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Sharma P, Cheng J, Coulthard A. Where does the gadolinium go? A review into the excretion and retention of intravenous gadolinium. J Med Imaging Radiat Oncol 2023; 67:742-752. [PMID: 37665796 DOI: 10.1111/1754-9485.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
Gadolinium-based contrast agents (GBCAs) are commonly used in medical imaging. Most intravenously (IV) administered gadolinium is excreted via the kidneys, and pathological retention in renal failure leading to nephrogenic systemic fibrosis (NSF) is well described. More recently, retention of gadolinium in the body in the absence of renal disease has been identified, with unknown clinical consequences. Many patients are aware of this, either through the media or via comprehensive consent documentation. Some internet sites, without hard evidence, have suggested a constellation of possible symptoms associated with GBCA retention. Recent experience with patients ascribing symptoms to a contrast-enhanced MRI examination prompted this review of the fate of injected GBCA after MRI study, and of information available to patients online regarding gadolinium retention.
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Affiliation(s)
- Pranav Sharma
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jeffrey Cheng
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Alan Coulthard
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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2
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Bhargava V, Singh K, Meena P, Sanyal R. Nephrogenic systemic fibrosis: A frivolous entity. World J Nephrol 2021; 10:29-36. [PMID: 34136369 PMCID: PMC8176868 DOI: 10.5527/wjn.v10.i3.29] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/21/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
Gadolinium-based contrast agents (GBCAs) used in magnetic resonance imaging are vital in providing enhanced quality images, essential for diagnosis and treatment. Nephrogenic systemic fibrosis (NSF) with GBCAs has been a deterrent for the physician and has led to avoidance of these agents in patients with impaired kidney function. NSF is a progressive debilitating multisystem condition described classically in patients with renal insufficiency exposed to gadolinium contrast media. It is characterized by an induration and hardening of the skin. NSF is described to first involve the extremities and can imperceptibly involve internal organs. Lack of therapeutic interventions to treat NSF makes it more challenging and warrants deep insight into the pathogenesis, risk factors and treatment strategies.
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Affiliation(s)
- Vinant Bhargava
- Department of Nephrology, Institute of Renal Science, SIR Ganga Ram Hospital, New Delhi 110060, India
| | - Kulwant Singh
- Department of Nephrology, Ivy Hospital, Mohali Punjab 160071, India
| | - Priti Meena
- Department of Nephrology, Institute of Renal Science, SIR Ganga Ram Hospital, New Delhi 110060, India
| | - Rupan Sanyal
- Department of Radiology, University of Alabama School of Medicine, FL, 35294-3412, United States
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3
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Soloff EV, Wang CL. Safety of Gadolinium-Based Contrast Agents in Patients with Stage 4 and 5 Chronic Kidney Disease: a Radiologist's Perspective. KIDNEY360 2020; 1:123-126. [PMID: 35372905 DOI: 10.34067/kid.0000502019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Erik V Soloff
- Radiology Department, University of Washington, Seattle, Washington
| | - Carolyn L Wang
- Radiology Department, University of Washington, Seattle, Washington
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4
