Nephrogenic systemic fibrosis: a report of 29 cases. AJR Am J Roentgenol. 2008;190:736-741. [PMID: 18287446 DOI: 10.2214/ajr.07.3115]

The safety of magnetic resonance imaging contrast agents

Gadolinium-based contrast agents are increasingly used in clinical practice. While these pharmaceuticals are verified causal agents in nephrogenic systemic fibrosis, there is a growing body of literature supporting their role as causal agents in symptoms associated with gadolinium exposure after intravenous use and encephalopathy following intrathecal administration. Gadolinium-based contrast agents are multidentate organic ligands that strongly bind the metal ion to reduce the toxicity of the metal. The notion that cationic gadolinium dissociates from these chelates and causes the disease is prevalent among patients and providers. We hypothesize that non-ligand-bound (soluble) gadolinium will be exceedingly low in patients. Soluble, ionic gadolinium is not likely to be the initial step in mediating any disease. The Kidney Institute of New Mexico was the first to identify gadolinium-rich nanoparticles in skin and kidney tissues from magnetic resonance imaging contrast agents in rodents. In 2023, they found similar nanoparticles in the kidney cells of humans with normal renal function, likely from contrast agents. We suspect these nanoparticles are the mediators of chronic toxicity from magnetic resonance imaging contrast agents. This article explores associations between gadolinium contrast and adverse health outcomes supported by clinical reports and rodent models.

Risk of nephrogenic systemic fibrosis in patients with impaired renal function undergoing fixed-dose gadoxetic acid-enhanced magnetic resonance imaging

PURPOSE

To assess the risk of nephrogenic systemic fibrosis (NSF) in patients with renal impairment undergoing gadoxetic acid-enhanced magnetic resonance imaging.

METHODS

This retrospective study included patients who had an estimated glomerular filtration rate (eGFR) below 60 mL/min per 1.73 m² or had undergone dialysis around the time of gadoxetic acid exposure from January 2010 to November 2019. All patients received at least one intravenous injection of gadoxetic acid at a fixed dose of 2.5 mmol. The primary endpoint was the development of NSF after exposure to gadoxetic acid based on Girardi's clinicopathological scoring system.

RESULTS

A total of 204 patients with renal impairment received 424 injections of gadoxetic acid, of which 131 and 54 had an eGFR of 30-59 and < 30 mL/min per 1.73 m², respectively, and 19 had undergone hemodialysis. Eighty-two patients received multiple injections, with 23 receiving five or more injections. The dose of each exposure ranged from 0.02 to 0.07 mmol/kg and the cumulative doses ranged from 0.02 to 0.45 mmol/kg. Thirty-three patients had concomitant Child-Pugh class B or C cirrhosis. No NSF was detected during follow-up (median 20 months; range 6 days to 111 months). The upper bound of the 95% confidence interval for NSF risk was 2.2% and 1.1% per patient and examination, respectively.

CONCLUSION

No NSF was detected in this study. However, it is premature to ascertain the risk of NSF using gadoxetic acid in patients with renal impairment and further studies are warranted.

Neuroimaging Considerations in Patients with Chronic Kidney Disease

Chronic Kidney Disease is a common medical condition that frequently overlaps with neurologic disease. Neuroimaging can be a useful tool to aid in the diagnoses of neurologic illness, including those that result from renal impairment. Some neuroimaging studies also have the potential to lead to adverse effects on the kidneys necessitating a thoughtful approach to selection of imaging modalities. In particular, multimodal imaging is becoming increasingly common in patients presenting with symptoms of acute stroke, a population that may be at higher risk for renal complications. This article will summarize the neuroimaging manifestations of conditions with shared renal and neurologic involvement and highlight considerations regarding the use of contrast media, nephrogenic systemic fibrosis, and metformin-associated lactic acidosis.

Use of Intravenous Gadolinium-based Contrast Media in Patients with Kidney Disease and the Risk of Nephrogenic Systemic Fibrosis: Radiology In Training

A 66-year-old male patient with end-stage chronic kidney disease undergoing maintenance dialysis and with a history of group I intravenous gadolinium-based contrast media (GBCM) administration presented with clinical and pathologic findings consistent with nephrogenic systemic fibrosis. A summary of the evidence and recommendations for use of intravenous GBCM in patients with kidney disease is presented. © RSNA, 2021.

