Delayed type III hypersensitivity reaction with acute kidney injury in two dogs following administration of concentrated human albumin during treatment for hypoalbuminemia secondary to septic peritonitis

Crystalloids versus Colloids: Same Controversy, New Information

Intravenous fluid therapy is a regular component of care for cats and dogs with goals of restoring tissue perfusion, preventing organ dysfunction, and maintaining homeostasis. Veterinarians have a plethora of fluid choices, including hypertonic, hypotonic, and isotonic crystalloids, as well as synthetic and natural colloids. Studies published in both the human and veterinary medical literature have documented adverse events associated with synthetic and natural colloids. Reports of increased incidences of acute kidney injury, need for renal replacement therapy, and mortality in a variety of patient populations have called into question the use of synthetic colloids in humans and companion animals.

Current and Future Practice in the Diagnosis and Management of Sepsis and Septic Shock in Small Animals

This review will explore the current knowledge, beginning with the physiologic underpinnings and delve into the evolving scientific literature, encompassing the inextricably intertwined diagnosis and management of sepsis and septic shock in human and small animal patients. Sepsis is a significant cause of morbidity and mortality in patients, mostly for failure to recognize or treat promptly and adequately. Diagnosis is based on the individual patient, clinical context, and clinical acumen. High quality supportive care in the intensive care unit setting is patient-centered with intensive nursing, focused on physiologic systems, goal-oriented, and multi-disciplinary with a team-based approach to patient care.

Update on Canine Parvoviral Enteritis

Canine parvoviral enteritis is one of the most common causes of morbidity and mortality in young dogs worldwide. The virus is endemic in the environment and can be infective to unvaccinated or poorly vaccinated dogs. Standard in-patient therapies include use of antiemetics, intravenous fluids, antibiotics and provision of enteral nutrition. The use of antiviral drugs, immunomodulators and monoclonal antibody therapy are newer possibilities that may potentially improve outcome. Outpatient therapy also remains a viable possibility for treatment if financial constraints exist.

Evaluation of the safety and effect of lyophilized canine-specific albumin to increase serum albumin concentration and colloid osmotic pressure in healthy dogs

OBJECTIVE

To evaluate the safety of repeated administration of a lyophilized canine-specific albumin (CSA) product and to quantify its effect on serum albumin concentrations and colloid osmotic pressure (COP) in healthy dogs.

DESIGN

Prospective study.

SETTING

University research facility.

ANIMALS

Six healthy, adult, purpose-bred Beagles.

INTERVENTIONS

Dogs received 1 g/kg of 16% CSA intravenously on days 1, 2, and 14 and were observed, with serial measurement of vital parameters during and for 2 hours after each infusion, to monitor for adverse events or evidence of a hypersensitivity reaction. Serum albumin concentration and COP were measured at predetermined time points before and after each infusion.

RESULTS

One dog experienced a single episode of vomiting approximately 1 hour after completion of the second infusion. No other adverse reactions were observed during the 28-day study period. Serum albumin concentration was increased by a mean of 0.57 g/dL (5.7 g/L) (P = 0.003) when measured 2 hours after the first CSA infusion, and albumin concentration remained significantly higher than baseline at 24 hours after infusion, with a mean difference of 0.42 g/dL (4.2 g/dL) (P < 0.001). The second and third CSA infusions similarly increased serum albumin concentration at 2 hours (P = 0.001 and P = 0.001, respectively) and 24 hours (P = 0.012 and P = 0.007, respectively) after infusion. COP increased by a mean of 2.03 mm Hg at 2 hours after the first infusion (P = 0.013) and remained significantly higher than baseline at 24 hours after infusion, with a mean difference of 1.52 mm Hg (P = 0.002). The second CSA infusion similarly increased COP at 2 hours (P < 0.001) and 24 hours (P = 0.017) after infusion. The third CSA infusion increased COP at 2 hours after infusion (P = 0.004) but did not achieve statistical significance at 24 hours after infusion (P = 0.053).

CONCLUSIONS

A 1-g/kg dose of lyophilized CSA was effective at increasing serum albumin concentration and COP. Repeated infusions of CSA appear safe in healthy dogs.

Retrospective analysis of the use of canine-specific albumin in 125 critically ill dogs

OBJECTIVE

To describe the clinical use of canine-specific albumin (CSA) in critically ill dogs, report adverse events, and evaluate measurable clinical effects of CSA administration.

DESIGN

Retrospective case series from 2019 to 2020.

SETTING

Large, urban, private-practice referral and emergency center.

ANIMALS

Consecutive sample of 125 client-owned dogs administered CSA transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The conditions most commonly associated with the use of CSA were surgical (32/125) and nonsurgical (20/125) gastrointestinal disease. Both serum albumin and total plasma protein concentrations were significantly increased posttransfusion (P < 0.001), and 16% albumin transfusions produced the greatest magnitude increase in serum albumin (P = 0.0015). Concurrent crystalloid administration did not affect change in albumin. While there was no significant improvement in blood pressure seen in those patients that received albumin, a significant improvement in shock index was identified (P = 0.02). Adverse events were uncommon; however, 8 critically ill dogs died during CSA administration.

