Refractory Severe Hypertriglyceridemia With Insulin Resistance Treated by Early Therapeutic Plasma Exchange: A Case Report and Review of the Literature

A 44-year-old woman with a history of hypertension and gestational diabetes presented with a three-week history of pleuritic chest pain. Initial laboratory results revealed triglycerides (TG) > 4,000 mg/dL, glucose 452 mg/dL, corrected calcium 5.6 mg/dL, and normal lipase. In the intensive care unit (ICU), she received aggressive intravenous (IV) fluids and weight-based IV insulin, yet TG remained > 4,000 mg/dL, consistent with insulin-refractory hypertriglyceridemia. Given the risk of free-fatty-acid-mediated organ injury, two therapeutic plasma exchange (TPE) sessions were performed within 24 hours, lowering TG to 615 mg/dL and eventually to 349 mg/dL by discharge. This case highlights that insulin resistance can hinder its effectiveness in lowering lipids and demonstrates how early therapeutic plasma exchange may be a rational intervention in severe, refractory hypertriglyceridemia to mitigate the risk of organ dysfunction. This case highlights the potential role of early therapeutic plasma exchange in insulin-resistant hypertriglyceridemia before pancreatitis and end-organ damage develop.