{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T05:20:49Z","timestamp":1787721649381,"version":"build-2784847793"},"reference-count":41,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"\n Background<\/jats:title>\n Severe hypertriglyceridemia (SHTG), characterized by plasma triglycerides (TG)&gt;11.3 mmol\/L is a rare but serious complication in children who develop diabetic ketoacidosis (DKA). However, the current body of evidence is predominantly composed of case reports, highlighting a substantial gap in both the understanding and management of this condition.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n This was a retrospective electronic medical record review of pediatric patients with DKA complicated by SHTG who were referred to the Beijing Children\u2019s Hospital over a 10-year period.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n A total of 21 pediatric patients with DKA complicated by SHTG were identified, with a male-to-female ratio of 8:13. The median age at diagnosis was 11.3 years [interquartile range (IQR) 10.5-13.2, range 2.0-17.4], with approximately 76.2% (16\/21) of patients aged \u226510 years. Among these patients, 10 were diagnosed with type 1 diabetes mellitus, 5 with type 2 diabetes mellitus, and 6 with unclassified diabetes mellitus. 17 patients were newly diagnosed with diabetes, whereas 4 had a history of pre-existing diabetes. Notably, 3 of these 4 patients had discontinued insulin prior to admission. In terms of complications, 7 patients had acute pancreatitis. Regarding treatment, all patients received insulin therapy, among whom 7 patients were treated with plasmapheresis. Compared with insulin therapy alone, the plasmapheresis group showed a shorter median time to achieve the TG level &lt;5.6 mmol\/L, though this finding should be interpreted cautiously due to potential selection bias. Among the 7 patients who received plasmapheresis, 4 developed venous thrombosis. During follow-up, patients who underwent plasmapheresis maintained stable lipid profiles and achieved complete resolution of thrombosis.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n We present the largest single-center experience on SHTG in pediatric patients with DKA, with a particular focus on plasmapheresis. We recommend early assessment of dyslipidemia and pancreatic enzymes in patients with DKA. Insulin therapy remains the cornerstone of management. However, in children who show unsatisfactory reduction in triglyceride levels or persistent abdominal pain despite insulin treatment, prompt initiation of plasma exchange may be considered as a rescue therapy to rapidly lower TG levels, which could potentially mitigate the risk of developing or worsening acute pancreatitis. This hypothesis requires validation in larger prospective studies.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fendo.2026.1920206","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T04:50:27Z","timestamp":1787719827000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Insulin is central, plasmapheresis is salvage: clinical spectrum and management of severe hypertriglyceridemia in 21 children with diabetic ketoacidosis"],"prefix":"10.3389","volume":"17","author":[{"given":"Meijuan","family":"Liu","sequence":"first","affiliation":[{"name":"Department of Endocrinology, Genetics and Metabolism, Beijing Children\u2019s Hospital, Capital Medical University, National Center for Children\u2019s Health","place":["Beijing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Di","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Genetics and Metabolism, Beijing Children\u2019s Hospital, Capital Medical University, National Center for Children\u2019s Health","place":["Beijing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chang","family":"Su","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Genetics and Metabolism, Beijing Children\u2019s Hospital, Capital Medical University, National Center for Children\u2019s Health","place":["Beijing, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,26]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.3389\/fendo.2025.1638187","article-title":"Epidemiology and temporal trends of childhood type 1 diabetes in China: an analysis of the GBD 2021","volume":"16","author":"Jin","year":"2025","journal-title":"Front Endocrinol (Lausanne)"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/j.scib.2026.05.025","article-title":"Global, regional, and national burden of type 1 diabetes mellitus in children and adolescents: trend and health inequality analyses based on multiple databases, 1990-2021","volume":"71","author":"Liu","year":"2026","journal-title":"Sci Bull (Beijing)"},{"key":"B3","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1186\/s12916-025-03890-w","article-title":"Global, regional, and national burdens of type 1 and type 2 diabetes mellitus in adolescents from 1990 to 2021, with forecasts to 2030: a systematic analysis of the global burden of disease study 2021","volume":"23","author":"Chen","year":"2025","journal-title":"BMC Med"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1111\/pedi.13406","article-title":"ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state","volume":"23","author":"Glaser","year":"2022","journal-title":"Pediatr Diabetes"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.4239\/wjd.v6.i1.167","article-title":"Rare complications