Hipertrigliceridemia severa refractaria a tratamiento médico y pancreatitis aguda recurrente: uso de plasmaféresis crónica ambulatoria en el Hospital San Pablo de Coquimbo. Reporte de un caso

Severe Hypertriglyceridemia (HTG) is associated with complications such as acute pancreatitis (AP) with high morbidity and mortality rates. We report a 42 years-old man with refractory HTG diagnosed at 19 years of age, and multiple episodes of AP, admitted with the suspicion of a new AP episode. Serum triglycerides were over 2000 mg/dl. His body mass index was 18 kg/m2, there was no evidence of xanthomas or xanthelasmas, but lipemia retinalis was found. Management included heparin and insulin, added to his usual treatment with fibrates, statins, omega-3 fatty acids, and orlistat. Due to lack of response, apheresis was started. After five sessions, triglycerides decreased to 588 mg/dl (82% reduction) and levels remained below 1000 mg/dl with daily apheresis. The patient continued with weekly sessions as outpatient with a sustained good response.

Uso de plasmaféresis en pancreatitis hipertrigliceridémica / Use of plasmapheresis in hypertriglyceridemic pancreatitis

La hipertrigliceridemia es causa de 1-4% de las pancreatitis agudas. Presentamos el caso de una mujer de 42 años con antecedentes de obesidad, diabetes mellitus tipo 2, hipertrigliceridemia e hipercolesterolemia (9365 mg/dl y 1822 mg/dl, respectivamente, 1 mes previo a la consulta). Concurrió a nuestro hospital por cuadro de dolor abdominal de 5 días de evolución de tipo cólico con progresión continua en las últimas 48 horas. Se realizó tomografía de abdomen que informó imágenes compatibles con pancreatitis. A las 36 horas de su ingreso se inició la primera sesión de plasmaféresis con una reducción de triglicéridos y colesterol del 25 y 30% respectivamente y una segunda sesión al día siguiente con descenso de triglicéridos a 996 mg/dl y colesterol a 238 mg/dl. Durante su internación presentó bacteriemia por Klebsiella pneumoniae, sin colección ni necrosis pancreática detectables por tomografía de abdomen, y luego neumonía intrahospitalaria, ambas infecciones con buena respuesta a antibioticoterapia. Al alta, los triglicéridos habían descendido a 652 mg/dl, el colesterol a 167 mg/dl, el dolor abdominal había cedido y la paciente presentaba buena tolerancia por vía oral. Observamos una reducción del 90% de triglicéridos y 87% de colesterol luego de dos sesiones de plasmaféresis, comparado con 70% de reducción en promedio en la mayoría de los estudios consultados. En los mismos, no hemos encontrado la presencia de bacteriemia ni neumonía hospitalaria como complicaciones.

Hypertriglyceridemia is reported as cause of 1 to 4% of the episodes of acute pancreatitis. We report the case of a 42-year-old woman with a history of obesity, type 2 diabetes mellitus, hypertriglyceridemia and hypercholesterolemia, with triglycerides of 9365 mg/dl, total cholesterol of 1822 mg/dl, one month prior to the consultation. She presented at the emergency unit with a 5 day history of abdominal pain, which progressed in intensity in the last 48 hours. Abdominal computed tomography revealed pancreatic and peripancreatic inflammation. Thirty-six hours after admission, a first session of plasmapheresis was conducted with a plasma triglyceride and cholesterol reduction of 25 and 30%, respectively. A second session was performed the next day, with a further reduction of triglycerides to 996 mg/dl and cholesterol to 238 mg/dl. During hospitalization the patient presented fever and Klebsiella pneumoniae bacteremia with no pancreatic collection or necrosis in tomography and, later on, nosocomial pneumonia, both infections with adequate response to antibiotic therapy. At the time of discharge, triglycerides and cholesterol levels were 652 mg/dl and 167 mg/dl respectively, no abdominal pain was present and the patient resumed oral nutrition. We observed a 90% reduction of triglycerides and 87% of cholesterol after 2 sessions of plasmapheresis, compared to 70% in average of reduction in most of the studies reviewed. We did not find the presence of bacteremia or nosocomial pneumonia as complications in the reported cases.

Montelukast Induced Hypertriglyceridemia.

Montelukast a LT4 receptor antagonist is a prophylactic agent used in chronic asthma, to improve asthma control and reduce the frequency of asthma exacerbation. Advantage of Montelukast is, it is well tolerated in both adult and children upto 6 years of age. Suspected adverse effect reported to U.K, CSM follow the launch of Montelukast are anaphylaxis, angioedema, urticaria, chest pain, vertigo, athralgia, fever. Further suspected side effects are nightmare, palpitation, and sweating and Churg Strauss syndrome. Hypertriglyceridemia associated with this agent is rarely found in any published medical report or literature. This is a case of a male patient who was suffering from chronic asthma since childhood, developed allergic rhinitis since November´10. He developed hypertriglyceridemia and associated lipid profile abnormality after taking Montelukast and was also receiving salbutamol inhalation since childhood. His lipid profile before Montelukast administration was normal. Routine investigation done 4 months following drug intake shows serum triglyceride to be 732mg/dl.Montelukast was immediately withdrawn, but salbutamol was continued The triglyceride level reaches near the base line 4 months following drug withdrawal. This case highlights a rare case of Montelukast induced hypertriglyceridemia. Physician should be vigilant of the fact that Montelukast can induce hypertriglyceridemia following therapy with it.

