Intensive Care Med (2017) 43:949–951

DOI 10.1007/s00134-017-4722-3

LETTER

Plasmapheresis therapy has no

triglyceride‑lowering effect in patients
with hypertriglyceridemic pancreatitis
Kyohei Miyamoto1, Masayasu Horibe2,3, Masamitsu Sanui4*, Mitsuhito Sasaki5, Daisuke Sugiyama6,
Seiya Kato1, Takahiro Yamashita7, Takashi Goto8, Eisuke Iwasaki2, Kunihiro Shirai9, Kyoji Oe10,
Hirotaka Sawano11, Takuya Oda12, Hideto Yasuda13, Yuki Ogura3, Kaoru Hirose14, Katsuya Kitamura15,
Nobutaka Chiba16, Tetsu Ozaki17, Taku Oshima18, Tomonori Yamamoto19, Keiji Nagata20, Tetsuya Mine21,
Koji Saito22, Motohiro Sekino23, Tomoki Furuya24, Naoyuki Matsuda25, Mineji Hayakawa26, Takanori Kanai2
and Toshihiko Mayumi27

© 2017 Springer-Verlag Berlin Heidelberg and ESICM

Dear Editor,
The initial management of hypertriglyceridemic pan-
creatitis is identical to that of other types of pancreati-
tis, including early aggressive fluid therapy and adequate
analgesia [1], except for the use of plasmapheresis as
a specific therapeutic option to lower serum triglycer-
ide levels. Although several observational studies have
examined the efficacy of plasmapheresis [2, 3], direct
comparison of patients treated with plasmapheresis and
those treated without plasmapheresis was not performed.
Therefore, it remains unclear whether plasmapheresis
has a triglyceride-lowering effect. The aim of this retro-
spective multicenter study was to compare the triglycer-
ide-lowering effect of treatment with plasmapheresis and
that of treatment without plasmapheresis in patients with
hypertriglyceridemic pancreatitis.
This was a post hoc analysis of data obtained in the set-
ting of multicenter retrospective study of severe acute
pancreatitis conducted at 44 institutions in Japan that
enrolled all 1159 patients aged ≥18 years who had severe
acute pancreatitis between 2009 and 2013 [4] [Electronic
Supplementary Material (ESM)]. As a primary outcome,
the change in serum triglyceride concentration dur-
ing the first week of admission was compared between
*Correspondence: msanui@mac.com
4
Department of Anesthesiology and Critical Care Medicine, Jichi Medical
University Saitama Medical Center, 1‑847 Amanumacho, Omiya‑ku,
Saitama city, Saitama, Japan
Full author information is available at the end of the article
patients receiving plasmapheresis and those who did not
(non-plasmapheresis group). As secondary outcomes,
hospital mortality, incidence of pancreatic infection, and
requirement for invasive procedures were evaluated.
Of the 1159 patients with severe acute pancreatitis, 30
(2.6%) had hypertriglyceridemic pancreatitis. The median
serum triglyceride concentration upon admission was
2843 [interquartile range (IQR) 1663–4835]  mg/dL. Ten
patients (33.3%) were treated with plasmapheresis and
20 (66.7%) were not. The characteristics of patients in the
plasmapheresis and non-plasmapheresis groups did not
significantly differ (ESM Table S1). The methods of plas-
mapheresis are presented in ESM Table S2. The linear
mixed-effect model did not find any significant association
between the time-course of reduction in serum triglyc-
eride concentration and apheresis (p  =  0.54 for interac-
tion; Fig. 1). For the sensitivity analysis, we compared five
patients who underwent plasmapheresis on the first day
of admission with ten patients who did not. No significant
difference in median serum triglyceride concentration
was found between these two groups [1203 (IQR 872–
3222) mg/dL (plasmapheresis group) and 1622 (IQR 482–
3183) mg/dL (non-plasmapheresis group); p = 0.17; ESM
Fig. S1]. The following clinical outcomes did not differ sig-
nificantly between the two groups: hospital mortality [0/10
(0%) vs. 2/20 (10%); p  =  0.54], pancreatic infection [0/10
(0%) vs. ½0 (5.0%); p = 1.00], and requirement for invasive
procedures [0/10 (0%) vs. 2/20 (10.0%); p = 0.54]. Further
details of the study results are available in the ESM.
950

(mg/dl)
12000

10000
Plasmapheresis
8000

6000
Non
plasmapheresis
4000

2000

0
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
No. of plasmapheresis 9 9 8 7 9 8 8
patients*(Maximum = 10)
No. of non-plasmapheresis 15 13 7 5 8 5 8
patients‫(ݼ‬Maximum = 20)

