AKI in a Young Pregnant Woman with Hypertriglyceridemia-Induced Severe Acute Pancreatitis Treated with Urgent Plasma Exchange

Introduction: Acute kidney injury (AKI) is a common complication of severe acute pancreatitis in critically ill patients. It is associated with substantial risk of mortality, especially when kidney replacement therapy (KRT) is needed. We present a case of a pregnant patient who developed AKI secondary to hypertriglyceridemia (HTG) induced severe acute pancreatitis requiring plasma exchange and KRT. Case Description: A 34-year-old female G1P0 at 34 weeks gestation presented with diffuse abdominal pain. Lipase level was 7,686 U/L and triglyceride level was >10,000 mg/dl. CT abdomen showed severe edematous pancreatitis with extensive intra-abdominal fluid involving the omentum and retroperitoneum with diffuse gastric and bowel wall thickening. She required urgent C-section due to fetal distress. She received insulin drip and one session of plasma exchange with nadir of triglycerides to 514 mg/dl . Her baseline creatinine was 0.7mg/dl, peaked at 4.5 mg/dl, associated with oliguria necessitating CKRT initiation. She was subsequently transitioned to hemodialysis for two weeks followed by complete resolution of acute tubular necrosis and renal recovery. Discussion: Pancreatitis is a risk factor for AKI.The release of activated pancreatic enzymes and free radicals into the bloodstream in acute pancreatitis triggers an inflammatory cascade that impairs renal perfusion leading to AKI. Patients frequently develop hypovolemia, sepsis, tubular necrosis, and abdominal compartment syndrome. Hypertriglyceridemia has been hypothesized as an independent risk factor for AKI in pancreatitis. One proposed mechanism is accumulation of free fatty acids (FFA)in renal parenchyma induced by breakdown of triglycerides by pancreatic lipase. The FFA accumulation damages renal parenchyma. Our case is unique as our patient had no prior history of hyperlipidemia and presented in the third trimester with severe HTG induced pancreatitis and AKI requiring CKRT and plasmapheresis with recovery of renal function. Management should focus on volume resuscitation, monitoring compartment pressures, and kidney replacement therapy when indicated.