of pediatric diabetic ketoacidosis","volume":"6","author":"Bialo","year":"2015","journal-title":"World J Diabetes"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1111\/j.1464-5491.2004.01143.x","article-title":"Severe hypertriglyceridaemia in diabetic ketoacidosis: clinical and genetic study","volume":"21","author":"Karagianni","year":"2004","journal-title":"Diabetes Med"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.3390\/ijms26209910","article-title":"Triglycerides, glucose metabolism, and type 2 diabetes","volume":"26","author":"Wang","year":"2025","journal-title":"Int J Mol Sci"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1097\/00000441-199012000-00007","article-title":"Severe hypertriglyceridemia in diabetic ketosis","volume":"300","author":"Fulop","year":"1990","journal-title":"Am J Med Sci"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1111\/j.1572-0241.2000.03188.x","article-title":"Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA","volume":"95","author":"Nair","year":"2000","journal-title":"Am J Gastroenterol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1097\/01.mcg.0000436438.60145.5a","article-title":"Issues in hypertriglyceridemic pancreatitis: an update","volume":"48","author":"Scherer","year":"2014","journal-title":"J Clin Gastroenterol"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2004.03.045","article-title":"Pancreatic enzyme elevations in children with diabetic ketoacidosis","volume":"145","author":"Haddad","year":"2004","journal-title":"J Pediatr"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1155\/pedi\/8425032","article-title":"Hypertriglyceridemia in new-onset type 1 pediatric diabetes","volume":"2025","author":"Macke","year":"2025","journal-title":"Pediatr Diabetes"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2011-0217","article-title":"Plasmapheresis to treat hypertriglyceridemia in a child with diabetic ketoacidosis and pancreatitis","volume":"129","author":"Lutfi","year":"2012","journal-title":"Pediatrics"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1016\/j.jecr.2021.100099","article-title":"Severe hypertriglyceridemia: a rare complication of diabetic ketoacidosis in a 3-year-old with SARS-CoV-2 infection","volume":"22","author":"Basta","year":"2021","journal-title":"J Clin Transl Endocrinol Case Rep"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1210\/jcemcr\/luad046","article-title":"New-onset type 1 diabetes in a child with diabetic ketoacidosis and severe hypertriglyceridemia without pancreatitis","volume":"1","author":"Vitale","year":"2023","journal-title":"JCEM Case Rep"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.4158\/EP-2018-0106","article-title":"Clinical characteristics and sequelae of severe hypertriglyceridemia in pediatrics","volume":"24","author":"Richardson","year":"2018","journal-title":"Endocr Pract"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1016\/j.aace.2021.05.001","article-title":"Plasmapheresis as an early treatment for severe hypertriglyceridemia, acute pancreatitis, and diabetic ketoacidosis","volume":"7","author":"Kravetz","year":"2021","journal-title":"AACE Clin Case Rep"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1016\/j.transci.2021.103289","article-title":"Successful therapeutic plasma exchange in a case with extremely severe hypertriglyceridemia secondary to diabetic ketoacidosis concomitant with type IX glycogen storage disease","volume":"61","author":"Kisioglu","year":"2022","journal-title":"Transfus Apher Sci"},{"key":"B19","article-title":"Endocrine society releases guidelines on diagnosis and management of hypertriglyceridemia","volume":"88","year":"2013","journal-title":"Am Fam Physician"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1097\/MPG.0000000000001583","article-title":"Classification of acute pancreatitis in the pediatric population: clinical report from the NASPGHAN Pancreas Committee","volume":"64","author":"Abu-El-Haija","year":"2017","journal-title":"J Pediatr Gastroenterol Nutr"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1097\/MPG.0b013e31824f1516","article-title":"Definitions of pediatric pancreatitis and survey of present clinical practices","volume":"55","author":"Morinville","year":"2012","journal-title":"J Pediatr Gastroenterol Nutr"},{"key":"B22","doi-asserted-by":"crossref","DOI":"10.1210\/jc.2011-3213","article-title":"Evaluation and treatment of hypertriglyceridemia: an Endocrine Society clinical practice guideline","volume":"97","author":"Berglund","year":"2012","journal-title":"J Clin Endocrinol Metab"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1177\/2050313X221130582","article-title":"A 5-year-old with new-onset diabetes presenting with ketoacidosis, acute pancreatitis, and renal failure","volume":"10","author":"Alexander","year":"2022","journal-title":"SAGE Open Med Case Rep"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.99289","article-title":"Severe hypertriglyceridemia-induced pancreatitis presenting with diabetic ketoacidosis in a pediatric patient","volume":"17","author":"Padilla","year":"2025","journal-title":"Cureus"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1161\/ATVBAHA.107.160192","article-title":"Overproduction of very low-density lipoproteins is the hallmark of the dyslipidemia in the metabolic syndrome","volume":"28","author":"Adiels","year":"2008","journal-title":"Arterioscler Thromb