(p = 0.52 for interaction)

Fig. 1  Time course of the serum triglyceride concentration in the first week after admission. Based on repeated measures, the interaction p value
for plasmapheresis was calculated by using the linear mixed-effect model. *Number of patients in the plasmapheresis group for whom data on
triglyceride level (maximum = 10) were available. ✞Number of patients in the non-plasmapheresis group for whom data on triglyceride level (maxi-
mum = 20) were available

Chen et  al. reported 34 cases [2] and Gubensek et  al.
reported 111 cases [3] of hypertriglyceridemic pancrea-
titis treated with plasma exchange; in both studies this
treatment resulted in significant reductions in serum tri-
glyceride concentration (66 and 59% reduction, respec-
tively). However, it is difficult to conclude that treatment
with plasmapheresis has a higher triglyceride-lowering
effect than treatment without plasmapheresis due to a
lack of controlled comparison studies. Moreover, the cost
of a single plasmapheresis session is approximately €1360
(¥170,000; €1 = ¥125).
In summary, plasmapheresis therapy had no additional
triglyceride-lowering effect or improved outcomes in
patients with hypertriglyceridemic pancreatitis. A larger
prospective study is needed to confirm these results.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-017-4722-3) contains
supplementary material, which is available to authorized users.
Author details
1
 Department of Emergency and Critical Care Medicine, Wakayama Medical
University, 811‑1, Kimiidera, Wakayama city, Wakayama, Japan. 2 Division
of Gastroenterology and Hepatology, Department of Internal Medicine, Keio
University School of Medicine, 35, Shinanomachi, Shinjuku‑ku, Tokyo, Japan.
3
 Department of Gastroenterology and Hepatology, Tokyo Metropolitan
Tama Medical Center, 2‑8‑29, Musashidai, Fuchu city, Tokyo, Japan. 4 Depart-
ment of Anesthesiology and Critical Care Medicine, Jichi Medical University
Saitama Medical Center, 1‑847 Amanumacho, Omiya‑ku, Saitama city, Saitama,
Japan. 5 Department of Hepatobiliary and Pancreatic Oncology, National
Cancer Center Hospital, 5‑1‑1, Tsukiji, Chuo‑ku, Tokyo, Japan. 6 Department
of Preventive Medicine and Public Health, Keio University School of Medicine,
35, Shinanomachi, Shinjuku‑ku, Tokyo, Japan. 7 Emergency Medical Center,
Fukuyama City Hospital, 5‑23‑1, Zao‑cho, Fukuyama city, Hiroshima, Japan.
8
 Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima
Citizens Hospital, 7‑33, Motomachi, Naka‑ku, Hiroshima city, Hiroshima, Japan.
9
 Department of Emergency and Disaster Medicine, Gifu University Gradu-
ate School of Medicine, 1‑1, Yanagido, Gifu city, Gifu, Japan. 10 Department
of Intensive Care Medicine, Asahi General Hospital, I‑1326 Asahi, Chiba, Japan.
11
 Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1‑1‑6
Tsukumodai, Suita, Osaka, Japan. 12 Department of General Internal Medicine,
Iizuka Hospital, 3‑83, Yoshiomachi, Iizuka‑shi, Fukuoka, Japan. 13 Department
of Emergency and Critical Care Medicine, Japanese Red Cross Musashino
Hospital, 1‑26‑1, Kyounancho, Musashino city, Tokyo, Japan. 14 Depart-
ment of Emergency Medicine, Shonan Kamakura General Hospital, 1370‑1,
Okamoto, Kamakura city, Kanagawa 330‑8503, Japan. 15 Division of Gastro-
enterology, Department of Medicine, Showa University School of Medicine,
1‑5‑8, Hatanodai, Shinagawa‑ku, Tokyo, Japan. 16 Department of Emergency
and Critical Care Medicine, Nihon University Hospital, 1‑6 Kanda‑Surugadai,
Chiyoda‑ku, Tokyo, Japan. 17 Department of Acute care and General Medicine,
Saiseikai Kumamoto Hospital, 5‑3‑1, Chikami, minami‑ku, Kumamoto city,
Kumamoto, Japan. 18 Department of Emergency and Critical Care Medicine,
Chiba University Graduate School of Medicine, 1‑8‑1, Inohana, Chuo‑ku,
Chiba city, Chiba, Japan. 19 Department of Traumatology and Critical Care
Medicine, Osaka City University, 1‑4‑3 Asahimachi, Abenoku, Osaka city, Osaka,
Japan. 20 Department of Critical Care Medicine University Hospital, University
of Occupational and Environmental Health, 1‑1 Iseigaoka, Yahatanishi‑ku,
Kitakyushu City, Fukuoka, Japan. 21 Division of Gastroenterology and Hepatol-
ogy, Department of Internal Medicine, Tokai University School of Medicine,
143 Shimokasuya, Isehara, Kanagawa, Japan. 22 Intensive Care Unit, Tohoku
University Hospital, 1‑1 Seiryo‑cho, Aoba‑ku, Sendai, Miyagi, Japan. 23 Division
of Intensive Care, Nagasaki University Hospital, 1‑7‑1 Sakamoto, Nagasaki city,
Nagasaki, Japan. 24 Department of General Medicine, Japanese Red Cross Akita
Hospital, 222‑1 Naeshirozawa, Saruta, Kamikitate, Akita City 010‑1406, Japan.
25
 Department of Emergency & Critical Care Medicine, Nagoya University
Graduate School of Medicine, 65 Tsurumai‑cho, Showa‑ku, Nagoya, Aichi,

