Nephrogenic systemic fibrosis: A serious iatrogenic disease of renal failure patients

Brain relaxometry after macrocyclic Gd-based contrast agent

PURPOSE

To assess if ratios of T1-weighted (T1w) signal intensity (SI) and quantitative T1 relaxometry (qT1) change on serial administration of macrocyclic gadobutrol.

METHODS

A total of 17 glioblastoma patients were scanned at 3.0 T magnetic resonance imaging (MRI) every 6 weeks after tumor resection with standard MRI and T1 and T2 relaxometry before and after gadobutrol administration. On co-registered images T1w SI was measured and relaxation times T1 (qT1) and quantitative T2 (qT2) were quantified in several deep grey matter nuclei as ratios relative to frontal white matter and to the pons. Ratio changes were evaluated over time with a paired t‑test and multiple regression.

RESULTS

An average of 8 (range 5-14) scans per patient were completed. Ratios of T1w SI, qT1 and qT2 remained unchanged for all target regions from the first to the last time point (p > 0.05) and did not correlate with the number of gadobutrol administrations. Multivariate regression showed no significant impact of gadobutrol on qT1 or qT2 ratios, but a significant negative effect on T1w SI ratios. Gender also had no impact on the ratios but age had a significant negative influence on the qT1 ratio.

CONCLUSION

Multiple administrations of a macrocyclic contrast agent did not change relaxation time T1 ratios in any deep grey matter structure.

Nephrogenic systemic fibrosis and gadolinium-based contrast agents

The strong association between nephrogenic systemic fibrosis (NSF) and exposure to gadolinium-based contrast agents (GBCAs) has greatly affected the care of patients with kidney disease. NSF has been reported in patients with ESRD, CKD, and acute kidney injury (AKI). The majority of cases have occurred in patients with ESRD, but about 20% have been reported in patients with AKI or CKD stages 4 and 5. There is also a risk difference among GBCAs, with the Food and Drug Administration contraindicating 3 linear agents in patients at risk. Given the significant morbidity and mortality of NSF, it is imperative to identify individuals at risk. Although there are no data to support a role for hemodialysis (HD) in reducing the risk for NSF after administration of GBCAs, immediate HD is still recommended within 2 hours. Patients maintained on peritoneal dialysis seem to be at high risk and immediate HD is also recommended. However, this is not the current recommendation for CKD stages 4 and 5, especially with suspected lower risk of noncontraindicated agents. Individualized assessment is important and especially in those patients close to dialysis initiation. Instituting policies is important to address the imaging needs of patients with CKD and AKI while ensuring a balance between benefits and risks.

MRI safety: nephrogenic systemic fibrosis and other risks

Magnetic resonance imaging (MRI) is now a commonly used imaging modality in many neurosurgical and neurological conditions. Although generally regarded as safe, there are a number of important safety considerations. These include a recently recognised, rare condition termed nephrogenic systemic fibrosis (NSF) that occurs in patients with significant renal impairment who receive gadolinium based contrast. Currently, NSF remains poorly understood and there is no universally effective treatment beyond the avoidance of contrast in patients with significant renal impairment. Other safety considerations include MRI contraindicated devices and the role of MRI in pregnancy.

Risk factors for NSF: a literature review

Emerging evidence linking gadolinium-based contrast agents (GBCAs) to nephrogenic systemic fibrosis (NSF) has changed medical practice patterns toward forgoing GBCA-enhanced magnetic resonance imaging (MRI) or substituting other imaging methods, which are potentially less accurate and often radiation-based. This shift has been based on reports of high NSF incidence at sites where a confluence of risk factors occurred in patients with severe renal dysfunction. This review article explores the factors that affect NSF risk, compares risks of alternative imaging procedures, and demonstrates how risk can be managed by careful selection of GBCA dose, timing of injection with respect to dialysis, and other factors. Nearly half of NSF cases are a milder form that does not cause contractures or reduce mobility. It appears that eliminating even a single risk factor can reduce NSF incidence/risk at least 10-fold. Elimination of multiple risk factors by using single-dose GBCA, dialyzing dialysis patients quickly following GBCA administration, avoiding GBCA in acute renal failure while serum creatinine is rising, and avoiding nonionic linear GBCA in renal failure patients may reduce NSF risk more than a thousand-fold, thereby allowing safe GBCA-enhanced MRI in virtually all patients. J. Magn. Reson. Imaging 2009;30:1298-1308. (c) 2009 Wiley-Liss, Inc.

Nephrogenic systemic fibrosis in liver disease: a systematic review

Nephrogenic systemic fibrosis (NSF) may develop in patients with liver disease, a fact highlighted by Food and Drug Administration (FDA) announcements cautioning against the use of gadolinium-based contrast agents (GBCAs) in select liver disease patients. The purpose of this systematic literature review is to characterize the risk of NSF in patients with liver disease. All published articles on NSF from September 2000 through August 2008, were identified via PubMed searches and examination of articles' reference lists. Two reviewers independently read each article and identified unique patients with biopsy-proven or suspected NSF. Data on demographics, liver status, renal status, and GBCA exposure were collected. A total of 324 articles were reviewed, with 108 articles containing case descriptions of 335 unique NSF patients. After excluding the 95/335 (28%) patients in whom the presence or absence of liver disease was uncertain, liver disease was confirmed present in 41/239 (17%) patients. Renal insufficiency could be assessed in 35 of the liver disease patients; severe renal insufficiency, defined as a glomerular filtration rate (GFR) or estimated GFR (eGFR) <30 mL/min/1.73 m(2) or dialysis requirement, was present in 34/35 (97%) patients. The lone patient who developed NSF with mild/moderate renal insufficiency was atypical and received a total gadodiamide load of 0.76 mmol/kg over a 10-week period periliver transplantation. The published medical literature demonstrates that patients with liver disease who develop NSF also have severe renal insufficiency, suggesting that liver disease does not confer a risk for NSF beyond that of the underlying renal insufficiency. J. Magn. Reson. Imaging 2009;30:1313-1322. (c) 2009 Wiley-Liss, Inc.

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.