Nephrogenic systemic fibrosis: A frivolous entity

Gadolinium-based contrast agents (GBCAs) used in magnetic resonance imaging are vital in providing enhanced quality images, essential for diagnosis and treatment. Nephrogenic systemic fibrosis (NSF) with GBCAs has been a deterrent for the physician and has led to avoidance of these agents in patients with impaired kidney function. NSF is a progressive debilitating multisystem condition described classically in patients with renal insufficiency exposed to gadolinium contrast media. It is characterized by an induration and hardening of the skin. NSF is described to first involve the extremities and can imperceptibly involve internal organs. Lack of therapeutic interventions to treat NSF makes it more challenging and warrants deep insight into the pathogenesis, risk factors and treatment strategies.

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.

[Gadolinium deposition-"gadolinium deposition disease"]

Gadolinium (Gd)-based contrast agents have been routinely used worldwide in diagnostic MRI since 1988. All routinely applied contrast agents for clinical use were considered extremely safe with regard to tolerance, adverse effects and diagnostic efficacy and when used at Food and Drug Administration-approved doses. With the identification of Gd-associated disorders, namely nephrogenic systemic fibrosis and adverse reactions, and in the longer term Gd-retention in the brain, this view changed and led to the withdrawal or restriction of approval of linear Gd chelates in Europe. Even though Gd deposition in different human body areas was described very early, recently published literature of intracerebral accumulation of contrast agents as well as deposition in bone have created surprising attention. Not only was the fact of Gd deposition in the body well known for many years, but there is currently no clinical evidence of patient symptoms and no resulting health issues of patients have been observed yet. The expression "gadolinium deposition disease" has been termed by active patient advocacy groups with an online presence with reports of individual members stating a broad spectrum of disorders yielding a large symptom complex after administration of Gd-based contrast agents without evidence of any pre-existing or otherwise underlying disease process which could explain the mentioned disorder.

Updated Clinical Practice Guideline on Use of Gadolinium-Based Contrast Agents in Kidney Disease Issued by the Canadian Association of Radiologists

In 2017, the Canadian Association of Radiologists issued a clinical practice guideline (CPG) regarding the use of gadolinium-based contrast agents (GBCAs) in patients with acute kidney injury (AKI), chronic kidney disease (CKD), or on dialysis due to mounting evidence indicating that nephrogenic systemic fibrosis (NSF) occurs with extreme rarity or not at all when using Group II GBCAs or the Group III GBCA gadoxetic acid (compared to first generation Group I linear GBCAs). One of the goals of the work group was to re-evaluate the CPG after 24 months to determine the effect of more liberal use of GBCA on reported cases of NSF in patients with AKI, CKD Stage 4 or 5 (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2), or those that are dialysis-dependent. A comprehensive review of the literature was conducted by a subcommittee of the initial CPG panel between the dates of January 1, 2017-December 31, 2018 to identify new unconfounded cases of NSF linked to Group II or Group III GBCAs and an updated CPG developed. To our knowledge, when using a Group II or Group III GBCA between 2017-2018, only a single unconfounded case report of a fibrosing dermopathy has been reported in a patient who received gadobenate dimeglumine with Stage 2 CKD. No other unconfounded cases of NSF have been reported with Group II or III agents in during this timeframe. The subcommittee concluded that the main recommendations from the 2017 CPG should remain unaltered, but agreed that screening for renal disease in the outpatient setting is no longer justifiable, cost-effective or recommended. Patients on hemodialysis (HD) should, however, be identified prior to GBCA administration to arrange timely HD to optimize gadolinium clearance, although there remains no evidence that HD reduces the risk of NSF. When administering Group II or III GBCAs to patients with AKI, on dialysis or with severe CKD, informed consent relating to NSF is also no longer explicitly recommended.

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-Based Contrast Agents in Kidney Disease: A Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

PURPOSE OF REVIEW

Use of gadolinium-based contrast agents (GBCA) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCA are absolutely contraindicated in AKI, category G4 and G5 CKD (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2), and dialysis-dependent patients is outdated and may limit access to clinically necessary contrast-enhanced magnetic resonance imaging (MRI) examinations. This review and clinical practice guideline addresses the discrepancy between existing Canadian guidelines regarding use of GBCA in renal impairment and NSF.

SOURCES OF INFORMATION

Published literature (including clinical trials, retrospective cohort series, review articles, and case reports), online registries, and direct manufacturer databases were searched for reported cases of NSF by class and specific GBCA and exposed patient population.

