Nephrogenic systemic fibrosis: What the hospitalist needs to know

Fine, Derek M.; Perazella, Mark A.

doi:10.1002/jhm.493

Cited by 6 publications

(5 citation statements)

References 44 publications

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“…Therefore, in patients who have received a GBCA and underwent HD, the half-life of GBCAs in circulation approaches that in an individual with normal kidney function. 99 , 100 Little evidence exists on rates of NSF with differing duration between GBCA and subsequent dialysis. To minimize time of circulating GBCA and subsequent transmetallation and deposition, earlier HD might be potentially beneficial.…”

Section: Car Clinical Practice Guidelines For Administration Of Gbca mentioning

confidence: 99%

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Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Schieda

et al. 2018

Can J Kidney Health Dis

100

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Purpose of review:Use of gadolinium-based contrast agents (GBCA) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCA are absolutely contraindicated in AKI, category G4 and G5 CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2), and dialysis-dependent patients is outdated and may limit access to clinically necessary contrast-enhanced magnetic resonance imaging (MRI) examinations. This review and clinical practice guideline addresses the discrepancy between existing Canadian guidelines regarding use of GBCA in renal impairment and NSF.Sources of information:Published literature (including clinical trials, retrospective cohort series, review articles, and case reports), online registries, and direct manufacturer databases were searched for reported cases of NSF by class and specific GBCA and exposed patient population.Methods:A comprehensive review was conducted identifying cases of NSF and their association to class of GBCA, specific GBCA used, patient, and dose (when this information was available). Based on the available literature, consensus guidelines were developed by an expert panel of radiologists and nephrologists.Key findings:In patients with category G2 or G3 CKD (eGFR ≥ 30 and < 60 mL/min/1.73 m2), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with category G4 or G5 CKD (eGFR < 30 mL/min/1.73 m2) or on dialysis, administration of GBCA should be considered individually and alternative imaging modalities utilized whenever possible. If GBCA are necessary, newer GBCA may be administered with patient consent obtained by a physician (or their delegate) citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, those with category G4 or G5 CKD, or those on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCA. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCA is recommended.Limitations:Limited available literature (number of injections and use in renal impairment) regarding the use of gadoxetate disodium. Limited, but growing and generally high-quality, number of clinical trials evaluating GBCA administration in renal impairment. Limited data regarding the t...

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Section: Car Clinical Practice Guidelines For Administration Of Gbca mentioning

confidence: 99%

“…Therefore, in patients who have received a GBCA and underwent HD, the half-life of GBCAs in circulation approaches that in an individual with normal kidney function. 99 , 100 …”

Section: Car Clinical Practice Guidelines For Administration Of Gbca mentioning

confidence: 99%

Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Schieda

et al. 2018

Can J Kidney Health Dis

100

View full text Add to dashboard Cite

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“…B HD efficiently removes GBCA with about 70% clearance in 1 session and > 95% clearance after 3 sessions. Therefore, in patients who have received a GBCA and underwent HD, the half-life of GBCAs in circulation approaches that in an individual with normal kidney function [27,28]. B Little evidence exists on rates of NSF with differing duration between GBCA and subsequent dialysis.…”

mentioning

confidence: 99%

Updated Clinical Practice Guideline on Use of Gadolinium-Based Contrast Agents in Kidney Disease Issued by the Canadian Association of Radiologists

