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The Evolution of Osseous Metaplasia in Localized Cutaneous Nephrogenic Systemic Fibrosis: A Case Report. Am J Dermatopathol 2009; 31:674-81. [DOI: 10.1097/dad.0b013e3181a1fb55] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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52
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Kalisiak M, Courtney M, Lin A, Brassard A. Calcific uremic arteriolopathy (calciphylaxis): successful treatment with sodium thiosulfate in spite of elevated serum phosphate. J Cutan Med Surg 2009; 13 Suppl 1:S29-34. [PMID: 19480749 DOI: 10.2310/7750.2009.00007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michal Kalisiak
- Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB
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53
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Rehabilitation in Nephrogenic Systemic Fibrosis. PM R 2009; 1:684-6. [DOI: 10.1016/j.pmrj.2009.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Revised: 05/08/2009] [Accepted: 05/19/2009] [Indexed: 11/22/2022]
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54
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Effects of gadolinium-based magnetic resonance imaging contrast agents on human skin in organ culture and human skin fibroblasts. Invest Radiol 2009; 44:74-81. [PMID: 19077912 DOI: 10.1097/rli.0b013e31818f76b5] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Nephrogenic systemic fibrosis (NSF) is a clinical syndrome linked with exposure in renal failure patients to gadolinium-based magnetic resonance imaging contrast agents (GBCAs). The pathogenesis of the disease is largely unknown. The present study addresses potential pathophysiological mechanisms. MATERIALS AND METHODS Here, we have examined human skin in organ culture and human dermal fibroblasts in monolayer culture for responses to GBCA stimulation. RESULTS Treatment of normal human skin in organ culture with Omniscan had no significant effect on type I procollagen but increased both matrix metalloproteinase-1 and tissue inhibitor of metalloproteinases-1. At the histologic level, many interstitial cells demonstrated cytologic features characteristic of activation (ie, light staining, oblong, plump nuclei). Omniscan, as well as 3 other magnetic resonance imaging contrast agents (Magnevist, Multihance, and Prohance), increased proliferation of human dermal fibroblasts in monolayer culture. Increased proliferation was accompanied by an increase in production of both matrix metalloproteinase-1 and tissue inhibitor of metalloproteinases-1 but no increase in type I procollagen. Concentrations required for effects differed among the 4 agents (Omniscan < Magnevist and Multihance < Prohance). In contrast to its effects on fibroblast function, Omniscan did not stimulate human epidermal keratinocyte proliferation when examined over a wide range of concentrations. CONCLUSION These data provide evidence that GBCA exposure in ex vivo skin from healthy individuals increases fibroblast proliferation and has effects on the enzyme/inhibitor system that regulates collagen turnover in the skin.
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Asplin JR, Donahue SE, Lindeman C, Michalenka A, Strutz KL, Bushinsky DA. Thiosulfate reduces calcium phosphate nephrolithiasis. J Am Soc Nephrol 2009; 20:1246-53. [PMID: 19369406 DOI: 10.1681/asn.2008070754] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
An uncontrolled trial reported that sodium thiosulfate reduces formation of calcium kidney stones in humans, but this has not been established in a controlled human study or animal model. Using the genetic hypercalciuric rat, an animal model of calcium phosphate stone formation, we studied the effect of sodium thiosulfate on urine chemistries and stone formation. We fed genetic hypercalciuric rats normal food with or without sodium thiosulfate for 18 wk and measured urine chemistries, supersaturation, and the upper limit of metastability of urine. Eleven of 12 untreated rats formed stones compared with only three of 12 thiosulfate-treated rats (P < 0.002). Urine calcium and phosphorus were higher and urine citrate and volume were lower in the thiosulfate-treated rats, changes that would increase calcium phosphate supersaturation. Thiosulfate treatment lowered urine pH, which would lower calcium phosphate supersaturation. Overall, there were no statistically significant differences in calcium phosphate supersaturation or upper limit of metastability between thiosulfate-treated and control rats. In vitro, thiosulfate only minimally affected ionized calcium, suggesting a mechanism of action other than calcium chelation. In summary, sodium thiosulfate reduces calcium phosphate stone formation in the genetic hypercalciuric rat. Controlled trials testing the efficacy and safety of sodium thiosulfate for recurrent kidney stones in humans are needed.
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Affiliation(s)
- John R Asplin
- Litholink Corp., 2250 W. Campbell Park Drive, Chicago, IL 60612, USA.
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56
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Becker S, Witzke O, Kribben A. [Nephrogenic systemic fibrosis]. ACTA ACUST UNITED AC 2009; 104:204-9. [PMID: 19337710 DOI: 10.1007/s00063-009-1033-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 01/21/2009] [Indexed: 11/24/2022]
Abstract
Nephrogenic systemic fibrosis is a highly debilitating and emotionally depressing disorder. So far, it has exclusively occurred in patients suffering from acute or chronic renal failure. Most patients had been exposed to gadolinium- based contrast agents. Early symptoms include pain, swelling and pruritus, predominantly of the extremities. Fibrosis of the skin and other organs develops in the further course of the disease. The diagnosis is made based on the synopsis of medical history, clinical and dermatohistological findings. To avoid the application of gadolinium-based contrast agents in patients with highly impaired renal function is the best measure to prevent the disease. An effective therapy has not yet been established. Possible therapies, which have been successful in individual cases, comprise, among others, a quick restoration of renal function, physiotherapy, and extracorporeal photopheresis.