METHODS

A comprehensive review was conducted identifying cases of NSF and their association to class of GBCA, specific GBCA used, patient, and dose (when this information was available). Based on the available literature, consensus guidelines were developed by an expert panel of radiologists and nephrologists.

KEY FINDINGS

In patients with category G2 or G3 CKD (eGFR ≥ 30 and < 60 mL/min/1.73 m2), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with category G4 or G5 CKD (eGFR < 30 mL/min/1.73 m2) or on dialysis, administration of GBCA should be considered individually and alternative imaging modalities utilized whenever possible. If GBCA are necessary, newer GBCA may be administered with patient consent obtained by a physician (or their delegate) citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, those with category G4 or G5 CKD, or those on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCA. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCA is recommended.

LIMITATIONS

Limited available literature (number of injections and use in renal impairment) regarding the use of gadoxetate disodium. Limited, but growing and generally high-quality, number of clinical trials evaluating GBCA administration in renal impairment. Limited data regarding the topic of Gadolinium deposition in the brain, particularly as it related to patients with renal impairment.

IMPLICATIONS

In patients with AKI and category G4 and G5 CKD (eGFR < 30 mL/min/1.73 m2) and in dialysis-dependent patients who require GBCA-enhanced MRI, GBCA can be administered with exceedingly low risk of causing NSF when using macrocyclic agents and newer linear agents at routine doses.

Gadolinium-Based Contrast Agents in Kidney Disease: Comprehensive Review and Clinical Practice Guideline Issued by the Canadian Association of Radiologists

Use of gadolinium-based contrast agents (GBCAs) in renal impairment is controversial, with physician and patient apprehension in acute kidney injury (AKI), chronic kidney disease (CKD), and dialysis because of concerns regarding nephrogenic systemic fibrosis (NSF). The position that GBCAs are absolutely contraindicated in AKI, CKD stage 4 or 5 (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m²) and dialysis-dependent patients is outdated, and may limit access to clinically necessary contrast-enhanced MRI examinations. Following a comprehensive review of the literature and reported NSF cases to date, a committee of radiologists and nephrologists developed clinical practice guidelines to assist physicians in making decisions regarding GBCA administrations. In patients with mild-to-moderate CKD (eGFR ≥30 and <60 mL/min/1.73 m²), administration of standard doses of GBCA is safe and no additional precautions are necessary. In patients with AKI, with severe CKD (eGFR <30 mL/min/1.73 m²), or on dialysis, administration of GBCAs should be considered individually and alternative imaging modalities utilized whenever possible. If GBCAs are necessary, newer GBCAs may be administered with patient consent obtained by a physician (or their delegate), citing an exceedingly low risk (much less than 1%) of developing NSF. Standard GBCA dosing should be used; half or quarter dosing is not recommended and repeat injections should be avoided. Dialysis-dependent patients should receive dialysis; however, initiating dialysis or switching from peritoneal to hemodialysis to reduce the risk of NSF is unproven. Use of a macrocyclic ionic instead of macrocyclic nonionic GBCA or macrocyclic instead of newer linear GBCA to further prevent NSF is unproven. Gadopentetate dimeglumine, gadodiamide, and gadoversetamide remain absolutely contraindicated in patients with AKI, with stage 4 or 5 CKD, or on dialysis. The panel agreed that screening for renal disease is important but less critical when using macrocyclic and newer linear GBCAs. Monitoring for and reporting of potential cases of NSF in patients with AKI or CKD who have received GBCAs is recommended.

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.

Superior Abdominal 4D Flow MRI Data Consistency with Adjusted Preprocessing Workflow and Noncontrast Acquisitions

RATIONALE AND OBJECTIVES

To assess the impact of an alternative preprocessing workflow on noncontrast- and contrast-enhanced abdominal four-dimensional flow magnetic resonance imaging (4D flow MRI) data consistency.

MATERIALS AND METHODS

Twenty patients with cirrhosis and portal hypertension (5 women; 53 ± 10 years old) underwent 4D flow MRI at 3.0T before and after administration of 0.03 mmol/kg of gadofosveset trisodium with velocity sensitivities of 100 and 50 cm/s for arterial and venous flow quantifications, respectively. 4D flow MRI data were preprocessed using the conventional workflow (workflow 1), applying noise filters prior to eddy current correction, and an alternative workflow (workflow 2), first correcting for eddy currents and using noise filtering only if needed for anti-aliasing. Vessel segmentation quality was ranked by independent reviewers and compared via Wilcoxon signed-rank tests. Flow quantification and conservation of mass at two portal and one arterial branch points were compared via paired t tests.

