Nephrogenic Systemic Fibrosis: Clinical Picture and Treatment

Safety of gadoterate meglumine in over 1600 children included in the prospective observational SECURE study

Background

To date, few data on the safety profile of gadoterate meglumine in pediatric patients are available.

Purpose

To assess the safety profile of gadoterate meglumine in routine practice, to detect any case of nephrogenic systemic fibrosis (NSF) suspicion and to collect efficacy data.

Material and Methods

The pediatric population of the observational SECURE study comprised 1631 patients scheduled for contrast-enhanced magnetic resonance imaging (MRI) with gadoterate meglumine (dose: 0.1 mmol/kg). Risk factors, MRI types and immediate adverse events (AEs) were systematically recorded. Patients with moderate to severe renal impairment were followed up for at least 3 months for detection of any NSF suspicion. Efficacy was assessed by the on-site radiologist in terms of image quality and ability to come to diagnosis.

Results

The population included 106 children (6.5%) aged <2 years, 815 (50.0%) aged 2 to <12 years and 710 (43.5%) aged 12 to <18 years, with a mean (± SD) age of 10.2 (± 4.9) years. Central nervous system exploration was the most frequent MRI type (80.4%) and main risk factors were any stage of renal insufficiency (9.8%) and allergies (5.2%). Only one AE (vomiting) that was deemed doubtfully related to gadoterate meglumine was observed. No suspicions of NSF were reported. Good to very good image quality was obtained for 98.4% of pediatric patients and diagnosis was established in 99.6% of cases.

Conclusion

This study confirmed the good safety profile of gadoterate meglumine in routine practice in a large pediatric population. The study is registered on https://clinicaltrials.gov/ with the identifier NCT01523873.

[Mimetics of systemic sclerosis]

BACKGROUND

Systemic sclerosis (SSc) is characterized by heterogeneous clinical symptoms. Peripheral skin fibrosis can be a common symptom. Nevertheless, a variety of diseases with different etiologies are associated with a thickening of the skin and make the initial diagnosis of systemic sclerosis more difficult.

OBJECTIVE

The different disease entities that can lead to dermal fibrosis should be differentiated. An earlier diagnosis of SSc would therefore be facilitated.

METHODS

A literature search was carried out for clinical pictures that can be associated with skin fibrosis. The clinical picture, the etiology and the treatment of the individual diseases are described.

RESULTS

Diseases that can mimic the cutaneous symptoms of SSc include morphea, scleroderma, diabetic cheirarthritis, scleromyxedema, nephrogenic systemic fibrosis and eosinophilic fasciitis. The characteristic pronounced skin involvement, an accompanying Raynaud's phenomenon, capillary microscopy, histopathology and antinuclear antibodies help to enable a differentiation of SSc from its mimics.

CONCLUSION

An early differential diagnostic distinction between SSc and other sclerosing diseases is important due to SSc-associated and potentially life-threatening systemic organ involvement. If a diagnosis of SSc has been made, a critical and organ-specific evaluation with respect to pulmonary, gastrointestinal, renal and cardiac involvement is mandatory and should be repeated at regular intervals.

Incidence of Nephrogenic Systemic Fibrosis Using Gadobenate Dimeglumine in 1423 Patients With Renal Insufficiency Compared With Gadodiamide

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.

Nephrogenic systemic fibrosis: A survey of the use of gadolinium-based contrast agents in Ghana

INTRODUCTION

The aim of this study is to identify current practice of administration of gadolinium-based contrast agents (GBCAs) in Ghana.

METHOD

A total of 13 MRI (magnetic resonance imaging) facilities were sent a survey questionnaire to request information on their current practice with the use of GBCAs.

RESULTS

Gadodiamide, a high risk GBCA accounted for 67% of first line agents. 5 (42%) had a departmental protocol on the administration of GBCAs with regards to its association with nephrogenic systemic fibrosis (NSF). Of the 8 that use gadodiamide, 3 check kidney function in all patients, 2 check in selected patients, and 3 do not check at all. All 3 that screen all patients do not use contrast if the patient has an eGFR (estimated glomerular filtration rate) of 30-59 ml/min, 1 considers other modality; and if the patient has an eGFR of <30 ml/min, 2 do not use contrast but consider other modality, however 1 continues with the high risk agent.

CONCLUSION

Gadodiamide is widely used, with varied practice in screening for renal function, and risk factors associated with NSF. Current evidence shows that it is advisable to administer macrocyclic agents in patients with compromised renal function. It is also imperative to establish local guidelines in line with international guidelines in order to minimize the incidence of NSF.