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Affiliation(s)
- Stefan Becker
- Klinik für Nephrologie, Zentrum für Innere Medizin, Universitätsklinikum Essen, Universität Duisburg-Essen
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Ruangkanchanasetr P, Rojanamethin S, Ruamthanthong A, Chaiprasert A, Supaporn T. USE OF HIGH-DOSE GADOLINIUM AS CONTRAST MEDIA TO AVOID RADIOCONTRAST MEDIA-INDUCED NEPHROPATHY. J Ren Care 2009; 35:11-5. [DOI: 10.1111/j.1755-6686.2009.00085.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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58
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Skin problems in chronic kidney disease. Nat Rev Nephrol 2009; 5:157-70. [PMID: 19190625 DOI: 10.1038/ncpneph1040] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Accepted: 12/16/2008] [Indexed: 12/14/2022]
Abstract
Skin disorders associated with chronic kidney disease (CKD) can markedly affect a patient's quality of life and can negatively impact their mental and physical health. Uremic pruritus, which is frequently encountered in patients with CKD, is considered to be an inflammatory systemic disease rather than a local skin disorder. Biomarkers of inflammation are increased in patients with uremic pruritus and an imbalance of the endogenous opioidergic system might be involved in the complex pathogenesis of the disease. Treatment options for uremic pruritus include emollients, topical capsaicin cream, ultraviolet B phototherapy, gabapentin, oral activated charcoal and nalfurafine, a kappa-opioid-receptor agonist. Calcific uremic arteriolopathy is triggered by an imbalance of promoters and inhibitors of vascular calcification, caused by the inflammatory changes that occur in uremia. Promising therapeutic strategies for calcific uremic arteriolopathy include bisphosphonates and intravenous sodium thiosulfate. Nephrogenic systemic fibrosis is a devastating condition associated with the use of gadolinium-based contrast agents in patients with CKD. At present, no therapies are available for this complication. Preventive measures include use of iodine-based contrast agents, particularly in patients with CKD stage 4 and 5. If gadolinium contrast is necessary, administration of low volumes of the more stable macrocyclic ionic types of gadolinium-based contrast agent is advocated. Hemodialysis following gadolinium exposure might offer benefits but evidence is lacking.
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Cordova KB, Oberg TJ, Malik M, Robinson-Bostom L. Dermatologic Conditions Seen in End-Stage Renal Disease. Semin Dial 2009; 22:45-55. [PMID: 19250446 DOI: 10.1111/j.1525-139x.2008.00534.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Katharine B Cordova
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA
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Abstract
Background Contrast media are widely used in urogenital radiology. The ideal contrast agent should be totally inert, causing no interactions with organism, and with a rapid and complete excretion. Adverse reactions could occur after using any type of contrast media. Contrast enhanced procedures are performed with increasing frequency and the patients population is progressively older and with multiple co-morbid conditions, thus contrast media toxicity is becoming a serious problem. Contrast media-induced nephropathy (CIN) is considered an important cause of hospital-acquired renal failure. The administration of gadolinium-based contrast agents has been recently associated with the development of a serious adverse reaction, potentially lethal in patients with renal insufficiency, named nephrogenic systemic fibrosis (NSF). Methods Literature review on contrast media in urogenital radiology, CIN, NSF. Conclusions Since 1996, the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has released its guidelines regarding safety about the use of contrast media. CIN, and the emerging NSF, are topics of increasing interest for urologists, radiologists, nephrologists, dermatologists and all the clinicians. Contrast media have progressively become safer in the last years. Even if rare, some adverse reactions still occurr up to now. CIN and its prevention remain an issue under debate. In the past, whenever a patient required a contrast-enhanced imaging study, the trend was to select magnetic resonance imaging with gadolinium-based contrast agents in order to avoid the well-known CIN of iodinated-based contrast agents. The awareness of NFS is changing the contrast–enhanced imaging in patients with renal failure. At present we have to investigate NSF etiopathogenesis, in order to prevent and eventually to cure it. The understanding of the risk factors for both CIN and NSF is an emerging need, the adoption of all preventive measures to reduce the risks remain a mandatory issue.