RESULTS

Segmentation quality was significantly higher for workflow 2 (P < 0.05) with excellent interobserver agreement (κ = 0.92). Workflow 2 resulted in larger flow values (P < 0.05) with improved conservation of mass (7.3 ± 6.1% vs. 27.7 ± 25.0%, P < 0.001 [portal]; 10.7 ± 9.0% vs. 21.7 ± 21.6%, P = 0.02 [arterial]). Peak velocities and abdominal aortic flow were similar (P > 0.05). Noncontrast acquisitions yielded significantly smaller portal flow values (P < 0.05) with improved conservation of mass (5.8 ± 4.7% vs. 8.7 ± 6.9%, P = 0.05 [portal]; 6.2 ± 4.5% vs. 13.7 ± 10.2%, P = 0.03 [arterial]).

CONCLUSIONS

Superior abdominal 4D flow MRI data consistency was obtained by applying eddy current correction before any other data manipulation, using noise masking and velocity anti-aliasing cautiously, and using noncontrast acquisitions.

A Practical Guide to MR Imaging Safety: What Radiologists Need to Know

Magnetic resonance (MR) imaging can provide critical diagnostic and anatomic information while avoiding the use of ionizing radiation, but it has a unique set of safety risks associated with its reliance on large static and changing magnetic fields, high-powered radiofrequency coil systems, and exogenous contrast agents. It is crucial for radiologists to understand these risks and how to mitigate them to protect themselves, their colleagues, and their patients from avoidable harm and to comply with safety regulations at MR imaging sites. Basic knowledge of MR imaging physics and hardware is necessary for radiologists to understand the origin of safety regulations and to avoid common misconceptions that could compromise safety. Each of the components of the MR imaging unit can be a factor in injuries to patients and personnel. Safety risks include translational force and torque, projectile injury, excessive specific absorption rate, burns, peripheral neurostimulation, interactions with active implants and devices, and acoustic injury. Standards for MR imaging device safety terminology were first issued in 2005 and are required by the U.S. Food and Drug Administration, with devices labeled as "MR safe," "MR unsafe," or "MR conditional." MR imaging contrast agent safety is also discussed. Additional technical and safety policies relate to pediatric, unconscious, incapacitated, or pregnant patients and pregnant imaging personnel. Division of the MR imaging environment into four distinct, clearly labeled zones--with progressive restriction of entry and increased supervision for higher zones--is a mandatory and key aspect in avoidance of MR imaging-related accidents. All MR imaging facilities should have a documented plan to handle emergencies within zone IV, including cardiac arrest or code, magnet quench, and fires. Policies from the authors' own practice are provided for additional reference. Online supplemental material is available for this article.

Renal function and diffusion-weighted imaging: a new method to diagnose kidney failure before losing half function

AIM

To diagnose earlier kidney failure, we investigated renal functions with diffusion-weighted imaging (DWI).

METHODS

We evaluated the DWI of 62 patients with chronic kidney disease (CKD) and compared it with creatinine clearance provided by daily urine collection. The apparent diffusion coefficient (ADC) values were compared with the five stages of CKD.

RESULTS

For each stage of CKD, the ADC values were found to be significantly different (p < 0.01) and allowed the differentiation of stage 1 of the disease from the other stages.

CONCLUSION

Renal ADC values show a significant correlation with the clinical stages of CKD. DWI may detect renal failure prior to a rise in creatinine.

Intravenous Imaging Contrast Media Complications: The Basics That Every Clinician Needs to Know

Intravenous contrast is commonly used in noninvasive imaging procedures such as magnetic resonance imaging and computed tomography and can evaluate blood vessels and better characterize soft-tissue lesions. Although the incidence of adverse events after administration of contrast is low, it is important that clinicians and radiologists minimize risks and respond quickly and effectively when reactions occur. We will discuss a range of adverse events to iodinated and gadolinium-based contrast agents, including allergic-like reactions, nephrotoxicity, extravasation, and nephrogenic systemic fibrosis. We will review risk stratification for patients, as well as premedication and treatment of adverse events.

Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction

OBJECTIVE

The incidence and significance of complications related to intravascular contrast material administration have become increasingly controversial. This review will highlight current thinking regarding the imaging of patients with renal impairment and those at risk for an allergiclike contrast reaction.