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Braunagel M, Ortner F, Schönermarck U, Habicht A, Schindler A, Stangl M, Strobl FF, Reiser M, Clevert DA, Trumm C, Helck A. Dynamic CTA in Native Kidneys Using a Multiphase CT Protocol-Potential of Significant Reduction of Contrast Medium. Acad Radiol 2018; 25:842-849. [PMID: 29545025 DOI: 10.1016/j.acra.2017.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/19/2017] [Accepted: 11/20/2017] [Indexed: 12/26/2022]
Abstract
RATIONALE AND OBJECTIVE The objective of this study was to assess an optimized renal multiphase computed tomography angiography (MP-CTA) protocol regarding reduction of contrast volume. MATERIALS AND METHODS Thirty patients underwent MP-CTA (12 phases, every 3.5 seconds, 80 kV/120 mAs) using 30 mL of contrast medium. The quality of MP-CTA was assessed quantitatively measuring vessel attenuation, image noise, and contrast-to-noise ratio. MP-CTA was evaluated qualitatively regarding depiction of vessels, cortex differentiation, and motion artifacts (grades 1-4, 1 = best). Mean effective radiation dose was registered. Results were compared to standard renal computed tomography angiography (CTA) (80 mL). Student t test was applied, if variables followed normal distribution. For other variables, nonparametric Mann-Whitney U test was used. RESULTS All acquisitions were successfully performed, and no patient had to be excluded from the study. MP-CTA enabled high attenuation (aorta: 503 ± 91 HU, renal arteries: 450 ± 73 HU/456 ± 72 HU) at adequate image noise (13.7 ± 1.5) and good contrast-to-noise ratio (34.2 ± 10.2). Good attenuation of renal veins was observed (286 ± 43 HU/282 ± 42 HU). Arterial enhancement was significantly higher compared to renal CTA (aorta: 396 ± 90 HU, renal arteries: 331 ± 74 HU/333 ± 80 HU; P < .001). MP-CTA protocol enabled good image quality of renal arteries (1.5 ± 0.6) and veins (1.7 ± 0.6). Cortex differentiation and motion artifacts were ranked 1.8 ± 0.8 and 1.6 ± 0.8. The mean effective radiation dose was 9 mSv (MP-CTA). CONCLUSIONS Compared to standard renal CTA, the renal MP-CTA enabled the significant reduction of contrast volume and simultaneously provided a significantly higher arterial attenuation.
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Affiliation(s)
- Margarita Braunagel
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Florian Ortner
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Ulf Schönermarck
- Department of Internal Medicine IV, Ludwig-Maximilians-University Hospital (LMU),Munich, Germany
| | - Antje Habicht
- Transplant Center, Ludwig-Maximilians-University Hospital (LMU),Munich, Germany
| | - Andreas Schindler
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Manfred Stangl
- Department of Surgery, Ludwig-Maximilians-University Hospital (LMU), Munich, Germany
| | - Frederik F Strobl
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Maximilian Reiser
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Dirk A Clevert
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Christoph Trumm
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany
| | - Andreas Helck
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital (LMU), Marchioninistr. 15, 81377Munich, Germany.
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Schieda N, Blaichman JI, Costa AF, Glikstein R, Hurrell C, James M, Jabehdar Maralani P, Shabana W, Tang A, Tsampalieros A, van der Pol CB, Hiremath S. Gadolinium-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists. Can J Kidney Health Dis 2018; 5:2054358118778573. [PMID: 29977584 PMCID: PMC6024496 DOI: 10.1177/2054358118778573] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/31/2018] [Indexed: 12/29/2022] Open
Abstract
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 topic of Gadolinium deposition in the brain, particularly as it related to patients with renal impairment. IMPLICATIONS In patients with AKI and category G4 and G5 CKD (eGFR < 30 mL/min/1.73 m2) and in dialysis-dependent patients who require GBCA-enhanced MRI, GBCA can be administered with exceedingly low risk of causing NSF when using macrocyclic agents and newer linear agents at routine doses.
