Pregnancy With Diabetic Ketoacidosis and Hypertriglyceridemia-Induced Acute Pancreatitis: The Enigmatic Triad.
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SUBMITTER: Mishra N
PROVIDER: S-EPMC10798904 | biostudies-literature | 2023 Dec
REPOSITORIES: biostudies-literature
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Pregnancy With Diabetic Ketoacidosis and Hypertriglyceridemia-Induced Acute Pancreatitis: The Enigmatic Triad.
Cureus 20231220 12
Acute pancreatitis in pregnancy is a rare condition. Acute pancreatitis due to hypertriglyceridemia in a case of diabetic ketoacidosis is also a very rare condition with a very high mortality rate. Here, we report a case of a 34-week pregnancy with pregnancy-induced hypertension, diabetic ketoacidosis, and hypertriglyceridemia-induced acute pancreatitis with underlying gallstone disease, which might have contributed to the etiology of pancreatitis. There is no report of such a case in the availa ...[more]
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Project description:IntroductionAcute pancreatitis (AP) is a serious inflammatory condition of the pancreas. Hypertriglyceridemia (HTG) is considered an uncommon cause of AP. The current study aims to present a unique case of recurrent seasonal severe HTG-induced AP (HTG-AP); treated with insulin and heparin.Case reportA 36-year-old male presented with recurrent attacks of severe upper abdominal pain that was radiating to the back and associated with repeated vomiting. The condition has being occurring every autumn-winter for the last three years. He had thalassemia minor and had a history of HTG-AP. His TG levels were relatively normal from February to August; however, from September to February, his TG levels highly elevated which has resulted in HTG-AP every year for the past three years. The condition was confirmed via a contrast-enhanced computerized tomography scan of the abdomen. To prevent the next HTG-AP, his TG level was monitored monthly. When TG levels spiked again, the patient was put on an insulin infusion with heparin, glucose, and potassium to rapidly reduce TG level. After two days, serum TG was dramatically reduced (<500 mg/dL).DiscussionDespite multiple theories being proposed, the pathogenesis of HTG-AP is yet to be understood. Usually, HTG-AP is a single episodic, and recurrent HTG-AP is considered uncommon finding. Previous reports are contradictory regarding TG level and seasonal variation. There is currently no standard management approach to treat HTG-AP cases.ConclusionHTG-AP rarely reoccurs on an annual basis, and seasonal variation seems to play a major role in its onset. The condition can be managed with insulin, heparin, and glucose infusions.
| S-EPMC8977940 | biostudies-literature
Project description:Background and purposeIn cinical, some acute pancreatitis patients with diabetes may have diabetic ketoacidosis (DKA). However, the risk factors for DKA in these patients remain unclear. The purpose of this study is to analyze the risk factors for DKA in acute pancreatitis patients with type 2 diabetes.Patients and methodsTwenty-five patients were included in this prospective single-centre study to analyze the incidence and risk factors for DKA in acute pancreatitis patients with type 2 diabetes.ResultsSeven of the twenty-five patients (28%) developed DKA within 48 h of admission. According to whether they had DKA, the twenty-five AP patients were divided into DKA group and non-DKA group. There were significant differences in age (P = 0.014), BMI (P = 0.034), poor previous blood glucose control (P < 0.001) and uric acid concentration (P = 0.041), but no statistically significant differences in sex (P = 0.597), number of drinkers (P = 0.407), number of smokers (P = 1.000), triglyceride level (P = 0.389) and total cholesterol concentration (P = 0.534) between the two groups. In both groups, 1 patients had severe pancreatitis, and the difference was no statistically significant (P = 0.490).ConclusionsThe incidence of DKA in AP patients with diabetes is high. Age, BMI, worse glycemic control and uric acid concentration may be predictors of DKA in AP patients with diabetes.
