Hypertriglyceridemia

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Classification according to ICD-10
E78.1 Pure hypertriglyceridemia
E78.2 Mixed hyperlipidemia
E78.3 Hyperchylomicronemia
ICD-10 online (WHO version 2019)

As a hypertriglyceridemia , or hypertriglyceridemia (abbreviated HTG ) refers to a lipid metabolism disorder with increase of the triacylglycerides also (triglycerides) in the blood of people over a physiological value of about 1.7 mmol / l (150 mg / dl).

“Stale” blood samples from a patient with severe hypertriglyceridemia

This increase can be genetic , for example a deficiency of the enzyme lipoprotein lipase , apolipoprotein C2 or a reduced density of LDL receptors.

But lifestyle factors or other diseases can also result in hypertriglyceridemia. Examples are overweight or obesity (obesity), Metabolic Syndrome , increased consumption of alcohol (alcohol abuse) , diabetes mellitus , hypothyroidism , gout , kidney function disorders, glycogen storage diseases , Cushing's syndrome and systemic lupus erythematosus .

Hypertriglyceridemia can also occur when taking certain medications, including hormonal contraceptives , diuretics , as well as treatment with cortisol , beta blockers , certain antivirals and isotretinoin (used to treat acne ).

frequency

The prevalence (incidence of disease) of hypertriglyceridemia in adults is 15–20%. As a rule (80–90% of those affected), the triglyceride levels are only moderately increased at 180 mg / dl to 400 mg / dl, in around 15% the value is between 400 mg / dl and 1000 mg / dl and occasionally higher. Values ​​that go far beyond this are rare, but concentrations above 15,000 mg / dl are possible.

meaning

Hypertriglyceridemia is usually not associated with acute clinical symptoms, but can lead to disease in the long term. These include a slight acceleration in vascular aging (progressive arteriosclerosis ) and the associated increased risk of cardiovascular complications.

A sharp increase in the triglyceride concentration in the blood of more than 1000 mg / dl can trigger life-threatening, acute pancreatitis . Hypertriglyceridemia can be a serious complication during pregnancy . The simultaneous presence of diabetes mellitus and / or a pre-existing lipid metabolism disorder then increases the risk of acute pancreatitis. Outwardly visible symptoms of hypertriglyceridemia with very high triglyceride levels include eruptive xanthomas of the skin.

Classification

The classification of the HTG can be based on the measured triglyceride concentrations:

  • Normal finding: below 150 mg / dl (1.7 mmol / L)
  • moderate HTG: 150 to 1000 mg / dL (1.7 to 11.4 mmol / L)
    • according to other opinions 175 to between 500 and 1000 (often up to 885) mg / dL
  • heavy HTG: over 1000 mg / dl (11.4 mmol / L)

therapy

Basically, the underlying causes must first be eliminated or treated. Lifestyle changes have the greatest influence here ( evidence level A). The hypertriglyceridemia associated with a metabolic syndrome often occurs in overweight and obese people, in chronic alcohol abuse and in diabetes mellitus. In these cases, weight loss combined with physical activity or abstaining from alcohol can be advisable. In addition, the control of the blood sugar is just as important as the lifestyle change and weight reduction. An energy-reduced, lipid-lowering diet is recommended to reduce body weight. Sugar and foods containing sugar such as desserts, sweets and baked goods should be avoided or at least severely restricted, as mono- and disaccharides in particular increase the hepatic VLDL triglyceride synthesis.

Triglycerides can be lowered by giving MCT fats as a substitute for other fats and can be considered in severe triglyceridemia.

If these measures do not successfully treat hypertriglyceridemia, supportive drug treatment with fibrates may be necessary. Fibrates can lower triglycerides by 20–70% (evidence-based 30–50%). A comparable reduction (by around 25–30%) can be achieved with a high dose of omega-3 fatty acids . Statins and PCSK9 inhibitors can cause a reduction of 10–20%, ezetimibe by 5–10%. There is evidence of a reduction in cardiovascular mortality and all-cause mortality with statin use. Bile acid binders are contraindicated in pre-existing hypertriglyceridaemia because they can increase the triglyceride concentration.

In the case of acute and severe, particularly life-threatening, pancreatitis caused by high triglyceride concentrations in the blood of more than 1000 mg / dl (severe hypertriglyceridaemia), lowering the triglycerides by means of apheresis treatment can significantly improve the patient's prognosis . This is possible, for example, with the help of double filtration plasmapheresis (DFPP). In rare cases, patients with recurrent inflammation of the pancreas may require regular apheresis treatment. This can also reduce the likelihood of a relapse .

literature

Textbooks

  • Roche Lexicon Medicine . 5th edition. Urban & Fischer in Elsevier, Munich 2006, ISBN 3-437-15156-8 .
  • Peter C. Heinrich, Matthias Müller, Lutz Graeve (Eds.): Löffler / Petrides Biochemistry and Pathobiochemistry . 9th edition. Springer, Berlin 2014, ISBN 978-3-642-17972-3 .
  • Peter Schwandt, Klaus G. Parhofer: Handbook of fat metabolism disorders . 3. Edition. Schattauer, Stuttgart 2006, ISBN 3-7945-2370-9 .

