Society: AGA

Background: The incidence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) has been increasing recently. Plasmapheresis can effectively remove triglyceride(TG) from plasma, but its clinical value in HTG-AP is unclear due to the lack of solid evidence. This study aimed to assess the impact of plasmapheresis on the evolution of organ failure in HTG-AP patients.
Methods: This study is a prospective, multicenter cohort study. HTG-AP patients with clinical worrisome features and abdominal pain onset within 72 hours were included. Patients who underwent plasmapheresis were compared with those receiving conventional medical treatment. The primary outcome was organ failure-free days (OFFD) to 14 days of enrollment. Secondary outcomes included other measures for the evolution of organ failure, need for intensive care unit (ICU) admission, length of ICU and hospital stay, 60-day mortality, and the incidence of infected pancreatic necrosis. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analysis were used to control potential confounders.
Results: During the study period, 267 HTG-AP patients were enrolled from 28 sites, among whom 211 underwent conventional medical treatment and 56 underwent plasmapheresis. The PSM created 47 pairs of patients with balanced baseline characteristics. In the matched cohort, no difference was detected concerning OFFD between patients undergoing plasmapheresis or not (median (IQR), 12(8,14) vs. 13 (8,14); P = 0.94) (Table 1). Kaplan-Meier curves and Cox proportional hazards model also showed similar probability of organ failure resolution in both groups (HR:1.05, 95%CI:0.69-1.60, P=0.82) (Figure 1). Moreover, patients in the plasmapheresis group had higher rates of ICU admission (44(93.6%) vs. 24(51.1%), P<0.01). No difference was found in other secondary outcomes. IPTW results conform to the results from the PSM analysis.
Conclusion: In conclusion, early plasmapheresis may not be effective in improving organ failure and may be associated with more ICU admissions.

Table 1. Outcomes of plasmapheresis and conventional groups after propensity score matching

Table 1. Outcomes of plasmapheresis and conventional groups after propensity score matching

Figure 1. Kaplan–Meier plots for the OFFD in matched cohort

Figure 1. Kaplan–Meier plots for the OFFD in matched cohort

Background: While transient bacteremia is common during dental and endoscopic procedures [PMID: 18541739, 6354885], infections in sterile diseases like AP can be fatal. Fat necrosis occurs in human AP [PMID: 3950033, 3094241] and contains abundant NEFA from fat lipolysis [PMID: 25500204]. Here we study how NEFAs released in clinical AP may impair bacterial clearance, causing this sterile to infected transition.
Methods: All studies were approved by the IRB, IACUC. Mayo Clinic AZ emergency room patients with ≥ 2/3 AP criteria were included. Those with active malignancy, immuno-suppression, chemotherapy, age >90 years were excluded. Patients who had microorganisms isolated, developed sepsis, or required antibiotics for infection were grouped as infected. Antibiotic prophylaxis was not considered as infection. Admission serums were analyzed for NEFA, albumin-unbound NEFA, bacterial DNA amounts, microbiome, and immune cell injury (annexin V staining). Mice after IL12,18 pancreatitis [PMID: 18515422] +/- the triglyceride of linoleic acid [LA; PMID: 33514548] were analyzed similarly. Multiple groups were compared by ANOVA. A P value <0.05 was considered significant.
Results: There were 53 normal controls, 178 non-infected, 21 infected AP patients. Age, sex, BMI in all three groups were similar. Serum lipase, etiology of AP were similar in both AP groups. Infected AP had higher (p<0.001) serum unsaturated NEFA (737±526µM) vs. non-infected AP (475±293µM), controls (170±99µM). Unbound-NEFA were similarly higher in infected AP (5.6±3.0µM, 2.8±1.9µM, 0.9±0.4µM, P<0.001). Specifically unbound linoleic acid (LA; 3.4±3.1µM vs. 1.4±0.8µM in non-infected, 0.8±0.7µM control), and unbound-oleic acid (OA) were higher in infected AP. Bacterial 16S DNA copies (670±1201, 170±340, 2.9±6.3) were increased in infected AP with altered beta-diversity (Jaccard-Emperor, PERMANOVA <0.0001), and enrichment in Pseudomonadales on level 4 analysis. Annexin V positive myeloid (CD14) and CD3 cells increased only in infected AP to 15±20%, 11±11% respectively vs <3% in controls. In vitro 2µM Unbound-LA, and -OA depolarized mitochondria of macrophages unlike other -medium and -long chain NEFA. The patterns of cell injury, NEFA elevation, microbiome changes, enrichment of Pseudomonadales were replicated only in mice with AP and lipolysis of LA’s triglyceride.
Conclusions: Release of LA, OA during fat necrosis in AP can increase their circulating unbound levels, which injure immune cells. This injury may explain sterile to infected transition during AP and is consistent with bacteremia being common but transient during dental, endoscopic procedures in normal individuals with healthy immune cells. In a separate submission [Control ID:3866559] we mechanistically detail this amphipathic immune cell injury, and the consequent impairment of phagocytosis and bacterial clearance.