| S-EPMC10375676 | biostudies-literature
Project description:Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is the third most common cause of AP after gallstones and alcohol. Supportive measures, intravenous insulin, and plasmapheresis are possible treatment modalities for HTG-AP; however, definitive guidelines evaluating the best therapeutic approach are not clearly established. We present a rare case of a 42-year-old male without known comorbidities who was found to have HTG-AP. Despite early initiation of intravenous insulin and plasmapheresis and the initial decline in his triglycerides level, his condition was complicated by necrotizing pancreatitis and subsequent multi-organ failure. Future studies are warranted to evaluate the role of plasmapheresis in HTG-AP and its efficacy.
| S-EPMC11015164 | biostudies-literature
Project description:BackgroundMostly published as case reports or series, the role of apheresis in hypertriglyceridemia (HTG)-related acute pancreatitis (AP) remains unclear. We performed a systematic review of available literature on this topic with specific focus on disease severity.MethodsA search of electronic databases (PubMed, EMBASE, Cochrane) and gray literature yielded 5020 articles of which 74 met criteria for inclusion (301 unique patients). Relevant data were abstracted from full manuscripts and analyzed.ResultsMost patients were young (mean age 37.9 ± 10.4 years) and male (71.5%). About two-thirds (69.7%) received apheresis within 48 h and most required only 1 or 2 sessions (84.4%). Apheresis resulted in an average reduction of serum TG by 85.4% (p < 0.001). There was high variability in reporting the presence of and criteria to define severe AP (reported 221/301, 73.4%; present 85/221, 38.5%) or organ failure (reported 104/301, 34.6%; present 52/104, 50.0%). Improvement was reported in the majority of patients (reported 144/301, 47.8%, present 136/144, 94.4%) mainly by clinical symptoms or laboratory tests. Overall mortality was 7.1% (21/294) which increased to 11.8% (10/85) with severe AP and 19.2% (10/52) with organ failure.ConclusionsApheresis effectively reduces serum TG levels. However, due to uncontrolled data, reporting bias and lack of a comparison group, definitive conclusions on the efficacy of apheresis in reducing AP severity cannot be made. We propose which patients may be best suitable for apheresis, type of studies needed and outcome measures to be studied in order to provide empiric data on the role of apheresis in HTG-related AP.
| S-EPMC6609092 | biostudies-literature
Project description:IntroductionAcute pancreatitis (AP) is considered one of the potentially rare complications of severe hypertriglyceridemia (HTG). Multiple treatment modalities have been suggested for patients with HTG-AP, such as permanent removal of TG by plasmapheresis, the use of insulin and heparin to enhance lipoprotein lipase activity and fibrate therapy, but the data remains limited.Case managementwe reported a case of 33-year-old women admitted for HTG-induced PA (HTG-AP). The patient had hypertriglyceridemia for 7 years under fibrate therapy as a medical history. On admission to our intensive care unit, his triglyceride level was 1060 mg/dl and the lipase level was 298 IU/L. An abdominal CT scan revealed stage E AP. The patient was treated with a low dose insulin infusion (0.05 unit/kg/h) with heparin and 5-day course of plasmapheresis, Fibrate therapy was maintained. His triglycerides went down to 130.9 mg/dl and she was discharged.ConclusionEarly recognition of severe HTG can prevent progression to multiples diseases such as acute pancreatitis, can facilitate appropriate or even aggressive treatment to minimize complications of this.
| S-EPMC8519797 | biostudies-literature
Project description:BackgroundHypertriglyceridemia (HTG) is an important cause of acute pancreatitis (AP) in pregnant women. Due to the variable clinical features of acute pancreatitis, it is difficult to make a differential diagnosis when abdominal pain occurs in late pregnancy. Severe HTG induced acute pancreatitis during pregnancy is rare, but may be a fatal threat to both mothers and fetuses during the peripartum period, and can increase maternal and fetal mortality. If emotional disorder combined, difficulty of treatment increased. So, multidisciplinary diagnosis combination of psychiatric treatment could improve the diagnosis rate and cure rate of acute pancreatitis during pregnancy.Case descriptionWe present the case of a 27-year-old Chinese woman in her first pregnancy, who was admitted to the hospital in the planned delivery period, but then developed progressive abdominal pain and whose biochemistry parameters were high enough to underwent a cesarean section as a result of AP a few hours after admission. The patient developed organ failure after a successful labor, which rapidly evolved to multi-organ failure, accompanied by depressive symptoms. Afterwards She appeared such as agitated, uneasy, and sad, and did not comply with the treatment, according to the classification of symptoms and course of disease, postpartum depression (PPD) was highly suspected. The patient benefited from multidisciplinary treatments that combined and integrated traditional Chinese medicine (TCM) with Western medicine therapies. The patient was discharged 35 days after her admission.ConclusionsThis case highlights the importance of monitoring and managing excess dyslipidemia during pregnancy. A proactive strategy should be encouraged in the management of the patients with high risk of pancreatitis to improve the outcomes of patients. Our case report elucidates the possible long-term effects of HTG and reminds us of the need for long-term management of those affected.