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Affiliation(s)
- Nicola Schieda
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Jason I. Blaichman
- Faculty of Medicine, Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Andreu F. Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Rafael Glikstein
- Brain and Mind Research Institute, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
- Neuroradiology Section, MRI Modality Lead, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, Ontario, Canada
| | - Matthew James
- Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | | | - Wael Shabana
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - An Tang
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Québec, Canada
- Centre de recherche du Centre Hospitalier de l’Université de Montréal, Québec, Canada
| | - Anne Tsampalieros
- Division of Nephrology, Children’s Hospital of Eastern Ontario, Clinical Epidemiology Program and the University of Ottawa, Ontario, Canada
| | | | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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6
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Schieda N, Blaichman JI, Costa AF, Glikstein R, Hurrell C, James M, Jabehdar Maralani P, Shabana W, Tang A, Tsampalieros A, van der Pol C, Hiremath S. Gadolinium-Based Contrast Agents in Kidney Disease: Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists. Can Assoc Radiol J 2018; 69:136-150. [PMID: 29706252 DOI: 10.1016/j.carj.2017.11.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 01/04/2023] Open
Abstract
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 m2) 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 m2), 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 m2), 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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Affiliation(s)
- Nicola Schieda
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
| | - Jason I Blaichman
- Department of Radiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Rafael Glikstein
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; Brain and Mind Research Institute, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, Ontario, Canada
| | - Matthew James
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Wael Shabana
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - An Tang
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, Montreal, Quebec, Canada; Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Anne Tsampalieros
- Division of Nephrology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada
| | - Christian van der Pol
- Department of Radiology, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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7
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Bruce R, Wentland AL, Haemel AK, Garrett RW, Sadowski DR, Djamali A, Sadowski EA. Incidence of Nephrogenic Systemic Fibrosis Using Gadobenate Dimeglumine in 1423 Patients With Renal Insufficiency Compared With Gadodiamide. Invest Radiol 2017; 51:701-705. [PMID: 26885631 DOI: 10.1097/rli.0000000000000259] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the incidence of nephrogenic systemic fibrosis (NSF) before and after educational interventions, implementation of a clinical screening process, and change to gadobenate dimeglumine in patients who had an estimated glomerular filtration rate (eGFR) of 30 mL/min per 1.72 m or less. METHODS This is a Health Insurance Portability and Accountability Act compliant, institutional review board exempt study. Two periods were studied-July 2005 to June 2006, during which gadodiamide was utilized as our magnetic resonance (MR) contrast agent, and November 2006 to August 2014, during which gadobenate dimeglumine was used as our MR contrast agent in patients who had an eGFR 30 mL/min per 1.72 m or less. In addition to a change in the MR contrast agent, education of our staff physician to the risks of NSF with MR contrast agents and the implementation of a clinical screening process occurred. The rate of NSF before and after the interventions was compared using the χ test. RESULTS There was a statistically significant difference in the incidence of NSF in patients with an eGFR 30 mL/min per 1.72 m or less between the 2 periods: July 2005 to June 2006, 6 of 246 patients were diagnosed with NSF (P < 0.001), versus November 2006 to August 2014, 0 of 1423 patients were diagnosed with NSF. CONCLUSIONS Our data demonstrates a marked decrease in the incidence of NSF after education of our referring physicians, implementation of clinical screening process, and change to gadobenate dimeglumine from gadodiamide in patients with renal insufficiency. This approach potentially provides an acceptable risk-benefit profile for patients with renal insufficiency that required MR imaging for clinical care.
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Affiliation(s)
- Richard Bruce
- From the Departments of *Radiology, and †Medical Physics, University of Wisconsin, Madison, WI; ‡Department of Dermatology, University of California San Francisco, San Francisco, CA; §Department of Radiology, Saint Louis University, Saint Louis, MO; ∥Division of Dermatology, John H. Stroger Jr Hospital of Cook County, Chicago, IL; Departments of ¶Medicine, and #Obstetrics and Gynecology, University of Wisconsin, Madison, WI
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8
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Hoelter P, Lang S, Weibart M, Schmidt M, Knott MFX, Engelhorn T, Essig M, Kloska S, Doerfler A. Prospective intraindividual comparison of gadoterate and gadobutrol for cervical and intracranial contrast-enhanced magnetic resonance angiography. Neuroradiology 2017; 59:1233-1239. [PMID: 28913611 DOI: 10.1007/s00234-017-1922-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Gadobutrol (GB) is reported to provide improved relaxivity and concentration compared to gadoterate (GT). This study was designed to intraindividually compare quantitative and qualitative enhancement characteristics of GB to GT in cervicocranial magnetic resonance angiography (MRA) of patients with cerebrovascular disease (CVD). METHODS Patients (n = 54) with CVD underwent two identical contrast-enhanced magnetic resonance angiography (CE-MRA) examinations of the cervical and intracranial vasculature in randomized order, using GB and GT in equimolar dose. Signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were obtained by two independent neuroradiologists, blinded to the applied contrast agents. Qualitative assessment was performed using a three-point scale with a focus on M1/M2 segments. RESULTS One thousand and twenty-six vessel segments were analyzed. GB revealed a significantly higher SNR (p = 0.032) and CNR (p = 0.031) in all vessel segments. GB featured a significantly higher SNR and CNR in thoracic (p = 0.022; p = 0.016) and cervical vessels (p = 0.03; p = 0.038), as well as in the posterior circulation (p = 0.012; p = 0.005). In blinded qualitative assessment, overall preference was given to GB (p = 0.02), showing a significant better delineation of the M1/M2 segments (p = 0.041). CONCLUSION Compared to GT, the use of GB results in a significantly higher SNR and CNR in cervical and cerebral CE-MRA, leading to a better delineation of the intracranial vasculature. Present results underline the potential of GB for improved CE-MRA assessment of vasculature in CVD patients.