Vasc Biol"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1097\/MPA.0000000000000860","article-title":"Effect of serum triglycerides on clinical outcomes in acute pancreatitis: findings from a regional integrated health care system","volume":"46","author":"Sue","year":"2017","journal-title":"Pancreas"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1016\/j.hpb.2019.01.015","article-title":"Hypertriglyceridaemia-associated acute pancreatitis: diagnosis and impact on severity","volume":"21","author":"Zhang","year":"2019","journal-title":"HPB (Oxford)"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1016\/j.pan.2020.03.018","article-title":"Hypertriglyceridemia-induced acute pancreatitis: a prospective, multicenter, international cohort analysis of 716 acute pancreatitis cases","volume":"20","author":"Mosztbacher","year":"2020","journal-title":"Pancreatology"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1016\/j.eprac.2026.04.015","article-title":"Incidence and predictors of acute pancreatitis in patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS): a multicenter retrospective study","author":"Cho","year":"2026","journal-title":"Endocr Pract"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.3389\/fped.2024.1280330","article-title":"Plasma exchange treatment of a diabetic ketoacidosis child with hyperlipidemia to avoid pancreatitis: a case report","volume":"12","author":"Huang","year":"2024","journal-title":"Front Pediatr"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1368","DOI":"10.1016\/S0140-6736(78)92450-9","article-title":"Treatment of severe diabetic hypertriglyceridaemia by plasma exchange","volume":"1","author":"Betteridge","year":"1978","journal-title":"Lancet"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1111\/j.1423-0410.1982.tb00006.x","article-title":"Treatment by plasma exchange of a patient with hyperlipidemia and diabetic ketoacidosis with lesional pulmonary edema and acute pancreatitis","volume":"43","author":"G\u00e9rard","year":"1982","journal-title":"Vox Sang"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1007\/s44446-026-00078-y","article-title":"Efficacy and safety of pharmacological and procedural interventions in the management of hypertriglyceridemia-induced acute pancreatitis: a systematic review","volume":"34","author":"Al-Ismail","year":"2026","journal-title":"Saudi Pharm J"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.12659\/AJCR.944763","article-title":"Timely application of plasma exchange to correct acute pancreatitis related to serum triglyceride levels: a report of 6 cases and a literature review","volume":"25","author":"Liu","year":"2024","journal-title":"Am J Case Rep"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.1070056","article-title":"Treating hypertriglyceridemia","volume":"177","author":"Yavasoglu","year":"2007","journal-title":"CMAJ"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1016\/j.accpm.2022.101060","article-title":"Guidelines for the management of patients with severe acute pancreatitis, 2021","volume":"41","author":"Jaber","year":"2022","journal-title":"Anaesth Crit Care Pain Med"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1111\/1751-2980.12659","article-title":"Continuous intravenous infusion of insulin and heparin vs plasma exchange in hypertriglyceridemia-induced acute pancreatitis","volume":"19","author":"Jin","year":"2018","journal-title":"J Dig Dis"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.3109\/08880018.2011.558568","article-title":"Diabetic ketoasidosis is associated with prothrombotic tendency in children","volume":"28","author":"Bilici","year":"2011","journal-title":"Pediatr Hematol Oncol"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehab551","article-title":"Triglyceride-rich lipoproteins and their remnants: metabolic insights, role in atherosclerotic cardiovascular disease, and emerging therapeutic strategies\u2014a consensus statement from the European Atherosclerosis Society","volume":"42","author":"Ginsberg","year":"2021","journal-title":"Eur Heart J"},{"key":"B40","doi-asserted-by":"publisher","first-page":"3658","DOI":"10.1016\/j.jtha.2023.09.005","article-title":"Corrigendum to \u2018Evaluation of venous thromboembolism risk factors reveals subtype heterogenicity in children with central venous catheters: a multi-center study from the CHAT consortium\u2019 [Journal of Thrombosis and Haemostasis 21\/9 (2023) 2441-2450","volume":"21","author":"Jaffray","year":"2023","journal-title":"J Thromb Haemost"},{"key":"B41","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpedsurg.2012.03.043","article-title":"Characterization of central venous catheter-associated deep venous thrombosis in infants","volume":"47","author":"Gray","year":"2012","journal-title":"J Pediatr Surg"}],"container-title":["Frontiers in Endocrinology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2026.1920206\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T04:50:38Z","timestamp":1787719838000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2026.1920206\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,26]]},"references-count":41,"alternative-id":["10.3389\/fendo.2026.1920206"],"URL":"https:\/\/doi.org\/10.3389\/fendo.2026.1920206","relation":{},"ISSN":["1664-2392"],"issn-type":[{"value":"1664-2392","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,26]]},"article-number":"1920206"}}