Successful Pregnancy in a Hemodialysis Patient and Marked Resolution of Her Nephrogenic Systemic Fibrosis

The Clinical Manifestations and Efficacy of Different Treatments Used for Nephrogenic Systemic Fibrosis: A Systematic Review

Aim

Nephrogenic systemic fibrosis (NSF) is a rare disorder that occurs in association majorly with chronic kidney disease (CKD). The lack of collective quantitative data on its clinical manifestations and the different treatment options' efficacy, call the need for our investigation.

Methods

A systematic review was conducted covering a timeline from inception up to July 2022 without any restrictions. Article screening and data extraction were performed independently on PubMed, Google Scholar, ScienceDirect, and Cochrane Library. The keywords that we used were CKD, NSF, Gadolinium enduced fibrosis, etc; shortlisted articles were assessed for risk of bias. Data were presented as frequencies and percentages, with a confidence interval of 95%. A chi-square test was also done to find significant relationships, with a p-value <0.05 considered significant.

Results

We had 83 patients in this review consisting of 44 (55.7%) females with a mean age of 51.4±14.6 years. Sixty-nine (83.1%) patients had chronic kidney disease predisposition to NSF. Previous exposure to gadolinium-based contrast dyes was seen in 66 (79.5%) patients). The most common symptom in patients was cutaneous lesions in 69 (83.1%) patients. The most used treatments were ultraviolet therapy, renal transplant, and extracorporeal photopheresis; in 13.3% of the patients each. Condition in most patients either improved (67.1%) or remained stable (11.8%). Chi-square testing found that the treatments offered were also seen to be significantly related to outcome (p=0.015).

Conclusion

The findings in this study provide a quantitative measurement of NSF's presentations and treatment efficacies. This serves to make way for researchers to form comprehensive guidelines on the presentation-based treatment of NSF.

Gadolinium Retention in the Brain of Mother and Pup Mouse: Effect of Pregnancy and Repeated Administration of Gadolinium‐Based Contrast Agents

Background

The association of repeated administration of gadolinium‐based contrast agents (GBCAs) with the gadolinium (Gd) retention in the brains of mother and fetus remains unclear.

Purpose

To investigate the effects of pregnancy and repeated administration of GBCAs on Gd retention in the brains of mother and pup mice.

Study type

Cross‐sectional cohort toxicity study.

Animal Model

From gestational days 16–19, pregnant (n = 48) BALB/c mice.

Field Strength

A 9.4 T and fast spin echo sequence.

Assessment

Half of the mother mice (n = 24) were killed at postnatal day 1 (P1) for inductively coupled plasma mass spectrometry (ICP‐MS) and transmission electron microscopy (TEM). Besides the ICP‐MS and TEM, four pups were randomly selected from each mother and killed at P1 for ultraperformance liquid chromatography mass spectrometry (UPLC‐MS) and Nissl staining.

Statistical Tests

One‐way analysis of variance and unpaired t‐test.

Results

In the group of gadodiamide, retention of Gd in the brains of pregnant mice was significantly lower than that of nonpregnant mice in the area of the deep cerebellar nuclei (DCN) (10.35 ± 2.16 nmol/g vs. 18.74 ± 3.65 nmol/g). Retention of Gd in the DCN of pups whose mothers were administered gadoterate meglumine was significantly lower than that of pups whose mothers were administered gadodiamide (0.21 ± 0.09 nmol/g vs. 6.15 ± 3.21 nmol/g) at P1. In mice treated with gadodiamide, most of the retained Gd in the brain tissue was insoluble (19.5% ± 9.5% of the recovered amount corresponded to the intact complex in the DCN).

Data Conclusion

In different brain areas of the mother and pup mice, the retention of Gd after gadoterate meglumine administration was lower than that of gadodiamide and gadopentetate dimeglumine administration, and almost all the detected Gd in pups' brains was intact soluble GBCAs.