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Affiliation(s)
- Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Stefan Lang
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Marina Weibart
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Manuel Schmidt
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael F X Knott
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Marco Essig
- Department of Radiology, University of Manitoba, GA216-820 Sherbrook Street, Winnipeg, Manitoba, Canada
| | - Stephan Kloska
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
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10
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Semelka RC, Ramalho M, Jay M. Summary of special issue on gadolinium bioeffects and toxicity with a look to the future. Magn Reson Imaging 2016; 34:1399-1401. [PMID: 27639920 DOI: 10.1016/j.mri.2016.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 09/07/2016] [Indexed: 02/07/2023]
Abstract
This summary attempts to provide forward-looking concepts regarding gadolinium related toxicity, as discussed in further detail in this issue.
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Affiliation(s)
- Richard C Semelka
- Department of Radiology, University of North Carolina at Chapel Hill, NC, USA.
| | - Miguel Ramalho
- Department of Radiology, University of North Carolina at Chapel Hill, NC, USA; Department of Radiology, Hospital Garcia de Orta, Almada, Portugal
| | - Michael Jay
- Department of Pharmacy, University of North Carolina at Chapel Hill, NC, USA
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11
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Ramalho J, Semelka RC, Ramalho M, Nunes RH, AlObaidy M, Castillo M. Gadolinium-Based Contrast Agent Accumulation and Toxicity: An Update. AJNR Am J Neuroradiol 2015; 37:1192-8. [PMID: 26659341 DOI: 10.3174/ajnr.a4615] [Citation(s) in RCA: 270] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In current practice, gadolinium-based contrast agents have been considered safe when used at clinically recommended doses in patients without severe renal insufficiency. The causal relationship between gadolinium-based contrast agents and nephrogenic systemic fibrosis in patients with renal insufficiency resulted in new policies regarding the administration of these agents. After an effective screening of patients with renal disease by performing either unenhanced or reduced-dose-enhanced studies in these patients and by using the most stable contrast agents, nephrogenic systemic fibrosis has been largely eliminated since 2009. Evidence of in vivo gadolinium deposition in bone tissue in patients with normal renal function is well-established, but recent literature showing that gadolinium might also deposit in the brain in patients with intact blood-brain barriers caught many individuals in the imaging community by surprise. The purpose of this review was to summarize the literature on gadolinium-based contrast agents, tying together information on agent stability and animal and human studies, and to emphasize that low-stability agents are the ones most often associated with brain deposition.
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Affiliation(s)
- J Ramalho
- From the Departments of Neuroradiology (J.R., R.H.N., M.C.) Centro Hospitalar de Lisboa Central (J.R.), Lisbon, Portugal
| | - R C Semelka
- Radiology (R.C.S., M.R., R.H.N., M.A.), University of North Carolina Hospital, Chapel Hill, North Carolina
| | - M Ramalho
- Radiology (R.C.S., M.R., R.H.N., M.A.), University of North Carolina Hospital, Chapel Hill, North Carolina Hospital Garcia de Orta (M.R.), Almada, Portugal
| | - R H Nunes
- From the Departments of Neuroradiology (J.R., R.H.N., M.C.) Radiology (R.C.S., M.R., R.H.N., M.A.), University of North Carolina Hospital, Chapel Hill, North Carolina Santa Casa de Misericórdia de São Paulo (R.H.N.), São Paulo, Brazil
| | - M AlObaidy
- Radiology (R.C.S., M.R., R.H.N., M.A.), University of North Carolina Hospital, Chapel Hill, North Carolina King Faisal Specialist Hospital and Research Center (M.A.), Riyadh, Saudi Arabia
| | - M Castillo
- From the Departments of Neuroradiology (J.R., R.H.N., M.C.)