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Affiliation(s)
- N. Foschi
- Urologia, Università Cattolica del Sacro Cuore, Policlinico “A. Gemelli”, Roma
| | - A. Totaro
- Urologia, Università Cattolica del Sacro Cuore, Policlinico “A. Gemelli”, Roma
| | - A. Brescia
- Urologia, Università Cattolica del Sacro Cuore, Policlinico “A. Gemelli”, Roma
| | - G. Gulino
- Urologia, Università Cattolica del Sacro Cuore, Policlinico “A. Gemelli”, Roma
| | - P.F. Bassi
- Urologia, Università Cattolica del Sacro Cuore, Policlinico “A. Gemelli”, Roma
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Kadiyala D, Roer DA, Perazella MA. Nephrogenic Systemic Fibrosis Associated With Gadoversetamide Exposure: Treatment With Sodium Thiosulfate. Am J Kidney Dis 2009; 53:133-7. [DOI: 10.1053/j.ajkd.2008.09.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 09/19/2008] [Indexed: 11/11/2022]
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63
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Nephrogenic systemic fibrosis and the use of gadolinium-based contrast agents. Pediatr Nephrol 2008; 23:2121-9. [PMID: 18543004 DOI: 10.1007/s00467-008-0862-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 04/14/2008] [Accepted: 04/14/2008] [Indexed: 10/22/2022]
Abstract
Nephrogenic systemic fibrosis (NSF) is a disease seen exclusively in patients with decreased renal function. The use of gadolinium-based contrast agents (GBCAs) has a strong association with NSF. Linear non-ionic GBCAs that are more prone to release free gadolinium are the more likely to cause NSF. The number of reported cases has increased recently, and there are currently nine pediatric cases, the patients ranging in age from 8 years to 19 years, and the oldest adult patient is 87 years of age. The most successful treatment is improvement of renal function with renal transplantation or with recovery of acute kidney injury. NSF can be severely debilitating and even fatal. Avoidance of a GBCA in patients at risk, or limitation of the dose in the patients who need gadolinium enhancement, is recommended.
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65
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MRI safety update 2008: part 1, MRI contrast agents and nephrogenic systemic fibrosis. AJR Am J Roentgenol 2008; 191:1129-39. [PMID: 18806155 DOI: 10.2214/ajr.08.1038.1] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This article is the first part of a two-part series on MRI safety. In this article, part 1, the topic of MRI contrast agents and nephrogenic systemic fibrosis (NSF) is addressed. CONCLUSION To prevent incidents and accidents associated with MRI, it is necessary to regularly revisit the safety topics that directly impact patient management especially with respect to the subjects that are "new" (e.g., MRI contrast agents and NSF), those that should be reassessed because of recent changes, topics that deserve emphasis because of controversy or confusion, and information that should be considered in light of new findings.
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Calciphylaxis: calcific uremic arteriolopathy and the emerging role of sodium thiosulfate. Int Urol Nephrol 2008; 40:443-51. [PMID: 18369733 DOI: 10.1007/s11255-008-9373-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 03/11/2008] [Indexed: 01/12/2023]
Abstract
Calciphylaxis-calcific uremic arteriolopathy, is a serious disorder of arteriolar calcification of the arteriole media and is associated with endovascular fibrosis and thrombosis in subcutaneous adipose tissue. It frequently results in severe ischemia, intense pain, and tissue necrosis with nonhealing skin ulcerations. It usually occurs in chronic kidney disease and especially in patients requiring renal replacement therapy. It is associated with a very high mortality rate, and the number of reports and reviews seemed to have increased over the past 5 years. Advances in therapy and salvaging patients from this high mortality risk have recently been reported with the use of sodium thiosulfate. The new application for this old drug used to treat cyanide poisoning and recently preventing neurotoxic effects resulting in hearing loss in those patients with head and neck cancer receiving cisplatin and carboplatin therapy are discussed. Recently, multiple case reports have demonstrated that sodium thiosulfate therapy has resulted in rapid pain relief, healing of skin ulcerations, and prevention of high mortality risk. This emerging treatment and its success are relatively unknown to many physicians. The purpose of this report is to share with others the emerging role of sodium thiosulfate and its new application as a treatment option to be used in combination with other treatment modalities for calciphylaxis-calcific uremic arteriolopathy. Indeed, as with any new treatment this emerging therapy should be studied in greater detail, but this old drug seems to have a new life in the hands of treating physicians.
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67
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Pasch A, Schaffner T, Huynh-Do U, Frey BM, Frey FJ, Farese S. Sodium thiosulfate prevents vascular calcifications in uremic rats. Kidney Int 2008; 74:1444-53. [PMID: 18818688 DOI: 10.1038/ki.2008.455] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Accelerated vascular calcification is a severe complication of chronic kidney disease contributing to high morbidity and mortality in patients undergoing renal replacement therapy. Sodium thiosulfate is increasingly used for the treatment of soft tissue calcifications in calciphylaxis. Therefore, we determined whether it also prevents development of vascular calcifications in chronic kidney disease. We found that uremic rats treated by thiosulfate had no histological evidence of calcification in the aortic wall whereas almost three-fourths of untreated uremic rats showed aortic calcification. Urinary calcium excretion was elevated and the calcium content of aortic, heart, and renal tissue was significantly reduced in the thiosulfate-treated compared to non-treated animals. Sodium thiosulfate treatment transiently lowered plasma ionized calcium and induced metabolic acidosis. It also lowered bone strength in the treated animals compared to their normal controls. Hence, sodium thiosulfate prevented vascular calcifications in uremic rats, likely by enhancing acid- and/or chelation-induced urinary calcium loss. The negative impact on rat bone integrity necessitates a careful risk-benefit analysis before sodium thiosulfate can be used in individual human patients.