Background: Exocrine Pancreatic insufficiency (EPI) can occur following acute pancreatitis (AP), with impairment in pancreatic enzyme secretion and damage to the pancreatic acinar cells thought to be key contributors. The majority with AP experience rapid resolution of their symptoms of abdominal pain, however the timeline of exocrine function recovery is unknown. The aim of this study is to establish the incidence and predictors of EPI at 3 months after AP in a prospective cohort.

Methods: Adult participants (18 years or older) admitted to the hospital with an AP attack, were enrolled in the Post-Acute Pancreatitis Pancreatic Exocrine Insufficiency (PAPPEI) Study at the time of attempt to resume oral or enteral diet at three centers. AP was defined according to the Revised Atlanta Classification. Patients with a pre-existing history of pancreatic cancer, chronic pancreatitis, EPI, or diseases of malabsorption were excluded. Symptoms of EPI, along with blood and stool samples were collected at baseline and at 3-months after enrollment. EPI was evaluated using FE-1 levels from stool samples (FE-1 <200 µg/g indicating EPI).

Results: A total of 113 participants provided stool samples at enrollment, and 90 completed the 3 month assessment. EPI was seen in 36 (40%) at 3 months. At enrollment, 32/90 (36%) of the subjects had confirmed EPI and 25/32 (78%) had persistent EPI at 3 months. Of the 58 subjects without EPI at baseline, 4 developed new EPI at 3 months. Significant differences were seen in the short term rates of EPI between AP participants with different etiologies; gallstone AP made up only 17% of subjects with EPI at 3 months, whereas it comprised almost 55% of those without EPI at 3 months. Idiopathic etiology contributed the largest group of subjects with EPI at 3 months (39%). Severity of AP and presence of pancreatitis necrosis were both associated with EPI at 3 months after AP. (Table 1)

Conclusions: EPI is present in approximately 40% of prospectively assessed patients at 3-months post-AP, most frequently seen in subjects with idiopathic etiology, severe AP and pancreatic necrosis. Longer term data are needed to further understand the persistence of EPI following AP and the contributing mechanisms.

*EPI is defined by fecal elastase ≤200 ug/g. SIRS: systemic inflammatory response syndrome.

*EPI is defined by fecal elastase ≤200 ug/g. SIRS: systemic inflammatory response syndrome.