| S-EPMC9469118 | biostudies-literature
Project description:BackgroundAcute pancreatitis in pregnancy (APIP) is a life-threatening disease for both mother and fetus. To date, only three patients with recurrent hypertriglyceridemia-induced APIP (HTG-APIP) have been reported to carry rare variants in the lipoprotein lipase (LPL) gene, which encodes the key enzyme responsible for triglyceride (TG) metabolism. Coincidently, all three patients harbored LPL variants on both alleles and presented with complete or severe LPL deficiency.MethodsThe entire coding regions and splice junctions of LPL and four other TG metabolism genes (APOC2, APOA5, GPIHBP1, and LMF1) were analyzed by Sanger sequencing in a Han Chinese patient who had experienced two episodes of HTG-APIP. The impact of a novel LPL missense variant on LPL protein expression and activity was analyzed by transient expression in HEK293T cells.ResultsA novel heterozygous LPL missense variant, p.His210Leu (c.629A > T), was identified in our patient. This variant did not affect protein synthesis but significantly impaired LPL secretion and completely abolished the enzymatic activity of the mutant protein.ConclusionThis report describes the first identification and functional characterization of a heterozygous variant in the LPL that predisposed to recurrent HTG-APIP. Our findings confirm a major genetic contribution to the etiology of individual predisposition to HTG-APIP.
| S-EPMC7057096 | biostudies-literature
Project description:IntroductionThe risk of developing ketoacidosis in patients with type 1 diabetes at high altitude is high. Anorexia associated with acute mountain sickness, dehydration and additional exercise associated with climbing exacerbates the generation of ketones and the development of ketoacidosis.Case presentationA 33-year-old gentleman with known history of uncontrolled type 1 diabetes mellitus trekked to Everest Base Camp at an altitude of 3440 m and became unwell. He developed altered sensorium and shortness of breath. He ingested eight tablets of acetazolamide (250 mg each) to address these symptoms. Upon presentation to emergency, he was diagnosed with severe diabetes ketoacidosis (DKA) with shock. Resuscitation was started with fluid, insulin, vasopressors and mechanical ventilation. Despite adequate fluid resuscitation, insulin, bicarbonates and other supportive measures, his acidosis and shock persisted and then managed with hemodialysis. After the first session of hemodialysis, improvement in acidosis and shock was noted. He was successfully extubated and later discharged.DiscussionIn this case report, DKA due to acute mountain sickness was complicated by acetazolamide use and noncompliance to his regular insulin intake. There is no proper guideline regarding the role of renal replacement therapy in management of DKA. However, evidence of hemodialysis in DKA is limited to few case reports. Improvement seen in our patient after dialysis is related to dialyzable nature of acetazolamide.ConclusionWe present a case of a severe DKA potentially precipitated by acute mountain sickness, use of acetazolamide, noncompliance to his regular insulin intake and managed with hemodialysis in addition to conventional treatment for DKA.