CONCLUSION

The risk of contrast-induced acute kidney injury remains uncertain for patients with an estimated glomerular filtration rate (GFR) less than 45 mL/min/1.73 m(2), but if there is a risk, it is greatest in those with estimated GFR less than 30 mL/min/1.73 m(2). In this population, low-risk gadolinium-based contrast agents appear to have a large safety margin. Corticosteroid prophylaxis remains the standard of care in the United States for patients identified to be at high risk of a contrast reaction, but it has an incomplete mitigating effect on contrast reaction rates and the number needed to treat is large.

Failure of gastroenterologists to apply intestinal ultrasound in inflammatory bowel disease in the Asia-Pacific: a need for action

Intestinal ultrasound (IUS) is a cheap, noninvasive, risk-free procedure that is significantly underutilized in the diagnosis and management of patients with inflammatory bowel disease (IBD) in the Asia-Pacific region. More cost-effective methods of monitoring disease activity are required in light of the increasing global burden of IBD (especially in Asia), the advent of personalized medicine, and the rising cost of healthcare. IUS is a prime example of a technique that meets these needs. Its common clinical applications include assessing the activity and complications of IBD. In continental Europe, countries such as Germany and Italy use this imaging tool as the standard of care and have integrated it into management protocols. There are formal training programs in these countries to train gastroenterologists in IUS, and it is used in an outpatient setting during patient consultations. Barriers to its use in the Asia-Pacific region include lack of experience and research data, and there are few established centers with active training programs. These concerns can be addressed by investing more in IUS service provision and by increasing allocation of resources toward local research and training. Increased uptake of IUS will ultimately benefit patients with IBD.

Gadolinium and nephrogenic systemic fibrosis: an update

Nephrogenic systemic fibrosis (NSF) is a multisystem disease seen exclusively in patients with renal impairment. It can be severely debilitating and sometimes fatal. There is a strong association with gadolinium-based contrast agents used in magnetic resonance imaging (MRI). Risk factors include renal impairment and proinflammatory conditions, e.g. major surgery and vascular events. Although there is no single effective treatment for NSF, the most successful outcomes are seen following restoration of renal function, either following recovery from acute kidney injury or following renal transplantation. There have been ten biopsy-proved pediatric cases of NSF, with no convincing evidence that children have a significantly altered risk compared with the adult population. After implementation of guidelines restricting the use of gadolinium-based contrast agents in at-risk patients, there has been a sharp reduction in new cases and no new reports in children. Continued vigilance is recommended: screening for renal impairment, use of more stable gadolinium chelates, consideration of non-contrast-enhanced MRI or alternative imaging modalities where appropriate.

Emerging applications for ferumoxytol as a contrast agent in MRI

Ferumoxytol is an ultrasmall superparamagnetic iron oxide (USPIO) agent initially approved by the Food and Drug Administration (FDA) as an iron replacement therapy for patients with anemia due to chronic renal failure. Recently, ferumoxytol has been investigated extensively as an intravenous contrast agent in magnetic resonance imaging (MRI). Since it causes regional T1 and T2 * shortening in vivo, conventional pulse sequences can be used following ferumoxytol administration to demonstrate signal enhancement or loss. Ferumoxytol can be administered as a rapid bolus and has a long intravascular half-life on the order of 14-15 hours, making it a potentially useful agent for vascular and perfusion-weighted MRI. In comparison to other USPIOs, ferumoxytol is less limited by allergic and idiosyncratic reactions. Furthermore, since ferumoxytol is an iron-based agent with no potential for causing nephrogenic systemic fibrosis, it may be useful as an alternative to gadolinium-based contrast agents in patients with compromised renal function. Ferumoxytol is ultimately taken up by macrophages/the reticuloendothelial system in the liver, spleen, and lymph nodes, and this uptake mechanism is being explored as a novel imaging technique for vascular lesions, tumors, and lymph nodes. This article reviews the properties of ferumoxytol relevant to MRI as well as many of the uses for the agent currently under investigation.

Current status of nephrogenic systemic fibrosis

Nephrogenic systemic fibrosis (NSF) occurs in patients with advanced chronic kidney disease (CKD) or acute renal failure, most commonly following exposure to gadolinium-based contrast agents (GBCAs). NSF can be debilitating and associated with increased mortality. The putative association of NSF with GBCAs prompted the development of guidelines to limit the use of these contrast agents in at-risk patients. Indeed, the incidence of NSF has decreased dramatically following application of these guidelines, which appears to be the only effective means of decreasing NSF incidence. Thus, increasing clinician awareness of these updated guidelines is important. The present review introduces and compares updated guidelines for GBCA use and discusses the latest advances in the understanding of the pathogenic mechanisms and treatment of NSF.