Hipertrigliceridemias de origen genético / Hypertriglyceridemias of genetic origen

Hypertriglyceridemia (HTG) is defined as plasma triglycerides (TG) > 150 mg/dL, and it is a frequent disease in the general population. When plasma TG reach concentrations > 500 mg/dL (severe HTG), there is usually a genetic defect involved. This defect can involve a single gene or be of polygenic inheritance. In polygenic HTG, the phenotypic expression of the disease is usually associated to the presence of certain diseases such as diabetes, obesity or insulin resistance. The most common known genes associated with monogenic hypertriglyceridemia are LPL and APOC2, but in recent years a few cases caused by mutant APOA5, GPIHBP1 and LMF1, have been identified. Furthermore, genome wide association studies (GWA) have brought up new genes that are related to discrete changes in triglyceride plasma levels of the general population. Among them, it is worth mentioning GCKR, TRIB1, MLXIPL, GALNT2, APOB, APOC2, APOA5, APOE, LPL, ANGPTL3 and NCAN. It is remarkable that most severe hypertriglyceridemias are of polygenic origin, and they could involve a major susceptibility gene. Only in a few cases of severe or very severe HTG (TG > 2.000 mg/dL) the genetic cause is known.

Efeito dos ácidos graxos ômega-3 de origem marinha em parâmetros bioquímicos, antropométricos e inflamatórios de adultos que vivem com HIV em terapia antirretroviral: revisão da literatura e ensaio clínico / Effects of marine omega-3 fatty acids supplementation on biochemical, anthropometric, and inflammatory outcomes in subjects living with HIV on antiretroviral therapy review and clinical trial

Introdução: A terapia antirretroviral (ART) mudou o curso da Aids, porém está associada a alterações metabólicas e aumento do risco de doenças cardiovasculares. Objetivo: Avaliar o efeito da suplementação com ácidos graxos ômega-3 de origem marinha no perfil lipídico, na homeostase da glicose, na distribuição de gordura corporal e nos marcadores inflamatórios de adultos com HIV em ART. Métodos: Artigo 1. Trata-se de uma revisão sistemática da literatura com metanálise. Realizou-se busca por ensaios clínicos na base de dados PubMed; 33 artigos foram localizados, seis cumpriram os critérios de inclusão e quatro apresentavam qualidade metodológica adequada. Foi realizada metanálise com efeitos fixos e descrição das diferenças de médias sumárias (DMS (IC95 por cento)). Artigos 2 e 3. Trata-se de um ensaio clínico aleatorizado e controlado. Foram recrutados 120 adultos com idade entre 19 e 64 anos, de ambos os sexos. Os indivíduos alocados no grupo intervenção foram suplementados por 24 semanas com 3g de óleo de peixe-dia (900mg de ácidos graxos ômega-3) e indivíduos alocados no grupo controle receberam placebo (óleo de soja). Resultados: Artigo 1. Após 8-16 semanas de intervenção com 900-3360mg de ácidos graxos ômega-3-dia, observou-se redução de -80,34mg-dL (IC95 por cento: -129,08 a -31,60) nas concentrações de triglicérides. A análise agregada de estudos com média de concentração de triglicérides maior que 300mg-dL no baseline e intervenção com 1800-2900mg de ácidos graxos ômega-3-dia resultou em redução de -129,72mg-dL (IC95 por cento: -206,54 a -52,91). Artigos 2 e 3. Foram considerados nas análises dados de 83 sujeitos. Os modelos multinível não revelaram relação estatisticamente significante entre a suplementação com óleo de peixe e as mudanças longitudinais nas concentrações de triglicérides...

Background: Although the antiretroviral therapy (ART) revolutionized the care of HIV-infected subjects, it has been associated with metabolic abnormalities and increased risk of cardiovascular diseases. Aims: To review the effects of marine omega-3 fatty acids on lipid profile, insulin resistance and inflammatory markers in subjects living with HIV on ART. Methods: Paper 1. Thirty three articles were found in a PubMed search; six met the inclusion criteria; and four of them were considered of adequate quality and included. Meta-analysis with fixed effects was performed and weighted mean differences (WMD (95 per cent CI)) were described. Paper 2 and 3. The study was conducted in an HIV/Aids care centre affiliated to the Medical School, University of Sao Paulo. This was a randomized controlled trial that assessed the effects of 3g fish oil/day (900mg of omega-3 fatty acids) or 3g soy oil/day (placebo). A hundred and twenty subjects aged between 19 and 64 years were recruited. The statistical analyses were performed in Stata 9. Results: Paper 1. Data from 83 subjects were included in the analyses. The overall reduction on triglyceride concentrations after 8-16 weeks of treatment with 900-3360mg of omega-3/day was WMD=-80.34mg/dL (95 per cent CI: -129.08 to -31.60). The pooled result of studies with mean triglyceride > 300 mg/dL at baseline and 1800-2900mg omega-3/day was WMD=-129.72mg (95 per cent CI: -206.54 to -52.91). Paper 2 and 3. Multilevel analyses revealed no statistically significant relationships between fish oil supplementation and the longitudinal changes in triglyceride...