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Affiliation(s)
- Andreas Pasch
- Department of Nephrology and Hypertension, Inselspital, University of Bern, Bern, Switzerland
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68
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Hyland K, Cohen RM, Kwak A, Shlansky-Goldberg RD, Soulen MC, Patel AA, Mondschein JI, Solomon JA, Stavropoulos SW, Itkin M, Yeh H, Markmann J, Trerotola SO. Preoperative Mapping Venography in Patients Who Require Hemodialysis Access: Imaging Findings and Contribution to Management. J Vasc Interv Radiol 2008; 19:1027-33. [DOI: 10.1016/j.jvir.2008.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 03/07/2008] [Accepted: 03/10/2008] [Indexed: 10/22/2022] Open
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Hayden MR. Calciphylaxis and the cardiometabolic syndrome: the emerging role of sodium thiosulfate as a novel treatment option. ACTA ACUST UNITED AC 2008; 3:55-9. [PMID: 18326977 DOI: 10.1111/j.1559-4572.2008.08261.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Melvin R Hayden
- Department of Internal Medicine, University of Missouri School of Medicine, Columbia, MO 65020, USA.
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Pieringer H, Schumacher S, Schmekal B, Gitter T, Biesenbach G. Gadolinium-based contrast agents, erythropoietin and nephrogenic systemic fibrosis in patients with end-stage renal failure. Clin Kidney J 2008; 1:193-4. [PMID: 25983879 PMCID: PMC4421164 DOI: 10.1093/ndtplus/sfn030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Herwig Pieringer
- Section of Rheumatology and Nephrology, 2nd Department of Medicine and
| | - Sabine Schumacher
- Section of Rheumatology and Nephrology, 2nd Department of Medicine and
| | - Bernhard Schmekal
- Section of Rheumatology and Nephrology, 2nd Department of Medicine and
| | - Thomas Gitter
- Department of Radiology, General Hospital Linz, Krankenhausstr. 9 A-4020 Linz , Austria
| | - Georg Biesenbach
- Section of Rheumatology and Nephrology, 2nd Department of Medicine and
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In Reference to Visualization of Endolymphatic Hydrops in Patients With Meniere???s Disease. Laryngoscope 2008; 118:946; author reply 946-7. [DOI: 10.1097/mlg.0b013e318165aa01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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73
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Marckmann P. An epidemic outbreak of nephrogenic systemic fibrosis in a Danish hospital. Eur J Radiol 2008; 66:187-90. [DOI: 10.1016/j.ejrad.2008.01.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/04/2008] [Accepted: 01/08/2008] [Indexed: 11/16/2022]
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Nephrogenic systemic fibrosis: chronic imaging findings and review of the medical literature. Skeletal Radiol 2008; 37:457-64. [PMID: 18324398 DOI: 10.1007/s00256-008-0464-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 01/14/2008] [Accepted: 01/16/2008] [Indexed: 02/02/2023]
Abstract
Nephrogenic systemic fibrosis (NSF) is a systemic fibrosing disorder which has been strongly associated with exposure to gadolinium-based contrast media (GBCM) in the setting of renal insufficiency. Although this disorder primarily affects the skin, it can result in severe joint contractures, disabilities and even death. However, to date, there have been no published studies reporting chronic imaging findings of NSF. In this report we present three biopsy-proven cases of NSF with the associated chronic MRI, radiographic and bone scintigraphy findings. Two of the patients had been exposed to gadodiamide, and one had been exposed to gadopentetate dimeglumine prior to the onset of NSF. Two are newly reported cases. One patient's subacute imaging findings have previously been reported, but significant chronic images will now be presented. This patient became severely disabled from contractures and developed long bone smooth periosteal reaction, extensive intra-articular and periarticular calcifications, musculotendinous heterotopic ossification and ankylosis of several joints. One of the patients underwent renal transplantation 6 months after GBCM exposure, with near complete resolution of the skin fibrosis. The third patient had persistent MRI findings of skin thickening, with low T1 and high T2 signal intensity 5 years after exposure to gadodiamide. A review of the medical literature is provided, emphasizing the association of NSF with various GBCM. These cases broaden our understanding of the long-term imaging findings and complications of NSF and the stratified risk of NSF with various GBCM.
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76
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Nephrogenic systemic fibrosis associated with gadolinium based contrast agents: A summary of the medical literature reporting. Eur J Radiol 2008; 66:230-4. [DOI: 10.1016/j.ejrad.2008.02.011] [Citation(s) in RCA: 232] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 02/04/2008] [Accepted: 02/04/2008] [Indexed: 01/15/2023]
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Marckmann P, Nielsen AH, Sloth JJ. Possibly enhanced Gd excretion in dialysate, but no major clinical benefit of 3-5 months of treatment with sodium thiosulfate in late stages of nephrogenic systemic fibrosis. Nephrol Dial Transplant 2008; 23:3280-2. [PMID: 18436563 DOI: 10.1093/ndt/gfn217] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Gd-related nephrogenic systemic fibrosis was successfully treated with intravenous sodium thiosulfate according to a recent case report. METHODS Four haemodialysis patients with severe Gd-related nephrogenic systemic fibrosis were treated with intravenous sodium thiosulfate for 3-5 months. Symptoms and patients' experiences were investigated. The dialysate Gd content was monitored. RESULTS We observed no major clinical improvements in any patient. In one patient, we found slightly improved joint motion. Two patients had a subjective impression of slight improvements of joint motion and skin abnormalities. The dialysate Gd content was raised by the treatment, up to fivefold. CONCLUSIONS We could not confirm that sodium thiosulfate treatment results in marked and rapid improvement in late stages of Gd-related nephrogenic systemic fibrosis. However, dialysate contents of Gd seemed to increase. It is unknown whether increased Gd excretion will lead to long-term clinical improvements in late stages of nephrogenic systemic fibrosis.
