Hydroxyethyl starch 130/0.4 (6%) and succinylated gelatine (4%) interfere with refractometry in dogs with haemorrhagic shock

Prospective randomized controlled blinded clinical trial evaluating biomarkers of acute kidney injury following 6% hydroxyethyl starch 130/0.4 or Hartmann's solution in dogs

OBJECTIVE

To evaluate the effect of 6% hydroxyethyl starch (HES) 130/0.4, compared with a Hartmann's solution control (CRYST), on urine biomarkers of acute kidney injury (AKI) in dogs prescribed a fluid bolus.

DESIGN

Randomized, controlled, blinded clinical trial January 2018 to February 2019.

SETTING

University teaching hospital.

ANIMALS

Forty client-owned dogs.

INTERVENTIONS

Dogs prescribed a fluid bolus were randomized to receive at least 10 mL/kg of HES or CRYST with clinicians and investigators blinded to fluid type. Study fluid was used for further boluses as required in the following 24 hours, to a limit of 40 mL/kg total, after which fluid administration was open-label.

MEASUREMENTS AND MAIN RESULTS

Urine was collected prior to and 6, 12, and 24 hours after the first study fluid bolus. Urine concentrations of AKI biomarkers: neutrophil gelatinase-associated lipocalin (NGAL), cystatin C, kidney injury molecule-1 (KIM), clusterin, and osteopontin were measured using a magnetic bead multiplexed assay. Osmolality-indexed biomarker concentrations were compared between groups over time with linear mixed-effects models, with P < 0.05 considered significant. The mean volume of study fluid administered was not significantly different between groups (HES: 23.1 mL/kg, CRYST: 25.9 mL/kg; P = 0.47, t-test). There were no significant differences between groups in change over time of osmolality-indexed urine concentrations of NGAL (P = 0.91), cystatin C (P = 0.95), KIM (P = 0.77), clusterin (P = 0.63), or osteopontin (P = 0.91). The maximum Veterinary Acute Kidney Injury (VAKI) score up to 7 days during hospitalization (P = 1.0) and in-hospital mortality (P = 0.49) were not significantly different between groups, as compared by Fisher's exact test.

CONCLUSIONS

There were no differences in change over time of urine AKI biomarkers in dogs treated with 10 - 40 mL/kg HES or CRYST over 24 hours. Larger clinical trials with patient-centered outcomes are required to investigate the safety of HES in dogs.

Comparison of plasma total solids concentration as measured by refractometry and plasma total protein concentration as measured by biuret assay in pet rabbits and ferrets

OBJECTIVE

To determine the agreement between plasma total solids (TS) concentration as measured by refractometry and plasma total protein (TP) concentration as measured by biuret assay in pet rabbits and ferrets.

SAMPLE

253 and 146 blood samples from 146 and 121 ferrets and rabbits, respectively, with results of CBC and plasma biochemical analyses.

PROCEDURES

Data were collected from medical records regarding plasma TS and TP concentrations, PCV, plasma biochemical values, plasma appearance, and patient signalment. Agreement was determined between refractometer and biuret assay (reference method) values for plasma TS and TP concentration. Other variables were examined for an impact on this agreement.

RESULTS

Mean ± SD plasma TP and TS concentrations were 6.4 ± 0.8 mg/dL and 6.6 ± 0.8 mg/dL, respectively, for rabbits and 6.3 ± 1.2 mg/dL and 6.4 ± 1.1 mg/dL for ferrets. On average, refractometer values overestimated plasma TP concentrations as measured by biuret assay. Plasma cholesterol, glucose, and BUN concentrations and hemolysis and lipemia had significant effects on this bias for ferrets; only BUN concentration had an effect on bias for rabbits given the available data. Other variables had no influence on bias. The limits of agreement were wider than the total allowable analytic error, and > 5% of the data points were outside acceptance limits, indicating that the 2 methods were not in clinical agreement.

CONCLUSIONS AND CLINICAL RELEVANCE

Refractometer measurements of plasma TS concentration failed to provide a good estimation of biuret assay measurements of plasma TP concentration in rabbits and ferrets, suggesting that these 2 analytic methods and the results they yield cannot be used interchangeably in these species.

Intravenous Fluid Administration and the Coagulation System

Intravenous fluid administration in veterinary patients can alter coagulation function by several mechanisms. Both crystalloid and colloid fluids cause hemodilution, reducing platelet count and plasma coagulation protein concentrations. Hemodilution is associated with a hypercoagulable effect at low dilutions and a hypocoagulable effect at higher dilutions. Composition of crystalloid fluids likely has a minor effect, primarily dependent on fluid ion composition. Hypertonic crystalloids may also cause hypocoagulability. Colloids, both synthetic and natural, can cause hypocoagulability by several mechanisms beyond the effects of hemodilution. These include impaired platelet function, decreased plasma coagulation factor activity, impaired fibrin formation and crosslinking, and accelerated fibrinolysis. The vast majority of the veterinary literature investigates the hypocoagulable effects of hydroxyethyl starch-containing fluids using in vitro, experimental, and clinical studies. However, results are inconsistent, likely due to the varying doses and physicochemical properties of the specific fluid products across studies. In addition, some evidence exists for hypocoagulable effects of gelatin and albumin solutions. There is also evidence that these colloids increase the risk of clinical bleeding in people. Limitations of the veterinary evidence for the hypocoagulable effects of colloid fluids include a predominance of in vitro studies and in vivo studies using healthy subjects, which exclude the interaction of the effects of illness. Therefore, clinical relevance of these effects, especially for low-molecular-weight hydroxyethyl starch, is unknown. Firm recommendations about the most appropriate fluid to use in clinical scenarios cannot be made, although it is prudent to limit the dose of synthetic colloid in at-risk patients. Clinicians should closely monitor relevant coagulation assays and for evidence of hemorrhage in at-risk patients receiving any type of fluid therapy, especially in large volumes.