Pancreatitis aguda secundaria a hipertrigliceridemia: revisión a propósito de un caso / Hypertriglyceridemia-induced pancreatitis: review of a case report

La pancreatitis aguda es un proceso inflamatorio reversible. La hipertrigliceridemia como etiología de la pancreatitis aguda es alrededor de un 2 por ciento, diagnosticándose cuando los niveles de triglicéridos alcanzan valores por sobre los 1000 mg/dl. El objetivo terapéutico es disminuir los niveles de triglicéridos y prevenir el desarrollo de complicaciones. Esto se logra estimulando la actividad de la lipoproteinlipasa que aumenta la degradación de los quilomicrones disminuyendo así los valores plasmáticos de triglicéridos a niveles menores a 500 mg/dl Se puede plantear desde un manejo conservador hasta otro tipos de terapias como insulina, heparina, prostaféresis, entre otros. En el presente articulo se discute un caso de pancreatitis aguda por hipertrigliceridemia, atendido en el Hospital Regional de Talca, manejado con tratamiento conservador con adecuada respuesta clínica y significativa disminución de los niveles de triglicéridos a partir de las 48h. de iniciada la terapia, sin necesidad de medidas terapéuticas complementarias.

The hyperlipidemias

Despite clear and consistent clinical-trial evidence establishing a causal link between lipid disorders and coronary heart disease and that cholesterol-lowering therapy dramatically reduces the risk for that disease and its complications, many patients for whom such treatment is indicated remain either unidentified or untreated. Our objective is to present updated, practical information for primary-care physicians on the evaluation and management of lipid disorders, particularly those related to the primary and secondary prevention of coronary heart disease, the leading cause of morbidity and mortality in our population. A pertinent summary of the guidelines contained in the Third Report of the National Cholesterol Expert Panel on Detection, Evaluation and Treatment of Cholesterol in Adults (Adult Treatment Panel III), commonly known as ATP III, is utilized to better fulfill that objective

La hipertrigliceridemia como factor de riesgo para la aterosclerosis coronaria / Hypertriglyceridemia as a risk factor to coronary heart disease

El papel de los triglicéridos (TG) como factor de riesgo independiente para la enfermedad coronaria está en discusión. Sin embargo, la hipertrigliceridemia (HTG), TG ò200 mg/dl, asociada con C-HDL < 35 mg/dl o con C-LDL/C-HDL > 5,0 está fuertemente asociada con la incidencia de eventos coronarios. El propósito de este trabajo fue: a) determinar frecuencia de HTG, definida según distintos criterios, en un grupo poblacional de 913 sujetos "aparentemente sanos" de ambos sexos; b) determinar la frecuencia de TG ò 200 mg/dl con C-HDL < 35 mg/dl y TG ò 200 mg/dl con C-LDL/C-HDL > 5,0. Utilizando el criterio del NCEP-ATP II, 90,3 por ciento de los sujetos tenían TG < 200 mg.dl, 8,9 por ciento tenían TG entre 200 y 400 mg/dl (valores límites) y 0,8 por ciento tenían HTG. No se hallaron sujetos con TG > 1.000 mg/dl. Siguiendo los criterios del Comité Internacional para la Evaluación de Hipertrigliceridemia como Factor de Riesgo Vascular, 9,7 por ciento de los sujetos con TG ò 200 mg/dl (HTG) se distribuían en: 2,5 por ciento con CT < 200 mg/dl (HTG moderada aislada) y 5,4 por ciento con C-LDL > 130 mg/dl (HTG mixta). Sólo 0,8 por ciento tenían TG > 400 mg/dl (HTG severa). Del total de sujetos con TG ò 200 mg/dl 12,4 por ciento tenían C-HDL < 35 mg/dl y 14,6 por ciento C-LDL/C-HDL > 0,5. Se concluyó que la HTG no superó el 10 por ciento y las combinaciones de TG ò 200 mg/dl con C-HDL < 35 mg/dl o con C-LDL/C-HDL < 5,0 no superaron el 1,5 por ciento. Es decir, las HTG fuertemente asociadas con la enfermedad coronaria tenían baja frecuencia en esta muestra poblacional

Hipertrigliceridemia / Hypertriglyceridemia

The author in this review, makes an analysis of hypertriglyceridemia including its conceit, diagnostic and treatment