#2107 Therapeutic apheresis for the management of lipid disorders: a case series
Authors: Martínez Miguel Ángel González , Gómez María Ramírez , García Elena Hernández , Rodríguez Erick Donato Morales , Garrido María Dolores Prados 
Published: May 2024

Background and Aims

Hypertriglyceridemia (HTG) is defined as the plasmatic concentration of triglycerides above 150 mg/dl. With a current prevalence ranging from 15% to 20% in clinical practice, it's a prevalent condition that´s increasing alongside other cardiovascular risk factors such as diabetes mellitus, obesity and hypertension. In most patients HTG is asymptomatic, except in certain circumstances such as hereditary HTG, which can present with skin lesions such as eruptive xanthomas and xanthelasmas. Another exception is severe HTG, which can manifest with pancreatitis.

Pharmacological treatment for HTG is typically initiated when serum triglyceride levels exceed 885 mg/dl or when patients with a previous episode of pancreatitis. However, in cases of severe HTG (triglycerides &gt; 1000 mg/dl), conventional pharmacological therapies become less effective. Therefore, alternative therapeutic interventions, such as apheresis, become increasingly relevant for the management of severe HTG.

Current guidelines from the American Society of Apheresis (ASFA) consider the use of therapeutic plasmapheresis in patients with acute pancreatitis secondary to severe hypertriglyceridemia as a category III/grade 1C recommendation and that in most cases it is an adjunct to medical treatment.

Case series

Below, we describe a series of cases in which we used this technique to control metabolic in our center during the last year.

Case 1

A 30-year-old man with familial primary hypertriglyceridemia, schizophrenia, and sporadic drinking, was admitted from the Emergency Department with a 24h long severe abdominal pain with difficult management and vomiting. After complementary analysis, acute edematous pancreatitis without necrosis was diagnosed. Given the analytical values (Table 1), therapeutic plasmapheresis was decided, with a plasma volume of 3.5 liters calculated with the patient's weight and hematocrit and using albumin as the replacement fluid. As a complication, and despite administration of heparin, the filter required replacement halfway through the session due to problems with transmembrane pressure. Two sessions were completed on consecutive days until clinical and analytical control of triglycerides was achieved.

Case 2

A 55-year-old man with a history of mild dyslipidemia controlled with diet and hypertension, was admitted from the Emergency Department with abdominal pain of 12 hours duration. After completing the study and diagnosis of acute pancreatitis of probable HTG origin, a plasmapheresis session was completed with a volume of 3 liters, albumin replacement fluid and heparinization during the technique, without complications, along with triglyceride control after the procedure maintaining medical treatment.

Case 3

A 62-year-old man with a history of familial HTG, bronchial hyperreactivity, and occasional drinking, was admitted with abdominal pain of 72 hours duration accompanied by nausea and vomiting. Complementary studies confirmed acute severe pancreatitis with hemodynamic and respiratory failure. Given the analytical findings, a plasmapheresis session was performed with a volume of 2.5 liters per weight and hematocrit, with albumin replacement and heparin as per protocol. Subsequent HTG control with medical treatment was achieved without the need for further apheresis sessions.

Conclusion

Cardiovascular disease is responsible for the death of more than 4 million people in Europe each year, 2.2 million women (55%) and 1.8 million men (45%).

Lipoprotein apheresis has preventive effects on the progression of atherosclerosis in addition to being an effective technique for reducing LDL, so its indication in groups of patients with severe and primarily familial hypercholesterolemia is well established.

In our center, the recent start of the control of apheresis techniques from Nephrology in metabolic diseases, although still with limited experience and a limited number of patients, may constitute a new field of work in the specialty itself and collaboration with the different hospital specialties to improve the prevention, control, and treatment of patients with a high cardiovascular risk.