USE OF PLASMAPHERESIS IN THE MANAGEMENT OF SEVERE HYPERTRIGLYCERIDEMIA IN A PATIENT PRESENTING WITH DKA AND NSTEMI

A CASE REPORT

Abstract

INTRODUCTION/BACKGROUND
Severe hypertriglyceridemia is defined as triglyceride level >11.3 mmol/L and is associated with significant morbiditiesincluding pancreatitis and atherosclerotic cardiovascular disease. A commonly acquired cause is insulin resistance associated with obesity and type 2 diabetes.

CASE
We report a case of a 49-year-old male with underlying diabetes mellitus, fatty liver and class II obesity (BMI 37) who was admitted for severe diabetic ketoacidosis complicated with severe hypertriglyceridemia. His lipid profile was as follows: triglyceride 129.6 mmol/L, total cholesterol 24.5 mmol/L and HDL 2.90 mmol/L, with his plasma having a milky appearance. His HbA1c was 12.5%. He was admitted to the Intensive Care Unit and was started on fixed-rate insulin infusion and intravenous fluids. He was kept nil by mouth and given pharmacotherapy (statin and fenofibrate). He had no evidence of acute pancreatitis, however, required dialysis for oliguric acute kidney injury. He later suffered from non-ST elevation myocardial infarction with transaminitis requiring discontinuation of lipid-lowering drugs. His repeated triglyceride level remained elevated at 45.2 mmol/L on day 4 of admission. He underwent one session of plasmapheresis uneventfully, with a significant reduction in triglyceride to 5.7 mmol/L. Before discharge, his treatment for DM was intensified and lipid-lowering therapy was re-commenced following normalization of liver enzymes. Further history revealed his dietary habits consisted of a calorie-dense, high glycaemic load diet (estimated 3417 kcal/day, carbohydrates 50% of total calorie intake, protein 14.6% and fats 35%). He had no significant family history nor stigmata of hyperlipidaemia.

CONCLUSION
Despite the availability of effective lipid-lowering drugs, plasmapheresis remains a treatment option in severe hypertriglyceridemia, particularly in patients unresponsive or intolerant to pharmacotherapy. The rapid reduction of plasma triglyceride through plasmapheresis is effective in preventing hypertriglyceridemia-associated complications and can improve clinical outcomes in critically ill patients.