Admission HDL-C and recurrence risk of hypertriglyceridemia-induced acute pancreatitis: a multicenter cohort study.

Background: Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) carries a high risk of post-discharge recurrence. Whether admission high-density lipoprotein cholesterol (HDL-C) independently predicts recurrence and how its effect varies over time remain unclear. Methods: A multicenter retrospective study was conducted, including consecutive HTG-AP inpatients from three hospitals from January 2020 to March 2025. The primary endpoint was overall post-discharge recurrence; while the secondary endpoints included recurrence within 6 and 12 months. HDL-C, analyzed both as a continuous variable and by tertiles, was evaluated using Cox models with progressive adjustment. Dose-response was examined by restricted cubic splines (RCS). Time-varying effects were assessed with landmark analyses (0-6 and 6-12 months) and an HDL × log(time) interaction. Robustness was tested using inverse probability of treatment weighting (IPTW). Restricted mean time free of recurrence (RMST) quantified absolute differences. Results: A total of 440 patients were enrolled, and the median follow-up duration was 14.0 months. Lower admission HDL-C was associated with a higher recurrence risk. In the fully adjusted model, each 1 mmol/L increase in HDL-C was associated with a 77% lower hazard of overall recurrence (HR 0.23, 95% CI 0.11-0.48; Conclusion: Low admission HDL-C is an independent predictor of HTG-AP recurrence with a linear risk gradient, and its predictive effect is most pronounced within 12 months after discharge. Given its stability and accessibility, HDL-C can aid early identification of high-risk patients and inform targeted follow-up and prevention strategies.