StatSensor-i point-of-care creatinine analyzer may identify patients at high-risk of contrast-induced nephropathy

The current study assessed the accuracy of the StatSensor-i (STA) point-of-care creatinine analyzer prior to and following adjustment (offset correction) by linear regression scatter plots produced by the reference samples from patients and volunteers for detecting high risk of contrast-induced nephropathy in patients with an estimated glomerular filtration rate <45 ml/min/1.73 m². Blood samples were obtained from 233 consecutive outpatients scheduled for contrast-enhanced CT studies. Of the 233 patients, 123 patient samples were evaluated prior to adjustment and the other 110 following adjustment. Serum creatinine levels and estimated glomerular filtration rate were measured using the analyzer and compared with the values returned by laboratory tests. Analysis was with the paired t-test, the Pearson correlation coefficient and Bland-Altman plotting. The sensitivity, specificity, positive and negative predictive values (PPV, NPV), and accuracy for detecting patients with an estimated glomerular filtration rate <45 ml/min/1.73 m² were subsequently calculated. Mean serum creatinine levels measured with the analyzer were significantly higher than those returned by laboratory tests before (P<0.0001) and after adjustment (P<0.01). Following adjustment, the difference in serum creatinine values obtained with the STA analyzer and by laboratory methods did not exceed 0.3 mg/dl. Prior to adjustment, 9.7% of the samples were overdiagnosed as having an estimated glomerular filtration rate of <45 ml/min/1.73 m²; following adjustment, the overdiagnosis rate was 2.7%. The sensitivity, specificity, PPV, NPV and accuracy were 100, 89, 50, 100 and 90.2% before and 100, 96.3, 33.3, 100 and 96.4% after adjustment, respectively. With the adjusted point-of-care creatinine analyzer, estimated glomerular filtration rate may be reliably evaluated in the radiology suite.

Imaging patients with renal impairment

Imaging with intravascular contrast media is generally considered safe, particularly in patients without renal failure. However, as renal function deteriorates, the potential risk of nonallergic-type adverse events increases. This presents a unique challenge, particularly when the use of intravenous contrast media is deemed essential for diagnostic purposes. Following a discussion regarding the definition and epidemiology of kidney injury, this review focuses on the evolving understanding of both contrast-induced nephropathy and nephrogenic systemic fibrosis and discusses preventative strategies aimed at minimizing the risk of developing these entities. Alternative non-contrast imaging techniques are also discussed.

Scleroderma Mimickers

Cutaneous fibrosing disorders encompass a diverse array of diseases united by the presence of varying degrees of dermal sclerosis. The quality and distribution of skin involvement, presence or absence of systemic complications and unique associated laboratory abnormalities often help to distinguish between these diseases. It is imperative that an effort is made to accurately differentiate between scleroderma and its mimics, in order to guide long-term management and facilitate implementation of the appropriate treatment modality where indicated.

Extensive pneumatized air cells causing susceptibility artifacts in the petrosus part of the ICA

INTRODUCTION

3D-Time-of-flight magnetic-resonance-angiography (TOF MRA) is an established method in vessel analysis. However, many artifacts that occur may lead to a false diagnosis. This retrospective study evaluates the coherence of MR artifacts to extensive pneumatized air cells surrounding the internal carotid artery (ICA) in the petrosus part of the temporal bone.

MATERIALS AND METHODS

Patients who received 3D-TOF MRA and multidetector helical computed tomography (CT) angiography were registered from April 2012 to April 2013. Of these patients, both ICAs in the petrosus part were analyzed. Vertical maximum intensity projection (MIP) artifacts were graduated as normal, mild to moderate, and severe artifacts. The distinction of the vertical part of the pneumatized air cells was also categorized in three groups, regarding the circumference of the ICA in pneumatization ≤ 90°, between 90° and 180°, and ≥ 180°.

RESULTS

A total of 203 vessels were collected for analysis. The more extensive the pneumatized air cells were present, the more band-like artifacts and pseudostenosis at the vertical portion of the petrosus part of the ICA were registered.

CONCLUSION

Careful examination of the source images and evaluation of the size of the pneumatized air cells with CT scan are essential to avoid false positive diagnosis in the distal petrosus part of the ICA.

Advancing pharmacovigilance through academic-legal collaboration: the case of gadolinium-based contrast agents and nephrogenic systemic fibrosis-a Research on Adverse Drug Events and Reports (RADAR) report

OBJECTIVE

To compare and contrast three databases, that is, The International Centre for Nephrogenic Systemic Fibrosis Registry (ICNSFR), the Food and Drug Administration Adverse Event Reporting System (FAERS) and a legal data set, through pharmacovigilance and to evaluate international nephrogenic systemic fibrosis (NSF) safety efforts.

