Therapeutic Plasma‐albumin Exchange for Hyperlipidemia Induced Acute Pancreatitis

To the Editor: We read with great interest the Abu-El-Haija et al article published in January 2018 (1). This clinical report reviews the literature for pediatric acute pancreatitis (AP) and recommends management plan directly applied to the pediatric population. Hypertriglyceridemia (HTG), although an uncommon pediatric cause of AP, holds a progressive causative risk when serum triglyceride (TG) levels exceed 1000 mg/dL (normal <150 mg/dL) (2,3). Severe HTG-AP is a potentially lethal condition, and prompt removal of the TG excessive burden is essential to prevent further organ dysfunction. Beyond proposed workup, that is well described in Abu-El-Haija et al article (1), no recommendation regarding urgent management of HTG-AP is stated. Our experience has shown that therapeutic plasma exchange (TPE) should be considered in pediatric HTG-AP (unpublished data). We recently implemented urgent TPE in a 12-year-old boy with severe-HTG-AP due to type IV hyperlipidemia with no response to aggressive hydration, analgesia, and severe diet restriction. TPE dramatically reduced TG level from 6657 to 445 mg/dL within hours and no further sessions were required. Rapid removal of TG excess by TPE is recommended by the American Society for Apheresis (ASFA) (Grade 2C) (4). TPE can effectively and rapidly lower excessively elevated TG levels with no safety concerns (5). Case reports, series, and reviews have demonstrated improvement in morbidity and mortality of severe HTG associated AP managing with TPE; however, no controlled comparison studies have evaluated the outcome of these treatment modalities (6–8). We propose TPE be included in recommendations for managing severe pediatric HTG-associated AP.