Update on nephrogenic systemic fibrosis: are we making progress?

Cutaneous Markers of Systemic Disease in the Lower Extremity

The skin of the lower extremity can be a helpful diagnostic tool for systemic disease. Diabetes, renal disease, genetic disorders, and even cancer can have cutaneous manifestations in the legs and feet; moreover, proper diagnosis can facilitate earlier treatment of these diseases and not only clear up the skin symptoms but also bring about resolution of the systemic disease causing them. Although not comprehensive, this article discusses many of these disorders presenting with integumentary manifestations in the lower extremities. Where appropriate, it also enumerates the treatments involved, both systemic and localized.

Neuroradiological evaluation of demyelinating disease

Central nervous system inflammatory demyelinating disease can affect patients across the life span. Consensus definitions and criteria of all of the different acquired demyelinating diseases that fall on this spectrum have magnetic resonance imaging criteria. The advances of both neuroimaging techniques and important discoveries in immunology have produced an improved understanding of these conditions and classification. Neuroimaging plays a central role in the accurate diagnosis, prognosis, disease monitoring and research efforts that are being undertaken in this disease. This review focuses on the imaging spectrum of acquired demyelinating disease.

Diagnosis of common dermopathies in dialysis patients: a review and update

Cutaneous abnormalities in patients with end-stage renal disease (ESRD) receiving hemodialysis or peritoneal dialysis may demonstrate signs of their underlying condition or reveal associated disease entities. While a thorough examination of the scalp, skin, mucosa, and nails is integral to establishing a diagnosis, certain conditions will resolve only with dialysis or improvement of their renal disease and others may not require or respond to treatment. Half and half nails, pruritus, xerosis, and cutaneous hyperpigmentation are common manifestations in ESRD. With hemodialysis, uremic frost is no longer prevalent in ESRD patients and ecchymoses have decreased in incidence. Acquired perforating dermatoses are seen in over one-tenth of hemodialysis patients. Metastatic calcinosis cutis and calciphylaxis are both rarely reported, although the latter is seen almost exclusively in the setting of hemodialysis. Diagnosis of nephrogenic systemic fibrosis has historically been challenging; as such, new diagnostic criteria have been proposed. Blood porphyrin profiles are needed to differentiate between porphyria cutanea tarda and pseudoporphyria. We will review and provide an update on the aforementioned common cutaneous manifestations of ESRD in patients receiving dialysis.

Stable aqueous dispersion of superparamagnetic iron oxide nanoparticles protected by charged chitosan derivatives

This article presents the synthesis and characterization of biocompatible superparamagnetic iron oxide nanoparticles (SPIONs) coated with ultrathin layer of anionic derivative of chitosan. The water-based fabrication involved a two-step procedure. In the first step, the nanoparticles were obtained by co-precipitation of ferrous and ferric aqueous salt solutions with ammonia in the presence of cationic derivative of chitosan. In the second step, such prepared materials were subjected to adsorption of oppositely charged chitosan derivative which resulted in the preparation of negatively charged SPIONs. They were found to develop highly stable dispersion in water. The core size of the nanocoated SPIONs, determined using transmission electron microscopy, was measured to be slightly above 10 nm. The coated nanoparticles form aggregates with majority of them having hydrodynamic diameter below 100 nm, as measured by dynamic light scattering. Their composition and properties were studied using FTIR and thermogravimetric analyses. They exhibit magnetic properties typical for superparamagnetic material with a high saturation magnetization value of 123 ± 12 emu g(-1) Fe. Very high value of the measured r(2) relaxivity, 369 ± 3 mM(-1) s(-1), is conducive for the potential application of the obtained SPIONs as promising contrast agents in magnetic resonance imaging. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11051-012-1372-9) contains supplementary material, which is available to authorized users.