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.

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.

Precision of pulmonary vein diameter measurements assessed by CE-MRA and steady-state-free precession imaging

OBJECTIVE

Pulmonary vein (PV) diameter assessment is important for planning and follow-up of PV ablation in atrial fibrillation. Therefore, the aim of our study was to evaluate inter- and intraobserver reliability of PV diameter measurements by contrast-enhanced magnetic resonance angiography (CE-MRA) and ECG-gated 2D multislice unenhanced steady-state-free precession sequences (multislice SSFP).

METHODS

Sixty PV diameters in 17 consecutive patients were measured in transverse and coronal orientation with CE-MRA and multislice SSFP by two observers. Statistics to evaluate inter- and intraobserver reliability included Bland-Altman analysis and F-test.

RESULTS

Intraobserver limits of agreement (LAG) ranged between ±0.50 cm (transverse) and ±0.86 cm (coronal) for CE-MRA versus ±0.40 cm (transverse) and ±0.67 cm (coronal) for multislice SSFP. Interobserver agreement showed LAG ranging between ±0.59 cm (transverse) and ±0.83 cm (coronal) for CE-MRA versus ±0.34 cm (transverse) and ±0.75 cm (coronal) for multislice SSFP. Intra- and interobserver variances did not reveal significant differences between CE-MRA and multislice SSFP in any orientation (all p-values >0.05).

CONCLUSION

Multislice SSFP and CE-MRA enable comparable precision of PV diameter measurements. However, both methods reveal a wide range of intra- and interobserver agreement, which has to be thoroughly considered in clinical use.

KEY POINTS

• Unenhanced magnetic resonance imaging can now provide measurement of pulmonary vein diameters • Steady-state-free precession offers a new method of performing unenhanced MR imaging • Both unenhanced and enhanced MRI measurements show wide intra- and interobserver variation • PV diameter measurements assessed by MRI have to be interpreted with care • Nevertheless, unenhanced MRI might replace some CT examinations for pulmonary vein demonstration.

CMR imaging assessing viability in patients with chronic ventricular dysfunction due to coronary artery disease: a meta-analysis of prospective trials

OBJECTIVES

The purpose of this study was to compare the diagnostic accuracy of cardiac magnetic resonance (CMR) assessing myocardial viability in patients with chronic left ventricular (LV) dysfunction due to coronary artery disease using 3 techniques: 1) end-diastolic wall thickness (EDWT); 2) low-dose dobutamine (LDD); and 3) contrast delayed enhancement (DE).

BACKGROUND

CMR has been proposed to assess myocardial viability over the past decade. However, the best CMR strategy to evaluate patients being contemplated for revascularization has not yet been determined. Some centers advocate DE CMR due to its high sensitivity to identify scar, whereas others favor the use of LDD CMR for its ability to identify contractile reserve.

METHODS

A systematic review of MEDLINE, Cochrane, and Embase for all the prospective trials assessing myocardial viability in subjects with chronic LV dysfunction using CMR was performed using a standard approach for meta-analysis for diagnostic tests and a bivariate analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

A total of 24 studies of CMR evaluating myocardial viability with 698 patients fulfilled the inclusion criteria. Eleven studies used DE, 9 studies used LDD, and 4 studies used EDWT. Our meta-analysis indicates that among CMR methods, DE CMR provides the highest sensitivity as well as the highest NPV (95% and 90%, respectively) for predicting improved segmental LV contractile function after revascularization, followed by EDWT CMR, whereas LDD CMR demonstrated the lowest sensitivity/NPV among all modalities. On the other hand, LDD CMR offered the highest specificity and PPV (91% and 93%, respectively), followed by DE CMR, whereas EDWT showed the lowest of these parameters.

CONCLUSIONS

DE CMR provides the highest sensitivity and NPV, whereas LDD CMR provides the best specificity and PPV. In light of these findings, integrating these 2 methods should provide increased accuracy in evaluating patients with chronic LV dysfunction being considered for revascularization.