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12
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Ramalho J, Castillo M, AlObaidy M, Nunes RH, Ramalho M, Dale BM, Semelka RC. High Signal Intensity in Globus Pallidus and Dentate Nucleus on Unenhanced T1-weighted MR Images: Evaluation of Two Linear Gadolinium-based Contrast Agents. Radiology 2015; 276:836-44. [PMID: 26079490 DOI: 10.1148/radiol.2015150872] [Citation(s) in RCA: 186] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Joana Ramalho
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Mauricio Castillo
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Mamdoh AlObaidy
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Renato H Nunes
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Miguel Ramalho
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Brian M Dale
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
| | - Richard C Semelka
- From the Department of Radiology, University of North Carolina at Chapel Hill, CB 7510, 2001 Old Clinic Bldg, Chapel Hill, NC 27599-7510 (J.R., M.C., M.A., R.H.N., M.R., R.C.S.); Department of Radiology. King Faisal Specialist Hospital & Research Center, Riyadh. Saudi Arabia (M.A.); and Siemens Healthcare, Cary, NC (B.M.D.)
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Single-dose gadobutrol in comparison with single-dose gadobenate dimeglumine for magnetic resonance imaging of chronic myocardial infarction at 3 T. Invest Radiol 2015; 49:728-34. [PMID: 24872002 PMCID: PMC4196783 DOI: 10.1097/rli.0000000000000076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The aim of this study was to compare the contrast-to-noise ratio (CNR) values of infarct and remote myocardium as well as infarct and blood after application of 0.1 mmol/kg gadobutrol and 0.1 mmol/kg gadobenate dimeglumine on late gadolinium enhancement magnetic resonance (MR) images. MATERIAL AND METHODS The study was a prospective randomized controlled clinical study. After informed consent was obtained, 20 patients (12 men, 8 women; mean age, 67 ± 11 years) with known chronic myocardial infarction were included for an intraindividual comparison of a single-dose gadobutrol and a single-dose gadobenate dimeglumine. Two MR imaging examinations were performed within a period of 28 days in a crossover design. Late gadolinium enhancement imaging was performed 10 minutes after gadolinium administration using a 2-dimensional phase-sensitive inversion recovery gradient echo sequence at 3 T. Infarct size, signal intensities (SIs), signal-to-noise ratio, and CNR were determined on phase-sensitive MR images. Values for CNR were calculated as CNRinfarct/myocardium = (SIinfarct - SImyocardium)/SDnoise and CNRinfarct/blood = (SIinfarct - SIblood)/SDnoise. In addition, the areas of myocardial infarction were determined on single slices. The entire infarct volumes were calculated by adding the areas with hyperenhancement multiplied by the slice thickness. RESULTS Late gadolinium enhancement was present in all patients. Median values of the infarct area, infarct volume, and transmurality for gadobutrol and gadobenate dimeglumine showed good to excellent concordance (rc = 0.85, rc = 0.95, and rc = 0.71, respectively). The mean signal-to-noise ratio values for infarct, remote myocardium, and ventricular blood were 18.6 ± 6.5, 4.1 ± 3.7, and 14.6 ± 7.5, respectively, for gadobutrol and 18.8 ± 8.9, 4.9 ± 4.5, and 17.8 ± 10.1, respectively, for gadobenate dimeglumine (P = 0.93, P = 0.48, and P = 0.149, respectively). The mean values of CNRinfarct/myocardium and CNRinfarct/blood were 14.5 ± 5.9 and 4.0 ± 4.6, respectively, for gadobutrol and 13.9 ± 6.1 and 0.9 ± 4.5, respectively, for gadobenate dimeglumine (P = 0.69 and P = 0.02, respectively). CONCLUSION Both gadobutrol and gadobenate dimeglumine allow for successful late gadolinium enhancement imaging of chronic myocardial infarction after a single-dose application (0.1 mmol/kg) at 3 T. Gadobutrol provides a higher CNR between infarct and blood. The CNRs between infarct and normal myocardium, infarct size, and transmural extent were similar for both contrast agents.