Introduction:
Advancing current knowledge of insulin secretory defects during progression of pancreatitis from acute injury to chronicity would aid in developing newer strategies to manage diabetes associated with chronic pancreatitis (CP). We had reported enhanced Nuclear receptor4A1 (NR4A1) expression in human CP and mice models of CP. In this study, we aim to delineate the molecular mechanism of NR4A1 enhanced expression and insulin secretory defects, evaluate it in mice with L-arginine induced CP and in human CP.
Methods: MIN6 cells were transfected with pLenti NR4A1 overexpression (OE) plasmid employing PEI linear and the resultant transcriptome was studied (NovaSeq6000). DESeq2, gene ontology and KEGG pathway analysis were employed to identify differentially expressed genes and pathways. Transcription factors of insulin gene were evaluated by qPCR and western blotting. Cytokine exposure and inBio Discover were employed for identifying upstream signal for NR4A1 OE. Intracellular Ca²⁺levels were measured by fluorimetric assay. Ca²⁺imaging of OE/cytokine treated MIN6 cells, islets from CP patients and L-Arginine induced CP mice was performed using Fura2AM (EVOS M7000). CP mice were treated with IFN-γ neutralizing antibodies to assess the modulation of NR4A1 and effect on insulin secretion.
Results: NR4A1 OE in MIN6 cells (13.2±0.1 fold) resulted in decreased insulin secretion (18.1 ± 13.6 ng/mg protein). Higher expression of NR4A1 in CP patients and CP mice (19.8±0.1, 4.11±0.1 respectively) correlated with decreased insulin secretion by isolated islets (humans 3.7±0.2, r = -0.89, mice 2.1±0.1, r = -1.0). Transcriptomic analysis of OE MIN6 cells revealed decreased Ca²⁺ channel expression (L type -3.66/T type -4.29; p<0.001) and RFX6 expression (insulin gene transcription factor -1.6 fold). Transcriptome of CP patients and CP mice confirmed Ca²⁺ channel downregulation (human-1.4; mice-1.24 folds). KEGG pathway analysis of OE MIN6 identified downregulation of calcium and cAMP signalling. Fura2 AM based Ca²⁺imaging of islets from CP patients, CP mice and OE MIN6 showed a decrease in Ca²⁺Fluorescence intensity units (FIU) by 2.64, 2.4, 1.3 folds (p=0.0007,0.0004, <0.0001) compared to respective controls. IFN-γ was identified as the upstream signal for NR4A1 OE (2.31±0.03) and decreased insulin secretion (-4.21±0.56), Fig.1. Administration of IFN-γ neutralizing antibodies to CP mice resulted in decreased NR4A1 expression by 3.4 ± 0.11fold (p=0.03), improved insulin secretion by 4.4±0.2 fold, p=0.01) associated with increased Ca²⁺ levels (2.39 ± 0.06 fold, p=0.009) Fig.2.
Conclusion: Modulation of NR4A1 expression to enhance Ca²⁺channel activity can be a therapeutic strategy to improve insulin secretory functions of β cells in chronic pancreatitis to prevent progression to pancreatogenic diabetes.

Figure 1. Nuclear receptor 4A1 and Insulin secretion

Figure 1. Nuclear receptor 4A1 and Insulin secretion

Figure 2. Therapeutic intervention to improve β-cell function in mice with Chronic Pancreatitis

Figure 2. Therapeutic intervention to improve β-cell function in mice with Chronic Pancreatitis

Introduction
The etiology and clinical course of acute pancreatitis (AP) in chronic kidney disease (CKD) patients is incompletely defined. It is hypothesized that baseline problems with calcium handling and clearance of toxic metabolites may impact its course.

Methods
A cohort of patients with acute pancreatitis presenting to the Los Angeles County Hospital were prospectively characterized from January 2015 to October 2022. We collected data on patient demographics and clinical features including admission lipase levels, admission and serial calcium levels, and imaging findings. Our primary predictor was CKD and primary outcome of interest was the confirmed etiology of pancreatitis.

Secondary outcomes included intensive care unit (ICU) admission, development of systemic inflammatory response syndrome (SIRS), severe pancreatitis, and death. Multivariate linear and logistic regression analyses were performed to control for demographic characteristics (age, sex, ethnicity) and clinical features such as history of recurrent pancreatitis and co-morbidities.