Evidence Level

1

Technical Efficacy

Stage 2

A Systematic Review of 639 Patients with Biopsy-confirmed Nephrogenic Systemic Fibrosis

Background Although nephrogenic systemic fibrosis (NSF) affects the use of gadolinium-based contrast agents (GBCAs) in MRI, there continues to be limited knowledge because of the small number of patients with NSF. Purpose To perform a systematic review of NSF. Materials and Methods PubMed database was searched by using the term "Nephrogenic systemic fibrosis" from January 2000 to February 2019. Articles reporting details on individual patients with NSF diagnosis on the basis of both clinical presentations and biopsy confirmation were included. Data were pooled and authors were contacted for clarifications. Rates of NSF were compared through 2008 versus after 2008 and for group I versus group II GBCAs, assuming equal market share. Results Included were 639 patients from 173 articles. Data regarding sex were found for 295 men and 254 women. Age at NSF symptom onset was reported for 177 patients (mean, 49 years ± 16 [standard deviation]; age range, 6-87 years). There were 529 patients with documented exposure to GBCAs including gadodiamide (n = 307), gadopentetate dimeglumine (n = 49), gadoversetamide (n = 6), gadobutrol (n = 1), gadobenate dimeglumine (n = 1), multiple (n = 41), and unknown (n = 120). Among patients with previous exposure, only seven patients were administered GBCA after 2008, yielding a lower rate of NSF after 2008 (P < .001). There were motion limitations in 70.8% (296 of 418) of patients, indicating a more serious debilitation. Associated factors reported for NSF included exposure to GBCA group I (P < .001), dialysis, proinflammatory conditions, hyperphosphatemia, β-blockers, and epoetin. For 341 patients with follow-up, 12 patients were cured and 72 patients partially improved including one during pregnancy. Among those 84 patients reported as cured or improved, in 34 patients cure or improvement occurred after renal function restoration. Four deaths were attributed to NSF. Conclusion Although 639 patients with biopsy-confirmed nephrogenic systemic fibrosis were reported, only seven were after gadolinium-based contrast agent exposure after 2008, indicating that regulatory actions and practice changes have been effective preventive measures. Improvement and sometimes cure with renal function restoration are now possible. © RSNA, 2019 See also the editorial by Davenport in this issue.

Gadolinium Retention: A Research Roadmap from the 2018 NIH/ACR/RSNA Workshop on Gadolinium Chelates

Gadolinium-based contrast agents (GBCAs) have revolutionized MRI, enabling physicians to obtain crucial life-saving medical information that often cannot be obtained with other imaging modalities. Since initial approval in 1988, over 450 million intravenous GBCA doses have been administered worldwide, with an extremely favorable pharmacologic safety profile; however, recent information has raised new concerns over the safety of GBCAs. Mounting evidence has shown there is long-term retention of gadolinium in human tissues. Further, a small subset of patients have attributed a constellation of symptoms to GBCA exposure, although the association of these symptoms with GBCA administration or gadolinium retention has not been proven by scientific investigation. Despite evidence that macrocyclic GBCAs show less gadolinium retention than linear GBCAs, the safety implications of gadolinium retention are unknown. The mechanism and chemical forms of gadolinium retention, as well as the biologic activity and clinical importance of these retained gadolinium species, remain poorly understood and underscore the need for additional research. In February 2018, an international meeting was held in Bethesda, Md, at the National Institutes of Health to discuss the current literature and knowledge gaps about gadolinium retention, to prioritize future research initiatives to better understand this phenomenon, and to foster collaborative standardized studies. The greatest priorities are to determine (a) if gadolinium retention adversely affects the function of human tissues, (b) if retention is causally associated with short- or long-term clinical manifestations of disease, and (c) if vulnerable populations, such as children, are at greater risk for experiencing clinical disease. The purpose of the research roadmap is to highlight important information that is not known and to identify and prioritize needed research. ©RSNA, 2018 Online supplemental material is available for this article .

Obstetric outcomes in women with end-stage renal disease on chronic dialysis: a review

Pregnancies in women on chronic dialysis for end-stage renal disease are high risk, but outcomes appear to have improved with increasing experience and advances in dialysis care. This paper reviews the existing data on outcomes in such pregnancies to enable evidence-based preconception counselling and anticipation of antenatal complications.