Nephrogenic systemic fibrosis: Center case review

Abstract

Purpose: To retrospectively analyze nephrogenic systemic fibrosis (NSF) cases at our center, to determine prior gadolinium based contrast agent (GBCA) administration and to evaluate possible common risk factors for the development of NSF by reviewing laboratory data and concurrent medications. Materials and Methods:A total of four data bases (pathology, MRI, dialysis, and medical records) were crossreferenced for identification and evaluation of NSF patients. Medical history of NSF patients was assessed as for previous deep venous thrombosis (DVT), surgery, or infections. Laboratory data (creatinine, anion gap, calcium, phosphorus, and albumin) as well as concurrent medication were evaluated. Findings were compared to those of a control group of non-NSF dialysis patients.Results: Between October 2003 and February 2007 a total of nine NSF cases were identified. All patients had undergone contrast-enhanced MRI prior to the diagnosis of NSF. Only one gadolinium chelate had been used at our MRI center (Omniscan, gadodiamide; GE Healthcare). Of nine patients, eight were receiving dialysis at the time of the MRI scan. During the same time 312 dialysis patients received gadodiamide. Thus, the prevalence of NSF within dialysis patients exposed to gadodiamide was 2.6%. NSF patients presented with a higher creatinine and anion gap than the control patients. Other laboratory values as well as medication did not show a significant difference. There were no patterns regarding previous history of DVT, surgery, or infection in the NSF group. Conclusion:Our findings are consistent with the previously reported association between gadodiamide exposure and NSF. All NSF patients had severe renal insufficiency with glomerular filtration rate (GFR) Ͻ 30 (highest GFR ϭ 25 mL/minute) at the time of last gadodiamide administration, and on average had received 71 mL of gadodiamide over an average of 2.9 administrations.

Simultaneous acquisition of MR angiography and venography (MRAV)

“…A technique using the time difference between the arterial phase and venous phase of a single contrast injection has been proposed for simultaneous acquisition of high-resolution intracranial MRA and MRV (20). The administration of gadolinium-based MR contrast agent, however, has recently been found to be linked to the risk of developing nephrogenic systemic fibrosis in patients with impaired renal function (21). This MRAV technique proposed in the present study offers a viable alternative for these patients since it does not require the injection of contrast agent.…”

Kidney transplantation: Structural and functional evaluation using MR Nephro‐Urography

“…It is believed that prolonged exposure to this agent occurs in the setting of reduced renal clearance and that Gd dissociated from its ligand will deposit in tissues, including skin, and lead to activation of the fibrotic process associated with NSF (33,(37)(38)(39). NSF is primarily a disease affecting patients with severely impaired renal function, usually less than 15 mL/min (40) and mostly affecting patients on dial-ysis Furthermore, NSF risk and severity appears to correlate with dose; a higher single dose, but also cumulative total gadodiamide dose (41,42). It has been found, for example, that dialysis patients who developed NSF had been given a cumulative average dose of 0.35 mmol/kg of gadodiamide (29).…”

“…This allows us to limit the total lifetime cumulative dose exposure to 0.3 mmol/kg in patients who have received Gd while on dialysis. This is based on data suggesting that cumulative and high dose administrations may increase risk of NSF (42), albeit that data are mostly based on administration of gadodiamide. Based on our current understanding of the different risks of the different Gd agents in relation to NSF, including our own observations, our approach should be related with an acceptably low risk of NSF, less than 1%.…”

Nephrogenic systemic fibrosis versus contrast‐induced nephropathy: Risks and benefits of contrast‐enhanced MR and CT in renally impaired patients

“…This is particularly the case for gadodiamide, since almost all NSF cases are associated with this agent. We have noted (15) [32][33][34]. Chemical analysis would suggest that, once deposited, gadolinium may collect and be retained indefinitely within the tissues, including skin and bone (35).…”

“…This may be at least partly accounted for by use of a variety of GBCAs, with highrisk agents (ie, gadodiamide) used in only a subset of institutions. In institutions that have reported NSF cases using accepted skin biopsy diagnostic technique, and measured incidence in high-risk patients, all have used gadodiamide, and the incidence in dialysis patients or patients with severe renal insufficiency has ranged from 2%-5% (15)(16)(17)32,33). The fraction of patients who develop severe fibrotic skin disease with loss of joint mobility has been reported in as high as 30%-50% of patients with NSF.…”