| Objectives To investigate the patterns of change in triglyceride during the clinical course of acute pancreatitis and its clinical significance; to evaluate the triglyceride-lowering effect of hemopurification therapy and its influence on the severity and clinical outcome of acute pancreatitis; to assess the safety of parenteral fat emulsions in patients with acute pancreatitis.Methods (A) Consecutive cases of acute pancreatitis receiving conventional therapy were collected. Based on their serum triglyceride (TG) levels at admission, the patients were divided into Severe Hypertriglyceridemia Group (TG>11.3 mmol/L), Moderate Hypertriglyceridemia Group (5.65<TG<11.3 mmol/L), Mild Hypertriglyceridemia Group (1.7<TG<5.65 mmol/L) and Normal Serum Triglyceride Group (TG<1.7 mmol/L). Analyses of the clinical characteristics and the patterns of change in triglyceride of each group, as well as the correlation between the concentrations of other serum lipids (including total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, lipoprotein (a), apolipoprotein Al, apolipoprotein B and apolipoprotein E) and triglyceride, were carried out. (B) Consecutive cases of hypertriglyceridemia-induced acute pancreatitis receiving hemopurification or conventional therapy were retrospectively reviewed. The levels of serum triglyceride, amylase, lipase, calcium, white blood cell count, C-reactive protein and the APACHE II scores and the percentages of change in serum triglyceride concentration at different time points during hospitalization were compared between the Hemopurification Group and the Conventional Treatment Group. The durations of abdominal pain, persisting tenderness or rebound tenderness and impaired gastrointestinal motility, the incidence of local or systemic complications, the need for surgical intervention, the efficacy and the length of hospital stay were also included in the comparison. (C) Consecutive cases of acute pancreatitis receiving intravenous fat emulsions or conventional therapy as the control were analyzed. The levels of serum triglyceride, amylase, lipase, calcium, white blood cell count and C-reactive protein and the APACHE II scores at different time points during hospitalization were compared between the Fat Emulsion Group and the Control Group. The durations of abdominal pain, persisting tenderness or rebound tenderness and impaired gastrointestinal motility, the incidence of local or systemic complications, the need for surgical intervention, the efficacy and the length of hospital stay were included in the comparison as well.Results (A) 134 cases of acute pancreatitis receiving conventional therapy were analyzed, including 51 cases (38.06%) in Severe Hypertriglyceridemia Group,24 (17.91%) in Moderate Hypertriglyceridemia Group,24 (17.91%) in Mild Hypertriglyceridemia Group and 35 (26.12%) in Normal Serum Triglyceride Group. Patients in Severe and Moderate Hypertriglyceridemia Groups were statistically younger than those in Normal Serum Triglyceride Group (41.29±8.80/40.88±9.27 VS 51.04±16.22 years, P=0.011). There was a 3-stage pattern of change in serum triglyceride in Severe and Moderate Hypertriglyceridemia Groups, as during the first 48 hours of hospitalization, the serum triglyceride concentration fell rapidly, followed by a gradual decline within the first week and the maintenance of serum triglyceride at a slightly higher-than-normal level thereafter. Percentages of fall in serum triglyceride level during the first 24 hours in the above two groups were (46.22±25.96)% and (50.87±26.09)% respectively, with the values being (61.10±21.07)% and (72.35±16.21)% during the first 48 hours. A2-stage pattern of change in serum triglyceride was noticed in Mild Hypertriglyceridemia Group, for the serum triglyceride level gradually declined within 3-4 days after admission and since then the level remained mildly elevated. In contrast, a trend of increase in serum triglyceride concentration was observed in Normal Serum Triglyceride Group but the value never exceeded 5.65 mmol/L. A positive correlation was seen between serum total cholesterol and triglyceride levels within the first week. (B) 16 patients with hypertriglyceridemia-induced acute pancreatits undergoing hemopurification therapy and 39 patients receiving conventional therapy as the control group were included in the analysis. For hypertriglyceridemia-induced moderately severe acute pancreatitis, there was no statistical difference between the Hemopurification Group and the Conventional Treatment Group in serum triglyceride level and the percentages of change in serum triglyceride concentration at different time points. Nor was there any significant difference between the two groups in the severity-related indices (serum amylase, lipase, calcium, white blood cell count and C-reactive protein level and the APACHE II scores) and the clinical outcome-related indices (durations of abdominal pain, persisting tenderness or rebound tenderness and impaired gastrointestinal motility, the incidence of local or systemic complications, the need for surgical intervention, the efficacy and the length of hospital stay). For hypertriglyceridemia-induced severe acute pancreatitis, the difference in triglyceride-lowering effect between the Hemopurification Group and the Conventional Treatment Group was not significant either. However, the serum calcium level in the Hemopurification Group on Day 3-4 was significantly higher than that in the Conventional Treatment Group (P=0.022). The white blood cell count, the concentration of C-reactive protein and the APACHE II scores on Day 3-4 and Day 7-8 in the former group were also significantly lower, producing better efficacy (P=0.041). (C) 31 patients with acute pancreatits receiving intravenous fat emulsions and 48 patients receiving conventional therapy as the control group were reviewed. For patients of any serum triglyceride level at admission, there was no difference between the Fat Emulsion Group and the Control Group in the serum triglyceride concentration, the severity-related indices or the clinical outcome-related indices on admission, Day 3-4 and Day 7-8.Conclusions The patterns of change in serum triglyceride during the clinical course of acute pancreatitis vary with the patients' serum triglyceride level at admission. A thorough inspection of the patient's lipid profile is necessary before making a personalized management plan. For patients with hypertriglyceridemia-induced acute pancreatitis, the serum triglyceride level failing to fall below 11.3 mmol/L or a decline by less than 50% after 24-48 hours of conventional treatment may warrant the commencement of hemopurification therapy. Patients with moderatly severe acute pancreatitis may not be able to reap the benefit of hemopurification while those with severe acute pancreatitis might partially be benefited. Parenteral fat emulsions might be safe for patients with acute pancreatitis whose serum triglyceride level at admission is less than 5.65 mmol/L. Normally, infusion could start on admission and the serum triglyceride level should be checked on a regular basis in order for any adjustment to the management plan if necessary. |
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