METHODS

The Research on Adverse Drug events And Reports methodology was used for assessment-the FAERS (through June 2009), ICNSFR and the legal data set (January 2002 to December 2010). Safety information was obtained from the European Medicines Agency, the Danish Medicine Agency and the Food and Drug Administration.

RESULTS

The FAERS encompassed the largest number (n = 1395) of NSF reports. The ICNSFR contained the most complete (n = 335, 100%) histopathological data. A total of 382 individual biopsy-proven, product-specific NSF cases were analysed from the legal data set. 76.2% (291/382) identified exposure to gadodiamide, of which 67.7% (197/291) were unconfounded. Additionally, 40.1% (153/382) of cases involved gadopentetate dimeglumine, of which 48.4% (74/153) were unconfounded, while gadoversetamide was identified in 7.3% (28/382) of which 28.6% (8/28) were unconfounded. Some cases involved gadobenate dimeglumine or gadoteridol, 5.8% (22/382), all of which were confounded. The mean number of exposures to gadolinium-based contrast agents (GBCAs) was gadodiamide (3), gadopentetate dimeglumine (5) and gadoversetamide (2). Of the 279 unconfounded cases, all involved a linear-structured GBCA. 205 (73.5%) were a non-ionic GBCA while 74 (26.5%) were an ionic GBCA.

CONCLUSION

Clinical and legal databases exhibit unique characteristics that prove complementary in safety evaluations. Use of the legal data set allowed the identification of the most commonly implicated GBCA.

ADVANCES IN KNOWLEDGE

This article is the first to demonstrate explicitly the utility of a legal data set to pharmacovigilance research.

Nephrogenic systemic fibrosis in Denmark--a nationwide investigation

Background

Nephrogenic systemic fibrosis is a debilitating and painful disorder with an increased stimulation of the connective tissue in the skin and systemic tissues. The disease is associated with exposure to gadolinium-based contrast agent used in magnetic resonance imaging in patients with renal impairment.

Methods

The prevalence of nephrogenic systemic fibrosis has so far never been determined at a national level. In 2009, Denmark was the first country to design a guideline for the tracing of nephrogenic systemic fibrosis patients. The aim of this paper is to communicate the main findings of this quest.

Results

The outcome of the nationwide investigation revealed that Denmark had 65 patients with nephrogenic systemic fibrosis and thereby the highest prevalence of nephrogenic systemic fibrosis worldwide with 65 per 5.6 million inhabitants, or 12 per million.

Conclusions

The nationwide investigation in Denmark revealed the highest prevalence of NSF worldwide. This may be rooted in a high level of awareness of NSF both among doctors, politicians and, not least, the media, combined with the fact that a nationwide NSF investigation was initiated.

Linking drugs to obscure illnesses: lessons from pure red cell aplasia, nephrogenic systemic fibrosis, and Reye's syndrome. a report from the Southern Network on Adverse Reactions (SONAR)

Identification of serious adverse drug reactions (sADRS) associated with commonly used drugs can elude detection for years. Reye's syndrome (RS), nephrogenic systemic fibrosis (NSF), and pure red cell aplasia (PRCA) among chronic kidney disease (CKD) patients were recognized in 1951, 2000, and 1998, respectively. Reports associating these syndromes with aspirin, gadodiamide, and epoetin, were published 29, 6, and 4 years later, respectively. We obtained primary information from clinicians who identified causes of these sADRs and reviewed factors contributing to delayed identification of these toxicities. Overall, 3,500 aspirin-associated RS cases in the United States, 1,605 gadolinium-associated NSF cases, and 181 epoetin-associated PRCA cases were reported. Delays in FDA regulation of over-the- counter medications and administration of aspirin to children contributed to development of RS. For NSF, in 1996, the Danish Medicine Agency approved high-dose gadodiamide administration to chronic kidney disease (CKD) patients undergoing MR scans. Overall, 88 % of Danish NSF cases were from two hospitals and 97 % of United States' NSF cases were from 60 hospitals. These hospitals frequently administered high-doses of gadodiamide to CKD patients. Another factor was the decision to administer linear chelated contrast agents versus lower risk macrocyclic chelated agents. For PRCA, increased use of subcutaneous epoetin formulations to CKD patients, in part due to convenience and cost-savings considerations, and a European regulatory requirement requiring removal of albumin as a stabilizer, led to toxicity. Overall, 81, 13, and 17 years elapsed between drug introduction into practice and identification of a causal relationship for aspirin, erythropoietin, and gadodiamide, respectively. A substantial decline in new cases of these sADRs occurred within two years of identification of the offending drug. Clinicians should be vigilant for sADRs, even for frequently-prescribed pharmaceuticals, particularly in settings where formulation or regulatory changes have occurred, or when over-the-counter, off-label, or pediatric use is common.