Nephrogenic systemic fibrosis: review of 370 biopsy-confirmed cases

Discovery of an association between gadolinium-based contrast agents (GBCAs) and nephrogenic systemic fibrosis (NSF) has led to less use of GBCA-enhanced magnetic resonance imaging in dialysis patients and patients with severe renal failure at risk of NSF, and the virtual elimination of new cases of NSF. But shifting patients with renal failure to alternative imaging methods may subject patients to other risks (e.g., ionizing radiation or iodinated contrast). This review paper examines 370 NSF cases reported in 98 articles to analyze NSF risk factors. Eliminating multiple risk factors by limiting GBCA dose to a maximum of 0.1 mmol/kg, dialyzing patients undergoing dialysis quickly following GBCA administration, delaying GBCA in acute renal failure until after renal function returns or dialysis is initiated, and avoiding nonionic linear GBCA in patients with renal failure especially when there are proinflammatory conditions may substantially reduce the risk of NSF.

Is administration of gadolinium-based contrast media to pregnant women and small children justified?

The use of gadolinium-based contrast media in pregnant or lactating women has been discouraged at many radiology departments due to the lack of knowledge of the risks for the fetus and the unwillingness to expose neonates to unnecessary drugs. In the present review the current literature and present guidelines regarding the use of gadolinium-based contrast media have been reviewed to validate the justification for their administration to pregnant or lactating women and small children.

Stimulation of fibroblast proliferation by insoluble gadolinium salts

The purpose of this study was to assess insoluble salts containing gadolinium (Gd(3+)) for effects on human dermal fibroblasts. Responses to insoluble Gd(3+) salts were compared to responses seen with Gd(3+) solubilized with organic chelators, as in the Gd(3+)-based contrast agents (GBCAs) used for magnetic resonance imaging. Insoluble particles of either Gd(3+) phosphate or Gd(3+) carbonate rapidly attached to the fibroblast cell surface and stimulated proliferation. Growth was observed at Gd(3+) concentrations between 12.5 and 125 μM, with toxicity at higher concentrations. Such a narrow window did not characterize GBCA stimulation. Proliferation induced by insoluble Gd(3+) salts was inhibited in the presence of antagonists of mitogen-activated protein kinase and phosphatidylinositol 3-kinase signaling pathways (similar to chelated Gd(3+)) but was not blocked by an antibody to the platelet-derived growth factor receptor (different from chelated Gd(3+)). Finally, high concentrations of the insoluble Gd(3+) salts failed to prevent fibroblast lysis under low-Ca(2+) conditions, while similar concentrations of chelated Gd(3+) were effective. In conclusion, while insoluble Gd(3+) salts are capable of stimulating fibroblast proliferation, one should be cautious in assuming that GBCA dechelation must occur in vivo to produce the profibrotic changes seen in association with GBCA exposure in the subset of renal failure patients that develop nephrogenic systemic fibrosis.

Fibroblast response to lanthanoid metal ion stimulation: potential contribution to fibrotic tissue injury

The purpose of this study was to compare each of the 14 naturally occurring lanthanoid metal ions for ability to stimulate pro-fibrotic responses in human dermal fibroblasts. When fibroblasts were exposed to individual lanthanoids over the concentration range of 1-100 μM, increased proliferation was observed with each of the agents as compared with control cells that were already proliferating rapidly in a growth factor-enriched culture medium. Dose-response differences were observed among the individual metal ions. Matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase-1 levels were also increased in response to lanthanoid exposure but type I procollagen production was not. A dose-response relationship between induction of proliferation and increased MMP-1 was observed. Non-lanthanoid transition metal ions (aluminum, copper, cobalt, iron, magnesium, manganese, nickel, and zinc) were examined in the same assays; there was little stimulation with any of these metals. When epidermal keratinocytes were examined in place of dermal fibroblasts, there was no growth stimulation with any of the lanthanoids. Several of the lanthanoid metals inhibited keratinocyte proliferation at higher concentrations (50-100 μM).

Patterns of intravenous contrast material use and corticosteroid premedication in children--a survey of Society of Chairs of Radiology in Children's Hospitals (SCORCH) member institutions

BACKGROUND

There are few data available concerning the use of intravenous contrast materials in children.

OBJECTIVE

To assess patterns of intravenous iodinated/gadolinium-based contrast material (ICM/GBCM) use in children.

MATERIALS AND METHODS

Society of Chairs of Radiology in Children's Hospitals (SCORCH) members were invited to complete a Web-based survey regarding intravenous contrast material use at their institutions.

RESULTS

Sixty-six percent (42/64) of SCORCH member institutions responded, 76% of which are academic hospitals. Ioversol and gadopentetate dimeglumine are the most commonly used ICMs and GBCMs (52% and 81%, respectively). Premedication policies to mitigate risk of allergic-like contrast reactions are more common for ICMs than GBCMs (71% vs. 32%). For both ICMs and GBCMs, most institutions premedicate or avoid contrast material in the setting of a prior allergic-like contrast reaction of any severity. Policies regarding ICM and GBCM use in children with renal insufficiency are in place at 74% and 88% of institutions, respectively, but are variable.