Results
During the study period, 1356 patients presented with AP of which 116 patients had baseline CKD stages 2-5 and 1237 patients did not have CKD. Of the 116 CKD patients, 23 patients were on hemodialysis (HD). CKD patients were older (61.4 ± 14.7 vs 43.5 ± 15.1; P < 0.001) and were more likely to be female (55.2% vs 53.8%; P = 0.004). While 44.4% of non-CKD patients presented with gallstone pancreatitis, 37.1% of CKD patients and 52.2% of HD patients presented with idiopathic etiology of AP (P < 0.001).

CKD patients were more likely to have BUN increase of >5 mg/dL (>1.79 mmol/L) during admission (P < 0.001). However, there were no significant differences in baseline calcium levels, changes in serial calcium levels, or findings of lesions upon imaging. CKD patients had significantly increased odds ratio of ICU care (OR 1.72, 95% CI 1.03-2.87) and developing severe pancreatitis (OR 3.89, 95% CI 2.14-7.06).

Discussion
A relatively high proportion of CKD patients with AP present with idiopathic AP. These patients have increased risk of developing severe pancreatitis and adverse outcomes. AP patients with CKD do not appear to have differences in serum calcium handling and structural findings but greater changes in BUN. Further studies are needed to elucidate the pathophysiology of idiopathic AP in patients with advanced kidney disease.

Table 1. Primary and Secondary Outcomes

Background and Aims: Dysfunction of acinar cell lysosomal and mitochondrial machinery initiates and drives pancreatitis. However, the underlying mechanisms remain poorly understood, and interrelationships between dysfunctional lysosomal/autophagic and mitochondrial pathways in pancreatitis have not been explored. Further, approaches to normalize these pathways and thus alleviate the disease severity are limited. Here, we test the hypothesis that dysregulation of transcriptional mechanisms of lysosomal and mitochondrial biogenesis drives organellar dysfunction in pancreatitis. We further examine whether NRF2, a master antioxidant transcription factor, regulates lysosomal and mitochondrial biogenesis in acinar cells; and whether pharmacologic activation of NRF2 restores organelle functions in experimental acute pancreatitis (AP). Methods: We measured the levels and activation of transcription factors TFEB, which controls synthesis of major lysosomal/autophagy mediators; PGC1α, which controls nuclear DNA-coded mitochondrial (mt) proteins; and TFAM, which mediates transcription from mtDNA-encoded genes, in cerulein and EtOH+POA models of AP, as well as in tissue from pancreatitis patients. The experiments were in wild-type mice with and without the selective NRF2 activator sulforaphane, and in mice with pancreas-specific NRF2 ablation. We used adenoviral siRNA transduction to modulate the levels of TFEB, PGC1α, and TFAM in ex-vivo pancreatitis models. Results: We found dramatic decreases in pancreatic levels of all 3 transcription factors, TFEB, PGC1α and TFAM, both in experimental AP models and human pancreatitis. The central event is the loss of TFEB causing reduction in its downstream targets PGC1α and TFAM, which ultimately leads to autophagic and mitochondrial dysfunctions. We found that NRF2 mediates TFEB synthesis in acinar cells. In AP models, accumulation in acinar cells of the autophagy substrate p62 (caused by impaired autophagy) and oxidative stress act in concert to activate NRF2; however, pancreatitis-induced NRF2 activation is not strong enough to counteract oxidative stress. The pharmacologic NRF2 activator sulforaphane abolished AP-induced oxidative stress, and we further showed that it restored pancreatic TFEB level and autophagic efficiency in pancreatitis. This resulted in increased levels of PGC1α and TFAM, normalizing mitochondrial functions in AP models. Conclusion: The results reveal a transcriptional circuit NRF2 > TFEB > PGC1α/TFAM that regulates lysosomal/autophagic and mitochondrial pathways in acinar cells. Sulforaphane (approved by FDA for other diseases) alleviates these pathways’ disordering in pancreatitis, as well as the disease severity, and thus represents a new promising approach for pancreatitis treatment.

Ilya Gukovsky

Appearances