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Affiliation(s)
- Peter Marckmann
- Department of nephrology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, DK-2730 Herlev, Denmark.
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Mercadal L, Servais A, Venditto M, Renault N, Isnard-Bagnis C, Deray G, Petitclerc T. Measuring plasma conductivity to detect sodium load in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:743-6. [PMID: 18372320 DOI: 10.2215/cjn.03780907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sodium thiosulfate therapy has been proposed for calcific uremic arteriolopathy and nephrogenic systemic fibrosis in hemodialysis patients. The treatment brings 3.7 g (161 mmol) of sodium. How to counterbalance this sodium load was studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Plasma conductivity (Cp) and mass balance index were compared for 20 sessions without thiosulfate and 20 sessions with thiosulfate infusion. Subsequently, the dialysate conductivity was set to 13.8 mS/cm during the entire session. Next, dialysate conductivity was set to 14 mS/cm for the first 3 h and to 13 mS/cm for the last hour of thiosulfate infusion (n = 25). RESULTS The Cp variation between beginning and end was equal to +0.005 +/- 0.13 mS/cm without thiosulfate, +0.24 +/- 0.13 mS/cm with thiosulfate, and 14 mS/cm dialysate conductivity (P < 0.001). The decrease in dialysate conductivity at 13.8 mS/cm did not counterbalance the sodium load. The last program adequately compensated the sodium load with a Cp increase of only +0.05 +/- 0.14 mS/cm (NS versus without thiosulfate). The total of the dialyzed sodium and the sodium load for this last program was equal to 603 mmol compared with 456 mmol for the sessions without thiosulfate, the difference of 147 mmol being close to the known content of 161 mmol in 25 g of infused thiosulfate. CONCLUSIONS Thiosulfate infusion requires a decrease of dialysate conductivity of -1 mS/cm during the infusion to counterbalance the added 3.7 g (161 mmol) sodium load.
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Affiliation(s)
- Lucile Mercadal
- Nephrology department, Pitié-Salpétrière Hospital, 83 bd de l'hôpital, Paris, France 75013.
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Possible involvement of gadolinium chelates in the pathophysiology of nephrogenic systemic fibrosis: a critical review. Toxicology 2008; 248:77-88. [PMID: 18440117 DOI: 10.1016/j.tox.2008.03.012] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 03/12/2008] [Accepted: 03/13/2008] [Indexed: 11/19/2022]
Abstract
Nephrogenic systemic fibrosis (NSF) is a recently described, highly debilitating scleroderma-like disease occurring in patients with severe or end-stage renal failure. NSF is characterized by cutaneous papules and coalescing plaques ("peau d'orange" appearance) and a wooden consistency. It may ultimately cause disabling contractures of several joints, thus making many patients wheelchair-dependent. NSF has been associated to prior administration of gadolinium chelates (GC) used as contrast agents for magnetic resonance imaging. The best available treatment option at the present time is renal transplantation. The mechanism of NSF has not been fully elucidated. Several hypotheses have been proposed so far and are critically discussed in the present review article. Gadolinium has been found in skin biopsy samples of patients. The most widely accepted hypothesis is related to dechelation of less stable GC, progressively releasing free Gd3+ which may subsequently lead to the attraction of CD34+, CD45+, pro-collagen+ circulating fibrocytes via the release of chemokines, thereby inducing systemic fibrosing disorders. Pre-existing renal failure may facilitate the process by delaying the excretion of GC. A complex interplay between gadolinium and co-factors (pro-inflammatory status, vascular injury, high dose of erythropoietin, high levels of calcium, phosphorus, etc.) may occur in patients with impaired renal function. This and other hypotheses remain to be investigated, as well as the role and independence of co-factors.
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Nephrogenic systemic fibrosis--implications for nephrologists. Eur J Radiol 2008; 66:208-12. [PMID: 18342470 DOI: 10.1016/j.ejrad.2008.01.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/04/2008] [Accepted: 01/08/2008] [Indexed: 11/23/2022]
Abstract
Nephrogenic systemic fibrosis (NSF) is a debilitating disorder seen in-patient with advanced chronic kidney disease (CKD). Recent evidence suggests a link between NSF and the administration of gadolinium-based contrast agents (Gd-CA). In addition, other risk factors have also been suggested to facilitate the development of NSF in this population after Gd-CA. These include metabolic acidosis, high-dose erythropoietin therapy, and the altered mineral metabolism of CKD. While it is possible that these factors may increase the risk of NSF after Gd-CA exposure, they may also simply reflect conditions that increase the risk of getting exposed to Gd-CA, particularly at high doses. Furthermore, given the risk of NSF in CKD, physicians must weigh the risks of NSF versus the risk of contrast-induced nephropathy (CIN) with iodinated agents in this population. In this review, we will provide a nephrologist's perspective on these issues and the nephrologist's role in the prevention of NSF.
