severe hypertriglyceridemia ( shtg ) with acute pancreatitis ( ap ) is a medical emergency . the main pharmacotherapy for high levels of triglycerides ( tg ) consists of insulin , heparin , omega-3 fatty acids , fibrates , statins , or niacin ( nicotinic acid ) ; however , slow mode of action of these agents is a concern in potentially life threatening situation . plasmapheresis is a therapeutic option in such an emergency in rapidly lowering tg and has been used in studies with varied results . we used early plasmapheresis in 2 cases of shtg induced severe ap ( sap ) and found significant rapid reduction of tg and improvement in organ failure . a 34-year - old female uncontrolled type ii diabetes mellitus , obese ( body mass index [ bmi ] 39/kg / m ) admitted with pain in epigastric region and vomiting since 3 days . on examination patient had pulse 135/min , respiratory rate ( rr ) 32/min , blood pressure ( bp ) 88/46 mm of hg , with normal respiratory and cardiovascular examination on auscultation , abdominal distention , epigastric tenderness and guarding . she was admitted in intensive care unit ( icu ) , with apache ii score 14 , started on fluid resuscitation and other supportive management . the blood was highly lipemic and on ultracentrifuge showed tg 9230 mg / dl [ table 1 ] . she had no history of alcohol use , drug intake , gallstones , and pancreatitis . the patient was managed as shtg induced sap and diabetic ketoacidosis with enteral fenofibrate other supportive management . her condition further deteriorated next day with increasing respiratory distress requirement of vasopressors to maintain bp and she was started on plasmapheresis . her tg after plasmapheresis decreased to 1620 mg / dl and 435 mg / dl after 1 and 2 session respectively [ figure 1 ] . her contrast enhanced computerized topography ( cect ) abdomen revealed severe pancreatitis with balthazar score 7 . she was shifted from icu on day 7 and discharged on day 14 with oral atorvastatin , fenofibrate and insulin . on her follow - up after 1-month a 35-year - old male admitted with pain abdomen since 5 days and vomiting since 2 days . on examination his temperature 38.3c , pulse 124/min , bp 118/46 mm hg , rr 27/min , bmi 35.7 kg / m   and decrease air entry in bases of both lungs with normal cardiovascular examination . he was started on fluid resuscitation and shifted to icu with apache ii score 11 . his abg showed metabolic acidosis and on ultrasound abdomen was unremarkable with obscured pancreas due to bowel gas . he had a history of poorly controlled type ii diabetes mellitus with hypertriglyceridemia , but he stopped fenofibrate since 6 months . his blood was lipemic and after ultracentrifuge showed tg 6241 mg / dl [ table 1 ] . he was taken for urgent plasmapheresis on day 2 in view of deteriorating clinical condition with replacement by thawed fresh frozen plasma [ figure 2 ] . postplasmapheresis , his tg decreased to 445 mg / dl and patient showed significant clinical improvement with resolution acidosis and respiratory distress . he was started on oral fat - free diet and fenofibrate on day 4 and discharged on day 10 . on follow - up after 2 month his tg were 109 mg / dl . severe hypertriglyceridemia with serum triglyceride concentrations > 1000 mg / dl is a risk factor for ap . shtg can also interfere with clinical laboratory tests , making patient diagnosis and management more difficult . in both of our patients due to very high levels of tg , the serum sample so lipemic that no sample testing could be performed initially . a proposed mechanism is hydrolysis of tg by pancreatic lipase , leading to accumulation of high concentrations free fatty acids and chylomicrons which can produce acinar cell injury and capillary plugging causing ischemia and acidosis activating trypsinogen and ap . conventional management of hypertriglyceridemia dietary fat restriction and pharmacotherapy is time consuming . also in the patients with sap urgent lowering of tg is necessary to prevent disease complications and oral pharmacological therapy may not always be feasible . the indications of plasmapheresis or lipid apheresis in such cases are ( a ) patient refractory to nutritional and pharmacological approaches , ( b ) serum tg exceed 1000 mg / dl , ( c ) serum lipase 3 times the upper limit of normal , ( d ) severe hypocalcemia , ( e ) lactic acidosis , and ( f ) worsening inflammation and organ dysfunction . our patients in case 1 had 5 and case 2 had 4 out of 6 criteria respectively . the beneficial effect of plasmapheresis is believed to be because of rapid decrease in tg levels , however , removal of excessive proteases from the plasma which are key enzymes in inflammation and replacement of consumed protease inhibitors might be an additionally benefit . in a recent review on plasmapheresis in hypertriglyceridemia - induced ap , though the triglyceride levels reduced by 4680% , there was still no benefit in outcome because of insufficient studies . in another observation study , the plasmapheresis effectively reduced tg faster than could be expected with conservative treatment and improve outcome . there are few reports showing that reduction in morbidity and mortality with plasmapheresis can be achieved when apheresis is used early . we used plasmapheresis in both of our cases within 48 h of diagnosing ap with hypertriglyceridemia . both the patients not only showed rapid reduction of tg but also improvement in organ failure . plasmapheresis is an effective therapeutic option for shtg induced sap with rapid reduction of serum tg and can be considered early in the management .