Case Report: Bloodletting to Treat Severe Hypertriglyceridemia in Ketoacidosis

Blood donation, blood letting
A case report illustrates the use of bloodletting to treat severe hypertriglyceridemia in the setting of ketoacidosis when plasmapheresis is not possible.

A case study found bloodletting to be helpful for reducing triglycerides and cholesterol levels in a male patient with severe hypertriglyceridemia and ketoacidosis who did not respond to plasmapheresis. The findings from this case study were published in the Annals of Internal Medicine.

A 39-year-old man with diabetes presented to the emergency department with nausea, malaise, headache, vomiting, and deteriorating alertness. At presentation, the patient’s medication history consisted of daily doses of 100 mg sitagliptin, 10 mg dapagliflozin, and 40 mg pantoprazole. In addition, the patient had a Glasgow Coma Scale score of 7, which subsequently decreased to 4 after admission.

He was then admitted to the intensive care unit with severe ketoacidosis, as well as hyperviscosity syndrome. Initial treatment comprised intravenous infusions of insulin, 40% glucose, heparin, and piperacillin-tazobactam.

The patient ultimately underwent blood withdrawal of approximately 1 L, which was replaced with 2 red cell concentrate units and 3 fresh frozen plasma units. After this procedure, the patient’s triglyceride and cholesterol levels decreased.

Another liter of blood was withdrawn and replaced with physiologic saline, resulting in further reductions in his triglycerides and total cholesterol.

After 2 previously failed attempts at plasmapheresis, a third try was successful and resulted in reductions in triglycerides and cholesterol.

On day 5, the patient was extubated and was free of residual neurologic symptoms.

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Considering this case study discussed only 1 patient, the efficacy of this bloodletting approach may not be applicable to other patients with similar conditions at presentation.

“If plasmapheresis can not be done due to extreme hyperviscosity,” the researchers wrote, “our experience demonstrates that conventional bloodletting with replacement may be an effective alternative. To our knowledge, this is the first report to describe this procedure.”


Koehler P, Brockelmann PJ, Hallek M, Kochanek M. Bloodletting to treat severe hypertriglyceridemia [published online February 26, 2019]. Ann Intern Med. doi: 10.7326/L18-0706