Gadolinium MRI contrast agents based on triazine dendrimers: relaxivity and in vivo pharmacokinetics

Four gadolinium (Gd)-based macromolecular contrast agents, G3-(Gd-DOTA)(24), G5-(Gd-DOTA)(96), G3-(Gd-DTPA)(24), and G5-(Gd-DTPA)(96), were prepared that varied in the size of dendrimer (generation three and five), the type of chelate group (DTPA or DOTA), and the theoretical number of metalated chelates (24 and 96). Synthesis relied on a dichlorotriazine derivatized with a DOTA or DTPA ligand that was incorporated into the dendrimer and ultimately metalated with Gd ions. Paramagnetic characteristics and in vivo pharmacokinetics of all four contrast agents were investigated. The DOTA-containing agents, G3-(Gd-DOTA)(24) and G5-(Gd-DOTA)(96), demonstrated exceptionally high r1 relaxivity values at off-peak magnetic fields. Additionally, G5-(Gd-DOTA)(96) showed increased r1 relaxivity in serum compared to that in PBS, which was consistent with in vivo images. While G3-(Gd-DOTA)(24) and G3-(Gd-DTPA)(24) were rapidly excreted into the urine, G5-(Gd-DOTA)(96) and G5-(Gd-DTPA)(96) did not clear as quickly through the kidneys. Molecular simulation of the DOTA-containing dendrimers suggests that a majority of the metalated ligands are accessible to water. These triazine dendrimer-based MRI contrast agents exhibit several promising features such as high in vivo r1 relaxivity, desirable pharmacokinetics, and well-defined structure.

Diagnosis and treatment of peripheral arterial disease in CKD patients

Peripheral arterial disease (PAD) is a cardiovascular disease risk equivalent and is a common problem in chronic kidney disease patients. Unlike in the general population, PAD in CKD occurs due to medial calcification as opposed to intimal atherosclerotic process. PAD intervention should be performed in select symptomatic patients, as described by the guidelines, and CVD risk factor modification should occur in all CKD patient, regardless of the presence of PAD. As a discipline, Interventional Nephrology has emerged out of a desire to create better outcomes for our patients and to "fix a problem." The core values of our discipline have evolved out of this fundamental desire to meet an unmet clinical need, to provide insight into a disease state specific to our patients, and to offer clinical/academic excellence in doing so. We must endeavor to follow a similar path in our approach to PAD. The purpose of this review is to educate interventional nephrologists in the diagnosis and treatment of PAD in their CKD patients.

Nephrogenic systemic fibrosis

OBJECTIVE

The purpose of this article is to discuss nephrogenic systemic fibrosis (NSF) in detail regarding its history, possible pathophysiology, clinical and pathologic presentations, diagnosis, and implications for the radiology community.

CONCLUSION

NSF is a potentially lethal disorder that occurs in patients with reduced kidney function. Current evidence suggests a strong association with gadolinium-based contrast agents--mostly used in MRI--in this patient group. This has urged the radiology community to emphasize careful screening for the presence of renal dysfunction among patients for whom gadolinium-enhanced MRI is contemplated. Appropriate selection of gadolinium-based contrast agent type, avoidance of nonstandard dosage, patient education, and informed consent have been recommended by authorities.

Nephrogenic systemic fibrosis: concepts and perspectives

Nephrogenic systemic fibrosis is a chronic, progressive condition that develops in some patients with renal impairment after exposure to gadolinium-based contrast agents used in magnetic resonance imaging. Thickening of the skin is typical, usually affecting the extremities. Visceral organs can also be affected. The diagnosis of the disease requires careful clinicopathological correlation. Treatment aims at restoring renal function, which is associated with delayed progression and, eventually, remission of skin changes. Reduction and prevention of nephrogenic systemic fibrosis cases are based on limiting the use of gadolinium-based contrast agents in patients with kidney disorders (especially in patients with advanced renal failure at stages 4 and 5), and restricting their use to situations in which they are essential to diagnosis/follow-up. Other than limiting exposure to gadolinium based contrast agents, no effective preventive methods have been reported. Due to increased awareness about the disease among radiologists and nephrologists, the incidence of nephrogenic systemic fibrosis is declining.