By Beth Eisenberg, DVM, DACVECC
Hypoalbuminemia can be the result of numerous conditions including protein losing nephropathy, protein losing enteropathy, intra-thoracic or intra-abdominal effusions, liver failure, or severe hemorrhage. Prior to the availability of canine serum albumin, albumin replacement required plasma transfusions or the use of human serum albumin. Although effective, both options carried potential risk. Use of frozen plasma to correct hypoalbuminemia requires 22.5ml/kg for an expected increase of 0.5mg/dL in albumin. This dose may be of concern in small patients or in patients for which there is potential for fluid overload. Human serum albumin requires a much smaller volume to replenish patient albumin, but it is highly antigenic and complications can include glomerulonephritis, hypersensitivity reactions, and polyarthropathy.
In 2004, the Saline verses Albumin Fluid Evaluation (SAFE) study showed that the use of 4% albumin solution had similar outcomes at 28 days as 0.9% saline when used as a resuscitation fluid for human ICU patients. A subgroup analysis of those patients determined that the odds ratio for death in patients with severe sepsis was significantly less in patients that received albumin versus those that received saline. Currently, the 2012 Surviving Sepsis guidelines suggest that albumin should be considered as a resuscitation fluid in patients with severe sepsis, especially if not responding to crystalloid therapy.
In 2006, a prospective, randomized, controlled study was performed to determine if replacement of albumin in hypoalbuminemic human patients would be beneficial or detrimental. Patients were evaluated daily using a Sequential Organ Failure Assessment score. In patients receiving albumin, respiratory, cardiovascular, and central nervous system function improvements led to an overall improved SOFA score when compared to patients not receiving albumin. It was also noted that while diuretic administration was similar between the two groups, patients not receiving albumin had a significantly greater mean fluid gain than patients receiving albumin. Daily caloric intake was higher in patients receiving albumin as well. The researchers concluded that contrary to previous reports, administration of albumin was not associated with a higher mortality risk.
The use of albumin therapy is well documented in veterinary medicine. Albumin serves as a carrier for endogenous and exogenous compounds, serves as a buffer molecule during acid-base derangements, is the primary protein responsible for maintenance of colloid oncotic pressure, and acts as a scavenger of reactive oxygen species.
A prospective veterinary study evaluating the use of canine serum albumin in cases of septic peritonitis used a dose of 800mg/kg for transfusion over six hours, per the manufacturer instructions. Of the seven patients randomized to receive canine albumin, only one patient displayed potential adverse effects.
Canine albumin is a lyophilized product derived from purified pooled canine plasma. No blood type or crossmatch is required prior to administration. All donors are tested for the same infectious diseases as blood donors in the Animal Blood Resources International donor population.
What is the dose?
Canine albumin is most commonly administered to hypoalbuminemic canine patients with the goal of raising the serum albumin to 2 g/dL. A 5% solution of canine albumin is administered based on the following calculation:
Volume of 5% alb. = BWkg x 90ml/kg x (2g/dL – patient alb.) x 0.2dL/g
Canine albumin can also be administered to hypotensive canine patients for the purpose of volume expansion and maintenance of intravascular volume. A more concentrated solution (16%) is used for these patients at a dose of 250-1000 mg/kg over 6 hours. Fluid overload is a concern when using the concentrated solution.
How do I use it?
- 5 gram vial of lyophilized product
- Store at room temperature for up to 24 months
- Once reconstituted, the product must be used within six hours
- For albumin supplementation, add 100ml of 0.9% NaCl to the vial to make a 5% solution.
- For volume expansion, add 30ml of 0.9% NaCl to the vial to make a 16% solution.
- Swirl gently to reconstitute. Avoid bubbling. Rehydration may take 15-30 minutes.
- Desired volume is drawn into a syringe and administered via syringe pump through a standard extension set and in-line filter (Hemo-Nate)
- Unused portions can be refrigerated for up to 6 hours
- Administration of the 16% solution requires a central IV catheter. The 5% solution can be administered through any IV catheter.
- No other fluids may be administered through the same catheter during infusion.
Adverse Effects and Monitoring
- Monitor the patient as with any other transfusion of blood products (heart rate, respiratory rate, temperature).
- Vomiting, urticaria, and fever are the most likely side effects. Hypotension, vasodilation, and nausea could occur.
- Anaphylaxis is considered rare.
- Fluid overload can occur in patients receiving the 16% solution
- Repeated dosing may be performed with caution
- Canine Albumin Package Insert. Animal Blood Resources International 2011.
- Craft EM, Powell LL. The use of canine-specific albumin in dogs with septic peritonitis. J Vet Emerg Crit Care 2012;22:631-9.
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
- Dubois MJ, Orellana-Jimenez C, Melot C, et al. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled pilot study. Crit Care Med 2006;34:2536-40.
- Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-56.