Cutaneous changes of nephrogenic systemic fibrosis: predictor of early mortality and association with gadolinium exposure

[Scleroderma and fibrosing diseases]

Fibroblasts and myofibroblasts play an important role in the pathogenesis of systemic sclerosis, fibromatoses, arthrofibrosis, and Ormond's disease. These conditions are characterized by an excessive fibroblast proliferation and partly accompanied by inflammation. Scleroderma is either localized or systemic, and features additional vasculopathy. Scleroderma-like skin lesions can be found in graft-versus-host disease following allogeneic hematopoietic stem cell transplantation, complicated malignoma or can represent an adverse drug reaction. The fibromatoses are found in superficial, or as semi-malignant desmoids in deep body compartments. Ormond's disease is a chronic periaortitis of unknown origin which extends into the retroperitoneal space. The diagnostic relevance of a histopathological diagnosis of fibrosing diseases varies and ranges from a disease-supporting to a disease-defining value.

[Nephrogenic systemic fibrosis]

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.

Prevalence of nephrogenic systemic fibrosis in renal insufficiency patients: results of the FINEST study

PURPOSE

Nephrogenic systemic fibrosis (NSF) is characterized by widespread tissue fibrosis, mainly affecting the skin. Gadolinium chelates have been implicated in the onset of NSF in patients with renal impairment (RI). The FINEST study (FIbrose Néphrogénique SysTémique) was designed to determine the prevalence of NSF after magnetic resonance imaging (MRI) in French RI patients.

MATERIALS AND METHODS

We studied all patients with RI who had at least one MRI examination during a one-year period, with or without gadolinium chelate administration. Data were collected retrospectively from 9 Nephrology Departments in France, and included sex, age, renal function, type of gadolinium administered, and subsequent cutaneous disorders. If a patient presented a cutaneous disorder, a skin biopsy was performed to confirm the diagnostic.

RESULTS

The 308 eligible patients had a mean age of 59.9 years, 59% were men, and 54% had stage 5 RI. 75% of those 308 patients received a Gadolinium chelate. Among those patients who received a gadolinium chelate, 76% received gadoterate, 20% gadopentetate, 3% gadodiamide and 1% gadobenate. No cutaneous disorders were recorded after MRI.

CONCLUSION

These results confirm that NSF is a rare disease. Based on a reported frequency, approximately 3.5% in patients with glomerular filtration rate <30ml/min/1.73m(2)), some cases should have been observed in our study which included 308 patients. Most patients received gadoterate, a macrocyclic gadolinium chelate for which no case of NSF has been observed worldwide. This suggests that more stable macrocyclic agents may be less likely to induce NSF.

Update on nephrogenic systemic fibrosis

Gadolinium-based contrast agents were for many years considered safe, but this is no longer the case. The least stable agents may trigger the development of nephrogenic systemic fibrosis (NSF), a generalized fibrotic disorder, in renal failure patients. The use of gadodiamide and gadopentetate dimeglumine is now contraindicated in Europe and Japan in patients who have a glomerular filtration rate less than 30 mL/min/1.73 m(2), including those on dialysis. The fear of NSF, however, should not lead to an enhanced MR imaging examination being denied when there is a good clinical indication to give a gadolinium-based contrast agent.

Blood oxygen level-dependent MR imaging of the kidneys

Oxygenation status plays a major role in renal physiology and pathophysiology, and thus has attracted considerable attention in recent years. While much of the early work and a significant amount of present work is based on invasive methods or ex vivo analysis, and is therefore restricted to animal models, blood oxygen level-dependent (BOLD) MR imaging has been shown to extend these findings to human beings. BOLD MR imaging is most useful in monitoring effects of physiologic or pharmacologic maneuvers. Several teams around the world have demonstrated reproducible data and have illustrated several useful applications. Studies supporting the use of renal BOLD MR imaging in characterizing disease with prognostic value have also been reported. This article provides an overview of current state-of-the art of renal BOLD MR imaging.

[What's new in clinical dermatology?]