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81
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Kramer U, Wiskirchen J, Fenchel MC, Seeger A, Laub G, Tepe G, Finn JP, Claussen CD, Miller S. Isotropic high-spatial-resolution contrast-enhanced 3.0-T MR angiography in patients suspected of having renal artery stenosis. Radiology 2008; 247:228-40. [PMID: 18270376 DOI: 10.1148/radiol.2471070565] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to prospectively evaluate the diagnostic performance of contrast material-enhanced magnetic resonance (MR) angiography performed at 3 T for assessment of renal artery stenosis (RAS) by using parallel acquisition techniques with high acceleration factors and with digital subtraction angiography (DSA) as the reference standard. The study was institutional review board approved, and written informed consent was obtained from all patients. Twenty-nine patients (18 men, 11 women; mean age, 57.1 years +/- 14.3 [standard deviation]) suspected of having RAS underwent MR angiography. Images were evaluated qualitatively and quantitatively. The interobserver variability, sensitivity, specificity, and positive and negative predictive values of 3-T MR angiography, as compared with DSA (performed in 15 patients), were calculated. All examinations yielded good or excellent image quality. The sensitivity and specificity of MR angiography in grading significant (>75%) stenosis were 94% and 96%, respectively. Owing to its high sensitivity, contrast-enhanced 3-T MR angiography can be used reliably to exclude RAS and can serve as a useful screening method in the diagnostic work-up of patients with arterial hypertension.
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Affiliation(s)
- Ulrich Kramer
- Department of Diagnostic Radiology, University of Tuebingen, Hoppe-Seyler-Str 3, 72076 Tuebingen, Germany.
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Abstract
Many conditions presenting with clinical hard skin and tissue fibrosis can be confused with systemic sclerosis (scleroderma). These disorders have very diverse etiologies and often an unclear pathogenetic mechanism. Distinct clinical characteristics, skin histology, and disease associations may allow one to distinguish these conditions from scleroderma and from each other. A prompt diagnosis is important to spare patients from ineffective treatments and inadequate management. This article highlights nephrogenic systemic fibrosis (nephrogenic fibrosing dermopathy), eosinophilic fasciitis (Shulman's syndrome), scleromyxedema, and scleredema. These often are detected in the primary care setting and referred to rheumatologists for further evaluation. Rheumatologists must be able to promptly recognize them to provide valuable prognostic information and appropriate treatment options for affected patients.
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Affiliation(s)
- Francesco Boin
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 4100, Room 405, Baltimore, MD 21224, USA.
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83
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Abstract
Nephrogenic systemic fibrosis (NSF) is a progressive, debilitating, and emotionally distressing disease that can affect patients with renal dysfunction. Prevention, early recognition and early treatment are essential to limiting its impact. The most significant risk factors for developing NSF are chronic or significant acute kidney disease (usually necessitating dialysis) and the administration of gadolinium-containing contrast agents (GCCA). Early symptoms include swelling, redness, pruritus, and pain in the limbs, sometimes with muscle weakness. Early signs are edema, erythema, and occasionally palpable warmth of the involved extremities; there may be florid scleral telangiectasia resembling conjunctivitis. We must redouble our efforts to avoid the administration of GCCA to patients with renal insufficiency. The most effective treatment for NSF to date is maximization of renal function via medical therapy or transplantation. There are data to support a beneficial effect from extracorporeal photopheresis, and all patients can gain from physical therapy.
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Affiliation(s)
- Eleanor A Knopp
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut 06520-8059, USA
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84
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Linfert DR, Schell JO, Fine DM. NSF: WHAT WE KNOW AND WHAT WE NEED TO KNOW: Treatment of Nephrogenic Systemic Fibrosis: Limited Options but Hope for the Future. Semin Dial 2008; 21:155-9. [DOI: 10.1111/j.1525-139x.2007.00407.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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85
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What nephrologists need to know about gadolinium. ACTA ACUST UNITED AC 2008; 3:654-68. [PMID: 18033225 DOI: 10.1038/ncpneph0660] [Citation(s) in RCA: 214] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Accepted: 08/17/2007] [Indexed: 01/03/2023]
Abstract
Gadolinium chelates are commonly used to improve tissue contrast in MRI. Until recently the use of gadolinium was thought to be risk-free compared with alternative contrast agents. Recent studies, however, have raised serious concerns regarding the safety of gadolinium chelates. Although safe in patients with normal kidney function, administration of these agents in people with renal dysfunction can result in up to three clinical problems that the nephrologist should be familiar with. The first is nephrogenic systemic fibrosis (NSF), which was initially observed in 1997. Although manifesting primarily in skin, NSF can also cause systemic fibrosis, leading to disabling contractures and even death. Gadodiamide is the agent that has been most frequently associated with NSF, but other chelates might also pose a risk. The second clinical problem is that gadolinium chelates cause acute kidney injury, especially at high doses required for angiography. The third problem is that several laboratory artifacts are associated with gadolinium administration, with pseudohypocalcemia being the most important. The risk of a patient experiencing all three of these complications increases as renal function declines. In light of these problems, nephrologists need to re-evaluate the risks and benefits of gadolinium administration in patients with chronic kidney disease stage 3 or greater, as well as in those with acute kidney injury.