Japan. 26 Emergency and Critical Care Center, Hokkaido University Hospital,
N14W5, Kita‑ku, Sapporo, Japan. 27 Department of Emergency Medicine, Uni-
versity of Occupational and Environmental Health, 1‑1, Iseigaoka, Yahata Nishi,
KitaKyushu, Fukuoka, Japan.
Acknowledgements
We would like to acknowledge Yoshimoto Seki, Kazuichi Okazaki, Tsukasa
Ikeura, Tsuyoshi Hamada, Tsuyoshi Takeda, Seiya Suzuki, Jun Kataoka, Tomohiro
Adachi, Wataru Shinomiya, Shin Namiki, Dai Miyazaki, Toshitaka Koinuma,
Morihisa Hirota, Sakue Masuda, Tomoaki Hashida, Naoki Shinyama, Hitoshi
Yamamura, Kazuo Inui, Satoshi Yamamoto, Takashi Muraki, Tetsuya Ito, Yukiko
Masuda, Natsuko Tokuhira, Junichi Sakagami, Hiroaki Yasuda, Yoshinori Azumi,
Masayuki Kamochi, Nobuyuki Saito, Mizuki Sato, Mioko Kobayashi, Shinjiro
Saito, Junko Izai, Kazunori Takeda, Youhei Kawashima, Masato Inaba, Takuyo
Misumi and Yuki Takeda for the support of the data collection at the follow-
ing 44 institutions: Osaka Saiseikai Senri Hospital, Hiroshima City Hiroshima
Citizens Hospital, Kansai Medical University Hirakata Hospital, The University
of Tokyo Hospital, Iizuka Hospital, Japanese Red Cross Musashino Hospital,
Tokyo Metropolitan Tama Medical Center, Japanese Redcross Maebashi Hos-
pital, Shonan Kamakura General Hospital, Showa University Hospital, Nihon
University Hospital, Saiseikai Kumamoto Hospital, Fukuyama City Hospital, Jichi
Medical University Hospital, Chiba University Hospital, Osaka City University
Hospital, Tohoku University Hospital, Nihon University Itabashi Hospital, Gifu
University Hospital, Second Teaching Hospital, Fujita Health University, Asahi
General Hospital, Shinshu University Hospital, National Hospital Organization
Nagasaki Medical Center, University Hospital, Kyoto Prefectural University of
Medicine, Mie University Hospital, Hospital of the University of Occupational
and Environmental Health, Nippon Medical School Chiba Hokusoh Hospital,
Jichi Medical University, Saitama Medical Center, Wakayama Medical University
Hospital, Tokyo Metropolitan Bokutoh Hospital, Jikei University School of
Medicine, Saka General Hospital, National Hospital Organization Sendai Medi-
cal Center, Nagasaki University Hospital, Keio University School of Medicine,
Japanese Red Cross Akita Hospital, Ibaraki Prefectural Central Hospital, Tokai
University Hospital, Nagoya University Hospital, Hokkaido University Hospital,
951
National Cancer Center, Akita City Hospital, Kobe University Hospital, Tokyo
Rosai Hospital. We also thank to the Japanese Society of Education for Physi-
cians and Trainees in Intensive Care (JSEPTIC) and the Japanese Society of
Intensive Care Medicine (JSICM) for the cooperation in designing the study [3]
and recruiting the participants.
Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflict of interest.
Accepted: 9 February 2017
Published online: 23 February 2017
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