For this What's new in clinical dermatology?, I have selected some important publications mainly in the field of the infectious dermatosis and drugs allergy. The Chikungunya virus which is responsible of several epidemics since 2005 seems to be a virus with a cutaneous tropism. Sexually transmitted diseases are still a public health problem and we shall review the situation for syphilis, lymphogranuloma venereum and the new dynamic profile of HIV in France. Lyme disease has been the subject of consensus conference in France and in the United States. Original clinical presentations in relation with infectious agent will be also presented. We shall give a large place to what I call the toxidermatology. During the year 2007, the role of gadolinium in the nephrogenic systemic fibrosis has been confirmed, many publications have reported the side effects of biotherapies on the skin and we shall emphasize the paradoxical of some of them. Hypersensitivity syndrome and notably the controversial role of viral reactivations has been reported. The relationship between psoriasis and metabolic syndrome or cardiovascular risks has been discussed since 2006. New clinical features have been described and will be presented during this session.

Nephrogenic systemic fibrosis and the use of gadolinium-based contrast agents

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.

Gadolinium-based contrast agents and nephrogenic systemic fibrosis: a systematic review and meta-analysis

BACKGROUND

In the past decade, more than 200 cases of nephrogenic systemic fibrosis (NSF) have been identified, primarily among patients with advanced kidney disease. Multiple studies have suggested an association between gadolinium-based contrast agents (GBCAs) and NSF. We performed a systematic review and meta-analysis to examine this potential association.

METHODS

A systematic review of studies examining the association between any GBCA and NSF was performed. A search for controlled studies was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. If controlled data for a GBCA was not available, we searched for case reports and series. Relevant data were extracted and meta-analyses were performed.

RESULTS

Seven of 144 identified studies met inclusion criteria; gadodiamide was the sole or predominant GBCA in four of these; one study exclusively examined gadopentetate. Other GBCAs were not specifically examined in controlled or uncontrolled studies. Meta-analysis of controlled trials demonstrated a significant association between GBCA exposure and NSF [odds ratio (OR) 26.7; 95% confidence interval (CI) 10.3-69.4] and gadodiamide and NSF (OR 20.0; 95% CI 3.7-107.8). Examination of the evidence using established criteria suggested that this association was causal.

CONCLUSIONS

The current state of evidence suggests an association and potentially causal link between the use of GBCAs and the development of NSF among patients with advanced kidney disease. Additional study is warranted to clarify the potential association of GBCAs other than gadodiamide with NSF.

MRI safety update 2008: part 1, MRI contrast agents and nephrogenic systemic fibrosis

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.

Novel contrast mechanisms at 3 Tesla and 7 Tesla

Osteoarthritis (OA) is the most common musculoskeletal degenerative disease, affecting millions of people. Although OA has been considered primarily a cartilage disorder associated with focal cartilage degeneration, it is accompanied by well-known changes in subchondral and trabecular bone, including sclerosis and osteophyte formation. The exact cause of OA initiation and progression remains under debate, but OA typically first affects weightbearing joints such as the knee. Magnetic resonance imaging (MRI) has been recognized as a potential tool for quantitative assessment of cartilage abnormalities due to its excellent soft tissue contrast. Over the last two decades, several new MR biochemical imaging methods have been developed to characterize the disease process and possibly predict the progression of knee OA. These new MR biochemical methods play an important role not only for diagnosis of disease at an early stage, but also for their potential use in monitoring outcome of various drug therapies (success or failure). Recent advances in multicoil radiofrequency technology and high field systems (3 T and above) significantly improve the sensitivity and specificity of imaging studies for the diagnosis of musculoskeletal disorders. The current state-of-the-art MR imaging methods are briefly reviewed for the quantitative biochemical and functional imaging assessment of musculoskeletal systems.

Imatinib mesylate treatment of nephrogenic systemic fibrosis

OBJECTIVE

To examine the effectiveness of imatinib mesylate in the treatment of nephrogenic systemic fibrosis (NSF).

METHODS

Two patients with stage 5 chronic kidney disease and NSF were treated with oral imatinib mesylate at a dosage of 400 mg/day. Skin thickening and tethering were assessed using the modified Rodnan skin thickness score (MRSS), and knee joint flexion contractures were measured with a goniometer.

