Gadodiamide-Based Coronary Angiography in a Patient with Severe Renal Insufficiency

Adverse Events Associated with Intra-Arterial Administration of Gadolinium-Based Contrast Agents: A Systematic Review and Meta-Analysis

PURPOSE

To determine the risk of immediate hypersensitivity reactions (HRs), contrast-associated acute kidney injury (CA-AKI), nephrogenic systemic fibrosis (NSF), and gadolinium retention associated with use of intra-arterial gadolinium-based contrast agents (GBCAs).

MATERIALS AND METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from 1988 (GBCAs approved for clinical use) to March 2021 for studies reporting adverse events associated with intra-arterial administration of GBCAs. The number of adverse events and GBCA administrations were used to calculate incidence in individual studies, and results across studies were pooled using random-effects meta-analysis.

RESULTS

There were 72 studies (patients = 1,221) that reported on HR, 59 studies (patients = 1,142) that reported on CA-AKI, and 6 studies (patients = 291) that reported on NSF. No studies reported gadolinium retention as an outcome. Based on 5 events and 1,451 GBCA administrations, the incidence of HR per 100 administrations was 0.95 (95% CI, 0.52-1.51). Based on 90 events and 1,318 GBCA administrations, the incidence of CA-AKI per 100 administrations was 5.94 (95% CI, 3.92-8.34). Based on 7 events and 361 GBCA administrations, the incidence of NSF per 100 Group I GBCA administrations was 4.72 (95% CI, 0.35-13.70). There were no unconfounded NSF events after Group II GBCA administration.

CONCLUSIONS

HRs to intra-arterial administration of GBCAs are rare, with no serious reactions. Limited data demonstrate a higher-than-expected rate of CA-AKI; however, multiple confounding factors were noted. Thus, any causative link of CA-AKI to GBCA remains controversial. Also, severe physiologic reactions (including life-threatening arrhythmias) during coronary angiography have been reported.

Gadolinium-based coronary angiography in patients with contraindication for iodinated x-ray contrast medium: a word of caution

BACKGROUND

In coronary angiography, the use of contrast agents containing iodine still defines the gold standard. In patients with contraindications for iodine exposition, gadolinium has been considered to be a safe alternative to standard iodinated contrast medium for coronary angiography. The aim of the present study was to assess the safety and technical quality of gadolinium-based coronary angiography.

METHODS

Nineteen consecutive patients with contraindication to iodinated contrast medium underwent gadolinium-based coronary angiography. Contraindications included previous anaphylactic shock or severe allergic reaction to iodinated contrast medium (n = 13) or thyrotoxicosis (n = 6). Gadolinium was diluted 1:1 with sodium chloride before application. Patients were clinically observed for potential side effects, and renal function was assessed by determination of creatinine values and calculation of creatinine clearance in pre- and postprocedural blood samples. Image quality was evaluated by two independent observers, and classified into three different categories (grade 1, high diagnostic quality; grade 2, moderate diagnostic quality; and grade 3, poor quality).

RESULTS

During angiography, a mean of 32.6 +/- 10.9 mL (range 10-45 mL) gadolinium was used. No patient developed a significant impairment of renal function within 24 hours after the examination (mean creatinine value preprocedural: 1.12 +/- 0.15 mg/dL, postprocedural: 6 hours 1.15 +/- 0.18 mg/dL, 24 hours 1.13 +/- 0.16 mg/dL) (baseline vs. 6 hours P = 0.23, baseline vs. 24 hours P = 0.66, 6 hours vs. 24 hours P = 0.12) (mean creatinine clearance preprocedural: 73.8 +/- 18 mg/dL, postprocedural: 6 hours 71.7 +/- 16.8 mg/dL, 24 hours 73.2 +/- 17.8 mg/dL) (baseline vs. 6 hours P = 0.2, baseline vs. 24 hours P = 0.71, 6 hours vs. 24 hours P = 0.21). Four patients (21%) suffered severe complications due to gadolinium application, such as malignant cardiac arrhythmias (n = 3) and hemodynamic decompensation (n = 1). Image quality was generally reduced in comparison to iodine contrast coronary angiography, but was adequate for diagnostic purposes (13 patients [68.4%] had reasonably good picture contrast [grade 2.1 +/- 0.3]; in 6 patients [31.6%], image quality was satisfactory [grade 2.6 +/- 0.13]). Opacification of distal vessels as compared to proximal segments was remarkably reduced.

CONCLUSIONS

Gadolinium-based coronary angiography is a potential alternative technique in patients with allergy to iodinated contrast medium or thyrotoxicosis with reduced, but acceptable, image quality for diagnostic purposes. Nevertheless, possible life-threatening side effects and complications have to be considered.

Cytotoxicity of iodinated and gadolinium-based contrast agents in renal tubular cells at angiographic concentrations: in vitro study

PURPOSE

To test in vitro whether gadolinium-based contrast agents induce fewer toxic effects on renal tubular cells than does an iodinated contrast medium at concentrations used for angiography.

MATERIALS AND METHODS

LLC-PK1 cells were incubated with iomeprol, gadopentetate dimeglumine, gadobenate dimeglumine, gadoterate meglumine, gadodiamide, and corresponding mannitol solutions for 24 hours at 37 degrees C in two experimental settings: measurements with equally attenuating solutions and measurements with equimolar solutions. Cytotoxicity was assessed with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay, trypan blue testing, and an assay to detect apoptosis and necrosis. Data were analyzed with analyses of variance and post hoc tests.

RESULTS

Yielding the same x-ray attenuation, iomeprol-300 and iomeprol-150 at concentrations of 2.34-18.75 mg of iodine per milliliter induced significantly (P < .001) lower inhibition of MTT conversion (74%-102% of undamaged control cells) compared with 15.63-125.00 mmol/L concentrations of the gadolinium-based agents (mean percentages of undamaged control cells: 48%-80%, 50%-87%, 60%-95%, and 56%-92% with gadopentetate dimeglumine, gadobenate dimeglumine, gadoterate meglumine, and gadodiamide, respectively). At equimolar concentrations (62.5 mmol/L), iomeprol-190 induced a mean extent of inhibition of MTT conversion (69% of undamaged control cells) similar to that induced by gadoterate meglumine (71%) and gadodiamide (70%), whereas gadopentetate dimeglumine and gadobenate dimeglumine induced stronger effects (63% and 64%, respectively; P < .001). At trypan blue testing, there were more dead cells after incubation with 125 mmol/L gadopentetate dimeglumine than after incubation with iomeprol-190 (57% vs 19%, P < .001). The 125 mmol/L gadopentetate and gadobenate formulations induced more necrosis and apoptosis than did gadoterate meglumine, gadodiamide, and iomeprol (mean percentage difference between treated and untreated control cells: for necrosis, +124%, +95%, +17%, -6%, and +3%, respectively; for apoptosis, +34%, +35%, +13%, +4%, and +5%, respectively; P < .001).

CONCLUSION

At angiographic concentrations, gadolinium-based contrast agents do not induce fewer cytotoxic effects on cultured renal tubular cells than does iomeprol.