| S-EPMC7330143 | biostudies-literature
Project description:ObjectiveTo assess the response of serum triglycerides (TG) to continuous insulin infusion (CII) in adults with hypertriglyceridemia-associated acute pancreatitis (HTGP).MethodsRetrospective analysis of TG response to standardized CII therapy in 77 adults admitted to intensive care with TG >1000 mg/dL and HTGP.ResultsParticipants had initial TG 3869.0 [2713.5, 5443.5] mg/dL and were 39.3 ± 9.7 years old, 66.2% males, 58.4% Hispanic, BMI 30.2 [27.0, 34.8] kg/m2, 74.0% with diabetes mellitus (DM) and 50.6% with excess alcohol use. TG-goal, defined as ≤1,000 ± 100 mg/dL, was achieved in 95%. Among the 73 TG-goal achievers (responders), 53.4% reached TG-goal in <36 hours after CII initiation (rapid responders). When compared to slow responders taking≥36 hours, rapid responders had lower initial TG (2862.0 [1965.0, 4519.0] vs 4814.5 [3368.8, 6900.0] mg/dL), BMI (29.4 [25.9, 32.8] vs 31.9 [28.2, 38.3] kg/m2), DM prevalence (56.4 vs 94.1%), and reached TG-50% (half of respective initial TG) faster (12.0 [6.0, 17.0] vs 18.5 [13.0, 32.8] hours). Those with DM (n = 57) vs non-DM (n = 20) were obese (31.4 [28.0, 35.6] vs 27.8 [23.6, 30.3] kg/m2), took longer to reach TG-final (41.0 [25.0, 60.5] vs 14.5 [12.5, 25.5] hours) and used more daily insulin (1.7 [1.3, 2.1] vs 1.1 [0.5, 1.9] U/kg/day). Among those with DM, the rapid responders had higher daily use of insulin vs slow responders 1.9 [1.4, 2.3] vs 1.6 [1.1, 1.8] U/kg/day. All results significant. In multivariable analysis, predictors of faster TG response were absence of DM, lower BMI and initial TG.ConclusionCII was effective in reaching TG-goal in 95% of patients with HTGP. Half achieved TG-goal within 36 hours. Presence of DM, higher BMI and initial TG slowed the time to reach TG-goal. These baseline parameters and rate of decline to TG-50% may be real-time indicators to initiate and adjust the CII for quicker response.
| S-EPMC8631651 | biostudies-literature
Project description:ImportanceThe incidence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is increasing. Plasmapheresis is theoretically effective in removing triglyceride from plasma, but whether it confers clinical benefits is unclear.ObjectiveTo assess the association between plasmapheresis and the incidence and duration of organ failure among patients with HTG-AP.Design, setting, and participantsThis is an a priori analysis of data from a multicenter, prospective cohort study with patients enrolled from 28 sites across China. Patients with HTG-AP were admitted within 72 hours from the disease onset. The first patient was enrolled on November 7th, 2020, and the last on November 30th, 2021. The follow-up of the 300th patient was completed on January 30th, 2022. Data were analyzed from April to May 2022.ExposuresReceiving plasmapheresis. The choice of triglyceride-lowering therapies was at the discretion of the treating physicians.Main outcomes and measuresThe primary outcome was organ failure-free days to 14 days of enrollment. Secondary outcomes included other measures for organ failure, intensive care unit (ICU) admission, duration of ICU and hospital stays, incidence of infected pancreatic necrosis, and 60-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses were used to control potential confounders.ResultsOverall, 267 patients with HTG-AP were enrolled (185 [69.3%] were male; median [IQR] age, 37 [31-43] years), among whom 211 underwent conventional medical treatment and 56 underwent plasmapheresis. PSM created 47 pairs of patients with balanced baseline characteristics. In the matched cohort, no difference was detected concerning organ failure-free days between patients undergoing plasmapheresis or not (median [IQR], 12.0 [8.0-14.0] vs 13.0 [8.0-14.0]; P = .94). Moreover, more patients in the plasmapheresis group required ICU admission (44 [93.6%] vs 24 [51.1%]; P < .001). The IPTW results conformed to the results from the PSM analysis.Conclusions and relevanceIn this large multicenter cohort study of patients with HTG-AP, plasmapheresis was commonly used to lower plasma triglyceride. However, after adjusting for confounders, plasmapheresis was not associated with the incidence and duration of organ failure, but with increased ICU requirements.
| S-EPMC10308255 | biostudies-literature