Plasmapheresis for Very Severe Hypertriglyceridemia-Induced Acute Pancreatitis

Introduction: Very Severe Hypertriglyceridemia (VSHTG), defined as triglyceride (TG) levels >2,000 mg/dL, is a rare but serious cause of acute pancreatitis and may account for up to 10% of cases. Prompt and aggressive reduction of triglycerides is essential to minimize systemic inflammation and prevent multiorgan failure. While insulin and fibrates are standard first-line treatments, therapeutic plasma exchange (TPE) can be life-saving in rapidly progressive or refractory cases.


Description: A 39-year-old man with no known medical history presented with acute epigastric pain. Laboratory evaluation revealed lipase 250 U/L, urine glucose >1,000 mg/dL, urine ketones 80 mg/dL, serum glucose 436 mg/dL, venous pH 7.04, sodium 108 mmol/L, chloride 79 mmol/L, and negative troponin. CT of the abdomen and pelvis showed inflammatory changes in the pancreatic tail. Triglycerides were >5,000 mg/dL. He was admitted to the intensive care unit for management of diabetic ketoacidosis (DKA) and hypertriglyceridemia-induced acute pancreatitis. Despite initial management with intravenous fluids, insulin infusion, and bowel rest, his triglyceride levels remained markedly elevated, and his clinical condition deteriorated. TPE was initiated within 24 hours of admission, resulting in rapid biochemical and clinical improvement. The patient was discharged on insulin, fibrates, and with comprehensive lifestyle counseling. Outpatient follow-up with endocrinology and lipidology was arranged.


Discussion: VSHTG is a rare but life-threatening cause of acute pancreatitis that requires early recognition and targeted intervention. This case highlights the importance of identifying secondary contributors (such as previously undiagnosed diabetes) and initiating extracorporeal lipid-lowering therapy when conventional treatments are inadequate. Early plasmapheresis may offer significant benefit in critically ill patients with refractory disease. Long-term success depends on addressing underlying metabolic abnormalities to prevent recurrence.