RESULTS

Each patient displayed progressive reduction of skin thickening and tethering, with a steady decrease in the MRSS, following the initiation of imatinib mesylate treatment. The patient who had knee joint contractures achieved increased knee extension with passive range-of-motion exercises once his skin thickening and tethering had begun to decrease. Within weeks of stopping imatinib mesylate, the skin changes recurred in each patient. Recurrent skin thickening and tethering again improved in the patient who resumed taking imatinib mesylate for longer than 2 weeks. Skin biopsies performed both before and after initial dosing of that patient revealed less fibrosis and less staining for type I procollagen after imatinib mesylate treatment, but essentially unchanged tissue gadolinium content.

CONCLUSION

Imatinib mesylate treatment decreases fibrosis and results in the relatively rapid and steady improvement of skin changes and knee joint contractures in patients with stage 5 chronic kidney disease and NSF, despite the persistence of gadolinium in the tissues. Because skin changes recurred after discontinuation of imatinib mesylate, the duration for which treatment may be required is undetermined.

Ultrastructural evidence of dermal gadolinium deposits in a patient with nephrogenic systemic fibrosis and end-stage renal disease

BACKGROUND AND OBJECTIVES

The pathogenesis of acquired nephrogenic systemic fibrosis recently described for patients with renal insufficiency and a history of exposition to gadolinium-based magnetic resonance contrast agents is not completely understood. A role for circulating fibroblasts in the fibrosing tissue is hypothetical, and the mechanism of the assumed trigger function of gadolinium remains elusive.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A skin lesion on a 76-yr-old man with symptoms of nephrogenic systemic fibrosis lasting 5 mo was studied at the ultrastructural level. After confirmation of he diagnosis by histopathologic methods, the presence and distribution of gadolinium, iron, calcium, and magnesium by energy filtering transmission electron microscopy was also examined.

RESULTS

The performed electron spectroscopic imaging and electron energy loss spectroscopic analyses on deparaffinized samples revealed deposition of gadolinium in irregular small aggregates that adhered to cell profiles and collagen fibers of the connective tissue, forming a perivascular "gadolinium-deposit zone" in the skin. Traces of iron signal were demonstrated in singular gadolinium-positive deposits, and iron presence was found in adjacent connective tissue. The ultrastructural cell analysis of the lesion showed among numerous poorly differentiated fibrocytes also higher differentiated cells with myofibroblastic characteristics, including bundles of intermediate filaments and attachment plaques in the cell periphery, indicating an ability of lesional fibroblasts to differentiate into myofibroblastic cells.

CONCLUSIONS

These findings support the pivotal role of gadolinium chelates in the development of nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis: chronic imaging findings and review of the medical literature

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.

Gadofullerene MRI contrast agents

A promising new class of MRI contrast-enhancing agents with high relaxivities is based on gadolinium-containing metallofullerenes, which are also termed gadofullerenes. Detailed study of the water-proton relaxivity properties and intermolecular nanoclustering behavior of gadofullerene derivatives has revealed valuable information about their relaxivity mechanisms and given a deeper understanding of this new class of paramagnetic contrast agent. Here, the latest findings on water-solubilized gadofullerene materials and how these findings relate to their future applications in MRI are reviewed and discussed.

Extracellular Gd-CA: differences in prevalence of NSF

Until recently it was believed that extracellular gadolinium-based contrast agents were safe for both the kidneys and all other organs within the dose range up to 0.3 mmol/kg body weight. However, in 2006, it was demonstrated that some gadolinium-based contrast agents may trig the development of nephrogenic systemic fibrosis, a generalized fibrotic disorder, in renal failure patients. As no prospective studies can be performed we must rely on retrospective data. From those data it is obvious that the prevalence of NSF is significantly higher after the unstable agent gadodiamide than after any other gadolinium-based agent (3-7% versus 0-1% per injection) in patients with reduced renal function. Prevalence after exposure to two gadodiamide injections is as high as 36% in patients with chronic kidney disease (CKD) stage 5. No report of NSF after the most stable agents has been reported in the peer-reviewed literature documenting that there is a difference between the various agents regarding triggering NSF.