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Contrast Dose, Temporal Footprint, and Spatial Resolution Tradeoffs in Dynamic Contrast-Enhanced MRA Performed in a Porcine Model of a Carotid Aneurysm. J Comput Assist Tomogr 2013; 37:105-10. [DOI: 10.1097/rct.0b013e318276fc92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Objective evaluation of acute adverse events and image quality of gadolinium-based contrast agents (gadobutrol and gadobenate dimeglumine) by blinded evaluation. Pilot study. Magn Reson Imaging 2012; 31:96-101. [PMID: 22898688 DOI: 10.1016/j.mri.2012.06.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 05/16/2012] [Accepted: 06/21/2012] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose was to objectively evaluate a recently FDA-approved gadolinium-based contrast agent (GBCA) in comparison to our standard GBCA for acute adverse events and image quality by blinded evaluation. METHODS Evaluation was made of a recently FDA-approved GBCA, gadobutrol (Gadavist; Bayer), in comparison to our standard GBCA, gadobenate dimeglumine (MultiHance; Bracco), in an IRB- and HIPAA-compliant study. Both the imaging technologist and patient were not aware of the brand of the GBCA used. A total of 59 magnetic resonance studies were evaluated (59 patients, 31 men, 28 women, age range of 5-85 years, mean age of 52 years). Twenty-nine studies were performed with gadobutrol (22 abdominal and 7 brain studies), and 30 studies were performed with gadobenate dimeglumine (22 abdominal and 8 brain studies). Assessment was made of acute adverse events focusing on objective observations of vomiting, hives, and moderate and severe reactions. Adequacy of enhancement was rated as poor, fair and good by one of two experienced radiologists who were blinded to the type of agent evaluated. RESULTS No patient experienced acute adverse events with either agent. The target minor adverse events of vomiting or hives, and moderate and severe reactions were not observed in any patient. Adequacy of enhancement was rated as good for both agents in all patients. CONCLUSIONS Objective, blinded evaluation is feasible and readily performable for the evaluation of GBCAs. This proof-of-concept study showed that both GBCAs evaluated exhibited consistent good image quality and no noteworthy adverse events.
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Changing trends in a decade of vascular radiology-the impact of technical developments of non-invasive techniques on vascular imaging. Insights Imaging 2012; 3:495-504. [PMID: 22865510 PMCID: PMC3443273 DOI: 10.1007/s13244-012-0188-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 07/13/2012] [Accepted: 07/17/2012] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES This review aims to establish the impact on conventional angiography and endovascular intervention of contrast-enhanced magnetic resonance angiography (CE-MRA) and contrast-enhanced computed tomography angiography (CE-CTA) on a background of evolving technology, changing clinical requirements and resulting clinical repercussions. METHODS The angiographic and interventional caseload was prospectively recorded between 1997 and 2010, along with the CE-MRA and CE-CTA caseload. Waiting times and the marginal cost analyses for 2001 and 2009 were also prospectively established. RESULTS Conventional diagnostic angiographies declined from a peak of 847 to 121 per year while endovascular interventions continue in similar numbers. CE-MRA increased from effectively none initially to 620 per year while CE-CTA has currently risen to 396 per year. Total diagnostic study numbers have increased but at reduced cost. Various influences are clear, including on-site modality availability, capability and accuracy along with impact of new therapies, research studies and adverse events. CONCLUSIONS Vascular imaging has undergone a metamorphosis in little over a decade because of CE-MRA and CE-CTA. With waiting times significantly reduced since the start of the study and the cost-effectiveness of both CE-MRA and CE-CTA as primary diagnostic investigations established, further development of these services is inevitable. MAIN MESSAGES • The availability of CE-MRA and CE-CTA has reduced the need for conventional angiography. • Both waiting times and the marginal cost analyses for CE-MRA and CE-CTA have reduced. • The impact of new therapies, research studies (e.g. ASTRAL) and adverse events is illustrated.
