elevated TG (e.g., >10,000 mg/dL [112.9 mmol/L]) | Weak recommendation | ### Critical Gap: Intra-Abdominal Infection The retrieved evidence contains **no data** specifically evaluating plasmapheresis outcomes in HTGP patients with concurrent intra-abdominal infection. In this context: - The theoretical concern is that plasmapheresis may remove inflammatory cytokines but also beneficial immune mediators, potentially worsening infection control - The invasive nature (central venous access) adds infection risk to an already infected patient - Standard management of infected pancreatic necrosis (antibiotics, source control if indicated) should take priority ### Recommended Management Algorithm (Based on Retrieved Guidelines) 1. **First-line**: Conservative management — bowel rest, aggressive IV hydration, pain control [1][2] 2. **TG reduction**: Insulin infusion (0.1 U/kg/hr with dextrose 5%) until TG <500 mg/dL [2] 3. **Plasmapheresis consideration**: Only if insulin fails AND worsening organ dysfunction/multi-organ failure develops [2][4] 4. **Infection management**: Antibiotics and source control per standard acute pancreatitis guidelines (not addressed in retrieved HTGP-specific sources) --- *This analysis is based on retrieved literature and is intended for clinical reference. Individual patient management should incorporate clinical judgment, local resources, and multidisciplinary consultation.*