Risk for nephrogenic systemic fibrosis with gadoteridol (ProHance) in patients who are on long-term hemodialysis

BACKGROUND AND OBJECTIVES

Recent studies strongly link nephrogenic systemic fibrosis to gadolinium administration for magnetic resonance imaging. In a recent advisory, the Food and Drug Administration stated that all gadolinium-containing chelates are potentially associated with nephrogenic systemic fibrosis; however, most reported cases are linked to gadodiamide (Omniscan) and gadopentetate dimeglumine (Magnevist). Given the severe consequences of nephrogenic systemic fibrosis, it is critical to define the risks associated with each gadolinium-containing chelate. The purpose of this study was to examine nephrogenic systemic fibrosis risk in a hemodialysis population exposed to gadoteridol (ProHance).

DESIGN, SETTING, PARTICIPANTS, & OBJECTIVES

Appointment logs were used to generate a database of all long-term hemodialysis patients at the Dallas Veterans Affairs hospital since August 2001. These patients were then examined in the Veterans Affair's electronic medical record system for gadolinium exposure during magnetic resonance imaging from 2000 through 2007, a period during which gadoteridol was the sole contrast agent used.

RESULTS

A total of 141 patients were identified with 198 gadoteridol exposures. No cases of nephrogenic systemic fibrosis were identified. The observed frequency of nephrogenic systemic fibrosis was compared with the expected frequency (2.4%) using one-way chi(2) and binomial analysis, yielding a P < 0.05, indicating that the result was not explained by chance alone.

CONCLUSIONS

It is concluded that the risk for nephrogenic systemic fibrosis with gadoteridol in patients who are on long-term hemodialysis may be lower than with gadodiamide and gadopentetate dimeglumine.

Patient characteristics and risk factors for nephrogenic systemic fibrosis following gadolinium exposure

Nephrogenic systemic fibrosis (NSF) is a systemic illness, which only affects patients with kidney failure. NSF risk increases with progressively lower levels of kidney function. It is characterized by red skin areas or plaques that develop over several weeks to painful thickened skin with a "woody" texture, resembling "peau d'orange." It may ultimately cause flexion contractures of joints. Skin biopsy reveals thickened collagen bundles, mucin deposition, proliferation of fibroblasts and elastic fibers, without inflammation. Originally described as nephrogenic fibrosing dermopathy (NFD), because of its primarily cutaneous manifestation, it was renamed NSF because of the involvement of various organs like the lungs, myocardium, or striated muscles. The pathogenesis of the disease is not known yet, but recently we suggested a strong association between development of NSF and exposure to gadolinium-based contrast (GBC) agents, thereafter confirmed by other authors. As a consequence of our recent observations, medical authorities imposed restrictions that exclude patients with advanced levels of renal insufficiency from potentially important magnetic resonance imaging studies with gadolinium. Unfortunately, the only alternatives in many situations (examination of brain, lungs, vasculature) are imaging modalities using iodinated radiocontrast agents. Thus, clinicians are faced with weighing the potential risk of NSF from GBC exposure against the risk of acute kidney injury-associated with radiocontrast media. In this dilemma, clinicians must identify patients at high-risk to develop NSF. Known risk factors critical for the development of NSF after exposure to GBC agents (certain chelates and higher doses) are end-stage renal disease requiring dialysis, especially those with little or no residual renal function, and advanced kidney disease not on dialysis. Other potential risk factors include metabolic acidosis, iron overload/intravenous iron, divalent ion disturbances, endothelial/vascular injury, and high erythropoietin doses. Further studies are required.

A High Relaxivity Magnetic Resonance Imaging Contrast Agent Targeted to Serum Albumin

EP-647 is a serum albumin-targeted magnetic resonance imaging contrast agent comprising a GdDTPA (DTPA, diethylenetriaminepentaacetate) chelate for magnetic resonance signal generation linked via a phosphodiester to a substituted biphenyl for albumin targeting. Albumin binding and relaxivity are higher than the benchmark magnetic resonance angiographic agent MS-325. EP-647 binds primarily to a unique site on serum albumin that is different from the MS-325 site and the binding sites of other drugs.