Schieda

Maralani

Hurrell³

et al. 2019

Can Assoc Radiol J

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In 2017, the Canadian Association of Radiologists issued a clinical practice guideline (CPG) regarding the use of gadolinium-based contrast agents (GBCAs) in patients with acute kidney injury (AKI), chronic kidney disease (CKD), or on dialysis due to mounting evidence indicating that nephrogenic systemic fibrosis (NSF) occurs with extreme rarity or not at all when using Group II GBCAs or the Group III GBCA gadoxetic acid (compared to first generation Group I linear GBCAs). One of the goals of the work group was to re-evaluate the CPG after 24 months to determine the effect of more liberal use of GBCA on reported cases of NSF in patients with AKI, CKD Stage 4 or 5 (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m 2 ), or those that are dialysis-dependent. A comprehensive review of the literature was conducted by a subcommittee of the initial CPG panel between the dates of January 1, 2017-December 31, 2018 to identify new unconfounded cases of NSF linked to Group II or Group III GBCAs and an updated CPG developed. To our knowledge, when using a Group II or Group III GBCA between 2017-2018, only a single unconfounded case report of a fibrosing dermopathy has been reported in a patient who received gadobenate dimeglumine with Stage 2 CKD. No other unconfounded cases of NSF have been reported with Group II or III agents in during this timeframe. The subcommittee concluded that the main recommendations from the 2017 CPG should remain unaltered, but agreed that screening for renal disease in the outpatient setting is no longer justifiable, cost-effective or recommended. Patients on hemodialysis (HD) should, however, be identified prior to GBCA administration to arrange timely HD to optimize gadolinium clearance, although there remains no evidence that HD reduces the risk of NSF. When administering Group II or III GBCAs to patients with AKI, on dialysis or with severe CKD, informed consent relating to NSF is also no longer explicitly recommended. R esum eEn 2017, l'Association canadienne des radiologistes a publi e des lignes directrices de pratique clinique (LDPC) sur l'utilisation de produits de contraste a base de gadolinium (PCBG) chez des patients atteints d'insuffisance r enale aigu€ e (IRA), de n ephropathie chronique ou sous dialyse, en raison de l'accumulation de donn ees d emontrant que la fibrose syst emique n ephrog enique (FSN) se manifeste avec une raret e extrême, voire pas du tout, lors de l'emploi de PCBG du groupe II ou d'acide gadox etique-PCBG du groupe III (par rapport aux PCBG lin eaires du groupe I de premi ere g en eration). L'un des objectifs du groupe de travail etait de r e evaluer les LDPC apr es 24 mois pour d eterminer l'effet d'une utilisation plus g en erale de PCBG sur des cas signal es de FSN chez des patients atteints d'IRA ou de n ephropathie chronique de stade 4 ou 5 (d ebit de filtration glom erulaire estim e [DFGe] < 30 mL/min/1,73 m 2 ), ou dialys es. Une revue approfondie des publications a et e conduite par un sous-comit e compos e du groupe d'experts d'origine sur ...

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“…There is insufficient evidence to support initiation of dialysis, change from PD to HD or altering dialysis prescription to reduce the risk of NSF. Qualifying statements: HD efficiently removes GBCAs with about 70% clearance in 1 session and >95% clearance after 3 sessions. Therefore, in patients who have received a GBCA and underwent HD, the half-life of GBCAs in circulation approaches that in an individual with normal kidney function [100],[101]. Little evidence exists on rates of NSF with differing duration between GBCAs and subsequent dialysis. To minimize time of circulating GBCAs and subsequent transmetallation and deposition, earlier HD might be potentially beneficial.…”

Section: Car Clinical Practice Guidelines For Administration Of Gbca mentioning

confidence: 99%

“…HD efficiently removes GBCAs with about 70% clearance in 1 session and >95% clearance after 3 sessions. Therefore, in patients who have received a GBCA and underwent HD, the half-life of GBCAs in circulation approaches that in an individual with normal kidney function [100],[101].…”

Section: Car Clinical Practice Guidelines For Administration Of Gbca mentioning

confidence: 99%

Gadolinium-Based Contrast Agents in Kidney Disease: Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

et al. 2018

View full text Add to dashboard Cite

Use of gadolinium-based contrast agents (GBCAs) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCAs are absolutely contraindicated in AKI, CKD stage 4 or 5 (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m) and dialysis-dependent patients is outdated, and may limit access to clinically necessary contrast-enhanced MRI examinations. Following a comprehensive review of the literature and reported NSF cases to date, a committee of radiologists and nephrologists developed clinical practice guidelines to assist physicians in making decisions regarding GBCA administrations. In patients with mild-to-moderate CKD (eGFR ≥30 and <60 mL/min/1.73 m), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with severe CKD (eGFR <30 mL/min/1.73 m), or on dialysis, administration of GBCAs should be considered individually and alternative imaging modalities utilized whenever possible. If GBCAs are necessary, newer GBCAs may be administered with patient consent obtained by a physician (or their delegate), citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, with stage 4 or 5 CKD, or on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCAs. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCAs is recommended.

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Nephrogenic systemic fibrosis: What the hospitalist needs to know

Cited by 6 publications

References 44 publications

Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Updated Clinical Practice Guideline on Use of Gadolinium-Based Contrast Agents in Kidney Disease Issued by the Canadian Association of Radiologists

Gadolinium-Based Contrast Agents in Kidney Disease: Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

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