Nephrogenic systemic fibrosis and gadolinium-based contrast media: updated ESUR Contrast Medium Safety Committee guidelines

PURPOSE

To update the guidelines of the Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) on nephrogenic systemic fibrosis and gadolinium-based contrast media.

AREAS COVERED

Topics reviewed include the history, clinical features and prevalence of nephrogenic systemic fibrosis and the current understanding of its pathophysiology. The risk factors for NSF are discussed and prophylactic measures are recommended. The stability of the different gadolinium-based contrast media and the potential long-term effects of gadolinium in the body have also been reviewed.

Role of Cardiac Imaging (CT/MR) Before and After RF Catheter Ablation in Patients with Atrial Fibrillation

Pre-procedure X-ray computed tomography (CT) and magnetic resonance imaging (MRI) angiography are commonly used to delineate the complex and variable relationship of the left atrium, pulmonary veins, and surrounding structures. 3D CT and MR angiography are routinely incorporated into electroanatomic mapping systems to guide ablation lesion placement in the context of patient specific anatomy. Post-procedure CT and MRI have also proven useful for evaluating complications such as pulmonary vein stenosis. In the future, these imaging modalities may be used to visualize more detailed tissue characteristics such as atrial fibrosis and ablation lesions. This could improve selection of patients for different treatment strategies and perhaps guide more effective ablation. This review will discuss current and emerging applications of CT and MRI before and after radiofrequency catheter ablation of atrial fibrillation.

Scleroderma mimics

Scleroderma is a rare systemic autoimmune disease with multiple organ manifestations, including skin fibrosis. The groups of disorders classified as scleroderma mimics share the common thread of skin thickening but are otherwise quite incongruous in terms of underlying disease process and other organ involvement. This article reviews the clinical presentation, etiology, and treatment options available for scleroderma mimics, including morphea, scleredema, diabetic cheiroarthropathy, scleromyxedema, nephrogenic systemic fibrosis, and eosinophilic fasciitis. Through greater understanding of these diseases and the associated extradermal implications, we hope to facilitate recognition of scleroderma and its mimics.

Immediate hypersensitivity reaction to gadolinium-based MR contrast media

PURPOSE

To determine the incidence and risk factors of immediate hypersensitivity reactions to gadolinium-based magnetic resonance (MR) contrast agents.

MATERIALS AND METHODS

Institutional review board approval and a waiver of informed consent were obtained. A retrospective study of patients who had been given gadolinium-based MR contrast media between August 2004 and July 2010 was performed by reviewing their electronic medical records. In addition to data on immediate hypersensitivity reaction, the kinds of MR contrast media and demographic data including age, sex, and comorbidity were collected. To compare the groups, the χ(2) test, Fisher exact test, χ(2) test for trend, Student t test, analysis of variance test, and multiple logistic regression test were performed.

RESULTS

A total of 112 immediate hypersensitivity reactions (0.079% of 141 623 total doses) were identified in 102 patients (0.121% of 84 367 total patients). Among the six evaluated MR contrast media, gadodiamide had the lowest rate (0.013%) of immediate hypersensitivity reactions, while gadobenate dimeglumine had the highest rate (0.22%). The rate for immediate hypersensitivity reactions was significantly higher in female patients (odds ratio = 1.687; 95% confidence interval: 1.143, 2.491) and in patients with allergies and asthma (odds ratio = 2.829; 95% confidence interval: 1.427, 5.610). Patients with a previous history of immediate hypersensitivity reactions had a higher rate of recurrence after reexposure to MR contrast media (30%) compared with the incidence rate in total patients (P < .0001). The incidence of immediate hypersensitivity reactions increased depending on the number of times patients were exposed to MR contrast media (P for trend = .036). The most common symptom was urticaria (91.1%), and anaphylaxis occurred in 11 cases (9.8%). The mortality rate was 0.0007% because of one fatality.

CONCLUSION

The incidence of immediate hypersensitivity reactions to MR contrast media was 0.079%, and the recurrence rate of hypersensitivity reactions was 30% in patients with previous reactions.

Gadolinium-induced nephrogenic systemic fibrosis: the rise and fall of an iatrogenic disease

Background.

