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

Abstract

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 ...

Use of Intravenous Gadolinium-based Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation

“…However, it is now apparent that the risk of NSF varies by GBCM and is extremely low for group II GBCM, even in high-risk patients (3,7,8,29). Based on these updated data, the ACR, European Society of Urogenital Radiology, and Canadian Association of Radiology have issued recommendations liberalizing the administration of group II GBCM in high-risk patients (20,30,31). In contrast to the Food and Drug Administration, these organizations do not consider group II GBCM to be contraindicated in high-risk patients and consider kidney function screening prior to use of group II GBCM optional.…”

Stasis Leg Ulcers: Venous System Revises by Triggered Angiography Non-Contrast-Enhanced Sequence Magnetic Resonance Imaging

“…Although MRI does not involve radiation exposure, the noniodinated contrast agents involved in the imaging process still have undesirable effects. For example, nephrogenic sclerosing fibrosis (NSF) is a dangerous complication of gadolinium-based contrast agents in patients with pre-existing impairment of kidney function, and it may even occur in patients with normal renal function [ 22 , 23 ]. Phase contrast-MRI (PC-MRI) depends on phase shifts caused by blood flow.…”

Use of Intravenous Gadolinium-Based Contrast Media in Patients With Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation

“…3,7,8,29 Based on these updated data, the ACR, European Society of Urogenital Radiology, and Canadian Association of Radiology have issued recommendations liberalizing the administration of group II GBCM in high-risk patients. 20,30,31 In contrast to the Food and Drug Administration, these organizations do not consider group II GBCM to be contraindicated in high-risk patients and consider kidney function screening prior to use of group II GBCM optional. However, unlike the ACR and the Canadian Association of Radiology, the European Society of Urogenital Radiology advises "caution" when administering group II GBCM to patients with eGFR less than 30 mL/min per 1.73 m 2 .…”