CONCLUSIONS

CSA appears to be a relatively safe alternative to synthetic colloids and complementary to crystalloids in critically ill patients. More concentrated solutions may be more effective in raising serum albumin concentration. Further investigation into the indications for and efficacy of CSA will continue to improve our knowledge of this blood product.

Successful Use of Mycophenolate Mofetil as Adjunct to Prednisolone for Treatment of Acute Kidney Injury Secondary to Human Serum Albumin Administration in a Dog

The use of human serum albumin (HSA) is described in dogs receiving critical care. However, despite the high degree of homology, anaphylactic and delayed hypersensitivity reactions are reported. Delayed type III hypersensitivity reactions can lead to glomerulonephritis and acute kidney injury (AKI). Undiluted 20% HSA was administered to a 4.8 yr old intact male Labrador Retriever with severe hypoalbuminemia, following surgical management of septic peritonitis of gastrointestinal origin. Nineteen days after HSA administration, the dog developed peracute high magnitude renal proteinuria and AKI. Rapid immunosuppression, using a combination of prednisolone and mycophenolate mofetil, resulted in full resolution of AKI, hypoalbuminemia, and proteinuria. Addition of mycophenolate mofetil may have resulted in the first documented case of full renal recovery from hypersensitivity-induced AKI caused by HSA administration.

Therapeutic plasma exchange for the management of a type III hypersensitivity reaction and suspected immune-mediated vasculitis assumed to be caused by human albumin administration in a dog

OBJECTIVE

To describe the successful treatment of a life-threatening type III hypersensitivity reaction suspected to have been related to human serum albumin (HSA) administration in a dog with therapeutic plasma exchange (TPE).

CASE SUMMARY

A 3-year-old neutered male mixed breed dog was suspected to have developed immune-mediated vasculitis 2 weeks after the administration of HSA (740 mg/kg) for the management of hypoalbuminemia resulting from septic peritonitis. The dog was presented with fever, edema, hypoalbuminemia (26 g/L [2.6 g/dL]; reference interval, 30-44 g/L [3.0-4.4 g/dL]), and coagulopathy. The dog was treated with fresh frozen plasma (FFP) and glucocorticoids but remained hypoalbuminemic (18 g/L [1.8 g/dL]) and developed acute kidney injury (AKI). Over 4 days, 3 TPE treatments were performed, with a total of 2.7 plasma volumes exchanged. Replacement fluids consisted of a combination of FFP, hydroxyethyl starch 6%, and 0.9% saline solution. Following TPE treatments, serum albumin concentration increased (from 18 g/L [1.8 g/dL] to 25 g/L [2.5 g/dL]), serum creatinine concentration decreased (from 340 μmol/L [3.9 mg/dL] to 87 μmol/L [0.98 mg/dL]), and clotting times normalized (activated partial thromboplastin time decreased from 33 seconds to 14.5 seconds). There was a gradual but consistent clinical improvement of the edema and overall demeanor of the dog. No significant adverse effects were noted during the TPE treatments, and the dog was discharged after 8 days of hospitalization. Following discharge, the dog had complete clinical resolution of edema and AKI. NEW/UNIQUE INFORMATION: This is the first report describing successful use of TPE for the management of an immune-mediated reaction (type III hypersensitivity) following HSA administration.

Colloids Yes or No? - a "Gretchen Question" Answered

Colloid solutions, both natural and synthetic, had been widely accepted as having superior volume expanding effects than crystalloids. Synthetic colloid solutions were previously considered at least as effective as natural colloids, as well as being cheaper and easily available. As a result, synthetic colloids (and HES in particular) were the preferred resuscitation fluid in many countries. In the past decade, several cascading events have called into question their efficacy and revealed their harmful effects. In 2013, the medicines authorities placed substantial restrictions on HES administration in people which has resulted in an overall decrease in their use. Whether natural colloids (such as albumin-containing solutions) should replace synthetic colloids remains inconclusive based on the current evidence. Albumin seems to be safer than synthetic colloids in people, but clear evidence of a positive effect on survival is still lacking. Furthermore, species-specific albumin is not widely available, while xenotransfusions with human serum albumin have known side effects. Veterinary data on the safety and efficacy of synthetic and natural colloids is limited to mostly retrospective evaluations or experimental studies with small numbers of patients (mainly dogs). Large, prospective, randomized, long-term outcome-oriented studies are lacking. This review focuses on advantages and disadvantages of synthetic and natural colloids in veterinary medicine. Adopting human guidelines is weighed against the particularities of our specific patient populations, including the risk-benefit ratio and lack of alternatives available in human medicine.

Update on Canine Parvoviral Enteritis

Canine parvoviral enteritis is one of the most common causes of morbidity and mortality in dogs worldwide. Tests can detect viral antigen in feces, and characteristic decreases in total leukocyte, neutrophil, and lymphocyte counts can increase the index of suspicion in affected cases and can be used to prognosticate morbidity and mortality. The standard of care for infected animals includes IV crystalloid and sometimes colloid fluids, antiemetics, broad-spectrum antibiotics, and early enteral nutrition. Vaccination induces protective immunity in most dogs. Vaccination, along with limiting exposure in young puppies, is the most effective means of preventing parvoviral enteritis in dogs.