In 2006, nephrologists in Denmark unexpectedly identified chronic kidney disease (CKD) patients with a new syndrome, nephrogenic systemic fibrosis (NSF). Subsequently, 1603 NSF patients were reported to the Food and Drug Administration. Sixty hospitals in the USA account for 93% of these cases, and two hospitals in Denmark account for 4% of these reports. We review Denmark’s identification and subsequent rapid eradication of NSF.

Methods.

NSF reports from clinicians, the Danish Medicines Agency (DMA) and gadolinium-based contrast agents (GBCAs) manufacturers were reviewed (2002–11).

Results.

In 1994, the DMA approved a non-ionic linear GBCA, gadodiamide (0.1 mmol/kg), for magnetic resonance imagings (MRIs), with a renal insufficiency contraindication. In 1996, 0.3 mmol/kg dosing received DMA approval. In 1998, the DMA removed renal contraindications. In 1997 and 2002, radiologists at Skejby Hospital and Herlev Hospital, respectively, began performing gadodiamide-enhanced magnetic resonance angiography scans (0.3 mmol/kg) of CKD patients. In 2005, Herlev clinicians requested assistance in evaluating etiological causes of NSF occurring among 10 CKD patients who had developed NSF. This investigation, focusing on infectious agents, was inconclusive. In 2006, Herlev clinicians reported that of 108 CKD patients who had received gadodiamide-enhanced MRI, 20 had developed probable NSF. Herlev radiologists voluntarily discontinued administering gadodiamide to all patients and no new NSF cases at Herlev Hospital developed subsequently. After meeting with Herlev radiologists, Skejby radiologists also discontinued administering gadodiamide to all patients. In 2007, the European Medicines Agency and the DMA contraindicated gadodiamide administration to CKD patients. In 2008, in response to these advisories, radiologists at the other 36 Danish hospitals discontinued administering gadodiamide to all patients, following on practices adopted at Skejby and Herlev Hospitals. In 2009, clinicians at Skejby Hospital reported that a look-back survey identified 33 CKD patients with NSF developing after undergoing GBCA-enhanced MRIs between 1999 and 2007. In 2010, an independent review, commissioned by the Minister of Health, concluded that the DMA had erred in rescinding gadodiamide’s renal insufficiency contraindication in 1998 and that this error was a key factor in the development of NSF in Denmark. In 2011, three NSF cases associated with macrocyclic GBCA-associated NSF and three NSF patients with Stages 3 and 4 CKD disease from Skejby Hospital were reported.

Conclusion.

A confluence of factors led to the development and eradication of NSF in Denmark.

Distribution of estimated glomerular filtration rate (eGFR) values in patients receiving contrast-enhanced magnetic resonance imaging

PURPOSE

The aim of this study was to elucidate the distribution of estimated glomerular filtration rate (eGFR) values in patients who underwent gadolinium-based contrast agent (GBCA)-enhanced magnetic resonance imaging (MRI) at different types of hospitals.

MATERIALS AND METHODS

We retrospectively studied 2,550 patients who underwent MRI at five institutions. We recorded the date and value of each patient's eGFR test. The distribution of eGFR values was compared with that in the general Japanese population.

RESULTS

A total of 84.3% of patients had their eGFRs evaluated before GBCA-enhanced MRI. Of these, 84.7% were evaluated within 3 months before the GBCA-enhanced MRI, and 1.3% were evaluated on the day of the GBCA-enhanced MRI. A total of 87.2% of patients tested had an eGFR of ≥60 ml/min/1.73 m(2); 12.8% had an eGFR of <60 and ≥30 ml/min/1.73 m(2), and no patients had an eGFR of <30 ml/min/1.73 m(2).

CONCLUSION

The rate of renal function evaluation differed among hospitals. The prevalence of low eGFR values was greater in Juntendo Tokyo Koto Geriatric Medical Center than in the other hospitals, and the prevalence of low eGFR values was greater in patients who underwent GBCA-enhanced MRI than in the general Japanese population.

Fibroblasts and myofibroblasts in renal fibrosis

Interstitial fibrosis, associated with extensive accumulation of extracellular matrix constituents in the cortical interstitium, is directly correlated to progression of renal disease. The earliest histological marker of this progression is the accumulation in the interstitium of fibroblasts with the phenotypic appearance of myofibroblasts. These myofibroblasts are contractile cells that express alpha smooth muscle actin and incorporate it into intracellular stress fibres. Although fibroblasts are histologically visible in normal kidneys, there are relatively few of them and proximal tubular epithelial cells predominate. In progressive disease, however, the interstitium becomes filled with myofibroblasts. In this review, we will examine the phenotype and function of fibroblasts and myofibroblasts in the cortical interstitium and the processes that may modulate them.