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86
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Abstract
Nephrogenic systemic fibrosis (NSF) is a debilitating disorder that affects patients with renal insufficiency. Recent evidence suggests that the development of NSF may be related to the administration of gadolinium-based contrast media (GBCM) in the setting of magnetic resonance imaging. As no treatment has consistently been effective in the management of NSF, strategies to prevent the development of this condition appear to be the best therapy. Identification of patients at greatest risk for developing NSF after exposure to GBCM is crucial. Risk factors include advanced chronic kidney disease (stages 4 and 5) and acute or chronic inflammatory events. The United States Food and Drug Administration has updated its public health advisory to include patients with moderate renal insufficiency (chronic kidney disease stage 3) as being at risk for developing NSF. However, these data require further verification and the vast majority of affected patients are already on renal replacement therapy. Another strategy in prevention may include consultation with a radiologist for imaging alternatives. If GBCM must be administered, immediate hemodialysis may be protective in patients already on hemodialysis; however, given the lack of data to support this, we do not recommend routine dialysis for patients not yet on dialysis or who are currently being treated with peritoneal dialysis. Decisions such as this should be made on a case by case basis after evaluating additional risk factors.
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Affiliation(s)
- Georges Saab
- Department of Internal Medicine, Division of Nephrology, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO 65212, USA.
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87
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Abraham JL, Thakral C, Skov L, Rossen K, Marckmann P. Dermal inorganic gadolinium concentrations: evidence for in vivo transmetallation and long-term persistence in nephrogenic systemic fibrosis. Br J Dermatol 2007; 158:273-80. [PMID: 18067485 DOI: 10.1111/j.1365-2133.2007.08335.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gadolinium (Gd)-based magnetic resonance contrast agents (GBMCA), including gadodiamide, have been identified as the probable causative agents of the serious disease, nephrogenic systemic fibrosis (NSF). OBJECTIVES To investigate retained Gd-containing deposits in skin biopsies from patients with NSF and to determine their relative concentrations over time from administration of GBMCA. METHODS An investigator-blinded retrospective study, analysing 43 skin biopsies from 20 patients with gadodiamide-related NSF and one NSF-negative gadodiamide-exposed dialysis patient, ranging from 16 days to 1991 days after Gd contrast dose. Utilizing automated quantitative scanning electron microscopy/energy-dispersive X-ray spectroscopy we determined the concentration of Gd and associated elements present as insoluble deposits in situ in the tissues. RESULTS We detected Gd in skin lesions of all 20 patients with NSF, whereas Gd was undetectable in the NSF-negative patient. Gd concentration increased over time in 60% of patients with multiple sequential biopsies (n=10), decreasing only when the initial sampling time was >23 months after first gadodiamide dose. All Gd-containing deposits contained phosphorus, calcium and sodium. The ratio of Gd to calcium in tissue deposits correlated positively with the gadodiamide dose and with serum ionized calcium at the time of Gd exposure. CONCLUSIONS These findings demonstrate the in vivo release (through transmetallation) of the toxic free Gd3+ from gadodiamide, and its retention in apatite-like deposits. We suggest that Gd may be mobilized over time from bone stores, explaining variably delayed onset of NSF and increasing skin concentration over time in patients with NSF.
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Affiliation(s)
- J L Abraham
- Department of Pathology, SUNY Upstate Medical University, Syracuse, NY 13210, USA.
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88
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Parsons AC, Yosipovitch G, Sheehan DJ, Sangüeza OP, Greenberg CS, Sane DC. Transglutaminases: the missing link in nephrogenic systemic fibrosis. Am J Dermatopathol 2007; 29:433-6. [PMID: 17890909 DOI: 10.1097/dad.0b013e318156e43f] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy (NFD), occurs in renal failure patients after gadolinium contrast exposure. The fibrosis of the dermis and subcutaneous septae accompanies fibrosis of other organs, including the heart, liver, lungs, and muscle. The fibrotic skin demonstrates increased dermal collagen, fibroblasts, and mucin. The mechanism by which gadolinium is associated with fibrosis is not known. We tested the hypothesis that upregulation of transglutaminases contributes to the fibrosis seen in the organs, including skin, of renal failure patients exposed to gadolinium contrast. We performed immunohistochemical studies using antibodies to transglutaminase-2, factor XIIIa, transglutaminase isopeptide, and the histiocyte marker CD68 on five archived skin biopsies of NSF. The results indicate that the dermal fibroblasts and histiocytes of NSF express transglutaminase-2, CD68, factor XIIIa, and transglutaminase isopeptide, indicating increased expression and/or activation of transglutaminases in NSF. We recommend further research into the use of transglutaminase inhibitors in the treatment and prevention of NSF.