Guidelines

Technical article

  • Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. In: Deutsches Ärzteblatt. Volume 116, Issue 49, December 6, 2019, pp. 825–842.

Web links

Individual evidence

  1. ^ RA Hegele, HN Ginsberg, MJ Chapman: The polygenic nature of hypertriglyceridaemia: implications for definition, diagnosis, and management . In: Lancet Diabetes Endocrinol . tape 2 , no. 8 , August 2014, p. 655-666 , PMID 24731657 .
  2. ^ KG Parhofer, U. Laufs: Diagnosis and therapy of hypertriglyceridemia . In: Dtsch Arztebl Int . tape 116 , September 2019, p. 825–833 , doi : 10.3238 / arztebl.2019.0825 .
  3. ↑ BG Nordestgaard, A. Varbó: Triglycerides and cardiovascular disease . In: Lancet . tape 384 , no. 9943 , August 2014, p. 626-635 , PMID 25131982 .
  4. ↑ H. Nawaz, E. Koutroumpakis, J. Easler, A. Slivka, DC Whitcomb, VP Singh, D. Yadav, GI Papachristou: Elevated serum triglycerides are independently associated with persistent organ failure in acute pancreatitis. In: Am J Gastroenterol . tape 110 , no. 10 , October 2015, p. 1497-1503 , PMID 26323188 .
  5. ↑ Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ: Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue . In: J Clin Apher. tape 34 , no. 3 , June 2019, p. 171-354 , PMID 31180581 .
  6. ↑ G. Ducarme, F. Maire, P. Chatel, D. Luton, P. Hammel: Acute pancreatitis during pregnancy: a review . In: J Perinatol . tape 34 , no. 2 , February 2014, p. 87-94 , PMID 24355941 .
  7. ^ Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. 2019, p. 826 f.
  8. ^ Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. In: Deutsches Ärzteblatt. Volume 116, Issue 49, December 6, 2019, pp. 825–842, here: pp. 828 f.
  9. ^ Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. 2019, p. 828.
  10. ^ RA Hegele et al. : The polygenic nature of hypertriglyceridaemia: implications for definition, diagnosis, and management. In: Lancet Diabetes Endocrinol. Volume 2, 2014, pp. 655-666.
  11. ^ Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. 2019, p. 828.
  12. ^ KR Feingold, C. Grunfeld: Triglyceride lowering drugs . In: KR Feingold et al. (Ed.): Endotext . South Dartmouth, MA 2018, PMID 28402615 .
  13. ^ KG Parhofer, U. Laufs: Diagnosis and therapy of hypertriglyceridemia . In: Dtsch Arztebl Int . tape 116 , September 2019, p. 825–833 , doi : 10.3238 / arztebl.2019.0825 .
  14. ^ Klaus G. Parhofer: Diagnosis and therapy of hypertriglyceridemia. In: Deutsches Ärzteblatt. Volume 116, Issue 49, December 6, 2019, pp. 825–842, here: p. 830.
  15. ↑ Richard Daikeler, idols Use, Sylke Waibel: diabetes. Evidence-based diagnosis and therapy. 10th edition. Kitteltaschenbuch, Sinsheim 2015, ISBN 978-3-00-050903-2 , p. 148.
  16. ↑ Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ: Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue . In: J Clin Apher. tape 34 , no. 3 , June 2019, p. 171-354 , PMID 31180581 .
  17. ↑ Chiz-Tzung Chang, Tsung-Yu Tsai, Hsin-Yi Liao, Chia-Ming Chang, Jyun-Shan Jheng, Wen-Hsin Huang, Che-Yi Chou, Chao-Jung Chen: Double filtration plasma apheresis shortens hospital admission duration of patients with severe hypertriglyceridemia-associated acute pancreatitis . In: pancreas . tape 45 , no. 4 , April 2016, p. 606-612 , PMID 26491906 .
  18. ↑ Grupp C, Beckermann J, Köster E, Zewinger S, Knittel M, Walek T, Hohenstein B, Jaeger B, Spitthöver R, Klingel R, Fassbender CM, Tyczynski B: Relapsing and Progressive Complications of Severe Hypertriglyceridemia: Effective Long-Term Treatment with double filtration plasmapheresis . In: Blood Purification . March 2020, p. 1-11 , PMID 32191938 .