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Wagner M, Schilling R, Doeblin P, Huppertz A, Luhur R, Schwenke C, Maurer M, Hamm B, Taupitz M, Durmus T. Macrocyclic contrast agents for magnetic resonance imaging of chronic myocardial infarction: intraindividual comparison of gadobutrol and gadoterate meglumine. Eur Radiol 2012; 23:108-14. [DOI: 10.1007/s00330-012-2563-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 05/18/2012] [Accepted: 05/24/2012] [Indexed: 01/25/2023]
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Gadobutrol for magnetic resonance imaging of chronic myocardial infarction: intraindividual comparison with gadopentetate dimeglumine. Invest Radiol 2012; 47:183-8. [PMID: 22183078 DOI: 10.1097/rli.0b013e318236e354] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To compare 0.15 mmol/kg gadobutrol with 0.20 mmol/kg gadopentetate dimeglumine with regard to late gadolinium enhancement (LGE) of infarcted myocardium at magnetic resonance (MR) imaging. MATERIALS AND METHODS Twenty patients with history of chronic myocardial infarction underwent 2 cardiac MR examinations at 1.5 Tesla. For the evaluation of myocardial infarction, late gadolinium enhancement (LGE) imaging was performed with an inversion recovery-prepared gradient-echo sequence 15 minutes after administration of either gadobutrol (r1 = 5.2 mmol(-1)s(-1)) or gadopentetate dimeglumine (r1 = 4.1 mmol(-1)s(-1)). The dose of the contrast agents was adjusted based on the relaxivity of both contrast agents. Hence, gadobutrol and gadopentetate dimeglumine were administered at 0.15 mmol/kg and 0.20 mmol/kg, respectively. Contrast-to-noise ratios (CNR) between infarcted myocardium and remote myocardium (CNR remote) and between infarcted myocardium and left ventricular lumen (CNR lumen) were assessed by 2 independent readers. Additionally, infarct size was assessed semiautomatically by using a threshold of 5 standard deviations above the mean signal intensity of remote myocardium. RESULTS Subendocardial or transmural LGE was present in 16 of 20 (80%) patients. The optimal inversion time for LGE imaging did not differ significantly between gadobutrol and gadopentetate dimeglumine (275 ± 21 milliseconds [range, 240-320 milliseconds] and 282 ± 23 milliseconds [range, 240-330 milliseconds], respectively; P = 0.32). The CNR remote after administration of gadobutrol (40.0 ± 4.6; 95% confidence interval [CI]: 30.3; 49.7) and gadopentetate dimeglumine (40.6 ± 4.6; 95% CI: 30.9; 50.3) did not show significant differences (P = 0.90), whereas gadobutrol yielded a significantly higher CNR lumen (6.2 ± 3.6; 95% CI: -1.5; 13.9) compared with gadopentetate dimeglumine (0.8 ± 3.6; 95% CI: -6.9; 8.5). Infarct size after administration of gadobutrol (23.7 ± 4.7 mL; 95% CI: 13.6; 33.7) and gadopentetate dimeglumine (23.7 ± 4.7 mL;95% CI: 13.7; 33.8) was not statistically different (P = 0.94). There was an excellent correlation between gadobutrol- and gadopentetate dimeglumine-enhanced assessment of infarct size (Spearman r = 0.99 and r = 0.97 for reader 1 and 2, respectively). CONCLUSION This pilot study shows that 0.15 mmol/kg gadobutrol is an effective contrast agent for LGE imaging with better delineation of infarcted myocardium from left ventricular lumen than 0.20 mmol/kg gadopentetate dimeglumine.
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Emond S, Brunelle F. Gd-DOTA administration at MRI in children younger than 18 months of age: immediate adverse reactions. Pediatr Radiol 2011; 41:1401-6. [PMID: 21786126 DOI: 10.1007/s00247-011-2167-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 04/07/2011] [Accepted: 05/14/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is a paucity of evidence with regard to the safety of contrast medium administration at MRI in neonates and infants. PURPOSE To assess immediate adverse reactions in children younger than 18 months of age during routine clinical utilization of gadoteric acid (Gd-DOTA) in a cohort of patients with nonselected indications. MATERIALS AND METHODS One hundred and four neonates and infants were enrolled in a postmarketing survey with Gd-DOTA (Dotarem, Guerbet, Roissy, France) from a single pediatric hospital. A standardized questionnaire was used to collect the patient information. RESULTS All included children, ages 3 days to 18 months, received one injection of Gd-DOTA (volume 0.6-4 ml). No immediate adverse event was reported. CONCLUSION This postmarketing study involving neonates and infants suggests a favorable safety profile of Gd-DOTA in routine practice.