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Affiliation(s)
- Amy C Parsons
- Department of Pathology, Wake Forest University Baptist Medical Center, Winston Salem, NC 27157-1045, USA
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89
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Sherman RA. Briefly noted. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.2007.00364.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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90
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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91
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Peak AS, Sheller A. Risk factors for developing gadolinium-induced nephrogenic systemic fibrosis. Ann Pharmacother 2007; 41:1481-5. [PMID: 17684032 DOI: 10.1345/aph.1k295] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To identify medications and other potential risk factors, in addition to renal dysfunction, for developing gadolinium-induced nephrogenic systemic fibrosis (NSF). DATA SOURCES Information was obtained from PubMed, International Pharmaceutical Abstracts, Iowa Drug Information Service, and Google Scholar, using the unlimited search terms nephrogenic systemic fibrosis, NSF, nephrogenic fibrosing dermopathy, NFD, gadolinium, gadodiamide, gadoversetamide, gadopentetate, gadobenate, and gadoteridol. Information was also obtained from the Food and Drug Administration, as well as the manufacturers of the above-mentioned products. Data were collected during April and May 2007. STUDY SELECTION AND DATA EXTRACTION All identified articles and information were evaluated. Articles and other information that included data regarding concurrent medications, disease states, and other risk factors for developing gadolinium-induced NSF were included in this review, as were clinical practice guidelines. DATA SYNTHESIS NSF is a mysterious and severe disorder that occurs in individuals with severe renal impairment. Virtually all cases of NSF have been associated with the administration of gadolinium-containing contrast media. However, not all renally impaired patients who receive gadolinium develop NSF. Thus, additional risk factors for the development of NSF have been suggested. These risk factors include medications that could cause transmetallation of gadolinium, medications that could cause acidosis, and high doses of erythropoietin. Concomitant medical conditions, including hyperphosphatemia, acidosis, recent surgery, hepatic disease, hypercoagulability, and proinflammatory processes may also predispose patients to NSF. CONCLUSIONS Gadolinium-based contrast agents should be avoided in patients with significant renal impairment unless the benefits clearly outweigh the risks. If gadolinium is required, nonionic linear chelates (eg, gadodiamide, gadoversetamide) should not be used. Renally impaired individuals who require gadolinium should be screened proactively for underlying disease states and concomitant drugs that may increase their risk of developing NSF; therapy should be adjusted accordingly.
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Affiliation(s)
- Amy S Peak
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA.
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92
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Plamondon I, Samson C, Watters AK, Bégin LR, Côté J, Déziel C, Quérin S. La fibrose systémique néphrogénique: nouveau coup dur pour les insuffisants rénaux. Nephrol Ther 2007; 3:152-6. [PMID: 17658442 DOI: 10.1016/j.nephro.2007.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 05/14/2007] [Accepted: 05/15/2007] [Indexed: 01/08/2023]
Abstract
To date, more than 200 cases of nephrogenic systemic fibrosis have been documented worldwide. All patients have had renal failure, most of them requiring dialysis. We herein describe the course of a hemodialyzed patient who developed nephrogenic systemic fibrosis in the months following magnetic resonance angiography of the lower extremities. The disease is characterized by skin thickening and tendon fibrosis leading to joint contractures that can quickly confine the patient to a wheelchair. Systemic involvement may occur, leading to cardiomyopathy, pulmonary fibrosis, pulmonary hypertension or even death. No consistently effective therapy has been reported. An association between gadolinium exposure and the development of the disease has been found, although no causal link has yet been proven. In a patient with renal failure, magnetic resonance imaging with gadolinium enhancement should be done only after having seriously considered the risk/benefit ratio. Implications concerning the choice of imaging methods when searching for ischemic nephropathy or aorto-iliac disease before renal transplantation are discussed.
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Affiliation(s)
- Isabelle Plamondon
- Service de néphrologie, hôpital du Sacré-Coeur de Montréal, 5400, boulevard Gouin-Ouest, H4J 1C5 Montréal, Québec, Canada
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93
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Rosenkranz AR, Grobner T, Mayer GJ. Conventional or Gadolinium containing contrast media: the choice between acute renal failure or Nephrogenic Systemic Fibrosis? Wien Klin Wochenschr 2007; 119:271-5. [PMID: 17571229 DOI: 10.1007/s00508-007-0801-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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95
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Perazella MA. Nephrogenic Systemic Fibrosis, Kidney Disease, and Gadolinium: Is There a Link?:
Figure 1. Clin J Am Soc Nephrol 2007; 2:200-2. [PMID: 17699407 DOI: 10.2215/cjn.00030107] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Nephrogenic Systemic Fibrosis: A Review and Exploration of the Role of Gadolinium. ACTA ACUST UNITED AC 2007; 23:131-54. [DOI: 10.1016/j.yadr.2007.07.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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