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Affiliation(s)
- Sophie Emond
- Department of Pediatric Radiology, Hôpital Necker Enfants Malades, Paris, France.
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Haemel AK, Sadowski EA, Shafer MM, Djamali A. Update on nephrogenic systemic fibrosis: are we making progress? Int J Dermatol 2011; 50:659-66. [DOI: 10.1111/j.1365-4632.2010.04851.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Quarter-dose (0.025 mmol/kg) gadobenate dimeglumine for abdominal MRI in patients at risk for nephrogenic systemic fibrosis: preliminary observations. AJR Am J Roentgenol 2011; 196:545-52. [PMID: 21343495 DOI: 10.2214/ajr.10.4500] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the feasibility of 0.025 mmol/kg gadobenate dimeglumine, which is one quarter of the standard dose, for abdominal 3-T MRI studies in patients considered to be at risk for nephrogenic systemic fibrosis, using qualitative and quantitative measures and comparison with higher doses. MATERIALS AND METHODS The MRI database was retrospectively searched to select consecutive patients who underwent quarter-dose gadobenate dimeglumine-enhanced abdominal MRI at 3 T, between January 1, 2009, and January 15, 2010, and who underwent half-dose (0.05 mmol/kg) gadobenate dimeglumine-enhanced abdominal MRI at 3 T during one randomly chosen month. There were 25 patients in the final quarter-dose group (16 men and nine women; mean age, 57 years) and 44 patients in the half-dose group (21 men and 23 women; mean age, 58 years). The enhancement of abdominal organs and aorta was evaluated qualitatively and quantitatively on contrast-enhanced images. The overall quality of abdominal enhancement was also evaluated. RESULTS Reviewers rated the diagnostic enhancement of the evaluated organs in all phases of enhancement for both studied doses, but the half dose had significantly higher ratings than did the quarter dose in all comparisons (p, 0.034 to < 0.0001), except in the pancreas in the early hepatic venous phase (p = 0.095 for reviewer 1; p = 0.0611 for reviewer 2). The overall enhancement quality of the quarter dose was rated as good in all phases of enhancement, although it was significantly lower than that for the half dose (p ≤ 0.0001). The liver, pancreas, renal cortex, and aorta had 1.52-1.93-fold, 1.53-1.90-fold, 1.46-1.77-fold, and 1.58-1.84-fold, respectively, higher percentages of enhancement with the half dose than with the quarter dose (p, 0.0049 to < 0.0001). CONCLUSION A one-quarter dose of gadobenate dimeglumine at 3 T is a feasible alternative for abdominal MRI in patients at risk for nephrogenic systemic fibrosis. Our results might have important clinical implications, because greater safety may be conferred on patients with poor renal function with this low dose of contrast agent.
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Affiliation(s)
- Angelique Louie
- Department of Biomedical Engineering, University of California, Davis, California 95616, USA.
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TOYA R, NAGANAWA S, KAWAI H, IKEDA M. Correlation between Estimated Glomerular Filtration Rate (eGFR) and Apparent Diffusion Coefficient (ADC) Values of the Kidneys. Magn Reson Med Sci 2010; 9:59-64. [DOI: 10.2463/mrms.9.59] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Current World Literature. Curr Opin Rheumatol 2010; 22:97-105. [DOI: 10.1097/bor.0b013e328334b3e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Altun E, Martin DR, Wertman R, Lugo-Somolinos A, Fuller ER, Semelka RC. Nephrogenic Systemic Fibrosis: Change in Incidence Following a Switch in Gadolinium Agents and Adoption of a Gadolinium Policy—Report from Two U.S. Universities. Radiology 2009; 253:689-96. [DOI: 10.1148/radiol.2533090649] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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