CONCLUSION

Policies concerning premedication for prevention of allergic-like contrast agent reactions and administration of contrast materials in children with renal insufficiency are variable and not consistently present at all pediatric institutions. This highlights the need for standardization of practice patterns and pediatric-specific research on these topics.

Fibroblast response to gadolinium: role for platelet-derived growth factor receptor

OBJECTIVE

The purpose of this study was to assess the effects of gadolinium (Gd3+), provided as gadolinium chloride, on fibroblast function.

MATERIALS AND METHODS

Human dermal fibroblasts in monolayer culture and intact skin in organ culture were exposed to the lanthanide metal (1-20 μM).

RESULTS

Increased proliferation was observed, in association with upregulation of matrix metalloproteinase-1 and tissue inhibitor of metalloproteinases-1, without an apparent increase in production of type I procollagen. A platelet-derived growth factor (PDGF) receptor-blocking antibody inhibited fibroblast proliferation in response to Gd3+ as did inhibitors of signaling pathways--that is, mitogen-activated protein kinase and phosphatidylinositol-3 kinase pathways--that are activated by PDGF.

CONCLUSION

The responses to gadolinium chloride are similar to responses previously seen with chelated Gd3+ in clinically used magnetic resonance imaging contrast agents. Fibroblast responses appear to reflect Gd3+-induced PDGF receptor activation and downstream signaling. Increased dermal fibroblast proliferation in conjunction with effects on matrix metalloproteinase-1 and tissue inhibitor of metalloproteinases-1 could contribute to the fibroplastic/fibrotic changes seen in the lesional skin of individuals with nephrogenic systemic fibrosis.

The use of gadolinium in patients with contrast allergy or renal failure requiring coronary angiography, coronary intervention, or vascular procedure

Coronary artery angiography remains an important procedure for the assessment of coronary arteries. It requires injection of iodinated contrast for the opacification of coronary arteries. Severe allergy to iodine contrast and renal insufficiency are two main problems with iodine-based contrast media. Gadolinium (Gd) has different chemical structure with no cross reactivity with iodine-based contrast media in patients with iodine allergy. The use of Gd is commonly used in contrast-enhanced magnetic resonance imaging for image enhancement, making it a potential alternative in patients in whom iodine is contraindicated. The aim of this manuscript is to review the available literature on the use of Gd in patients with contraindication to iodine contrast due to allergy or in patients with severe renal failure requiring coronary or vascular procedures.

Nephrogenic systemic fibrosis: review of 408 biopsy-confirmed cases

Nephrogenic systemic fibrosis (NSF) has now been virtually eliminated by the discovery of its association with gadolinium-based contrast agents (GBCAs) and the consequent reduced use of GBCA-enhanced magnetic resonance imaging (MRI) in severe renal failure patients. This review of 408 biopsy-confirmed cases shows how to minimize NSF risk when performing GBCA-enhanced MRI or magnetic resonance angiography. The absence of any NSF cases in patients less than 8 years old or greater than 87 years old suggests that infants and elderly patients are already protected. Limiting GBCA dose to a maximum of 0.1 mMol/kg, dialyzing dialysis patients quickly following GBCA administration, delaying administration of GBCA in acute renal failure until after renal function returns or dialysis is initiated, and avoiding nonionic linear GBCA in renal failure patients, especially when there are pro-inflammatory conditions, appear to have reduced NSF risk to the point where safe GBCA-enhanced MRI is possible in most patients.

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.

Imaging patients with kidney disease: how do we approach contrast-related toxicity?

The approach to imaging patients with kidney disease with iodinated radiocontrast and gadolinium-based contrast has changed dramatically in recent times. The complications of these contrast agents, radiocontrast nephropathy and nephrogenic systemic fibrosis, respectively, underlie the changes in the imaging practice used in these patients. Rather than to completely avoid the use of these contrast agents, one must remain judicious in the choice of imaging modality in this group of patients. A prudent approach would be to (1) identify patients at high risk to develop contrast-related complications, (2) use noncontrast-based imaging techniques in these patients, as long as they are suitably diagnostic and safe and (3) if the risk:benefit ratio of the imaging information favors a contrast-based study, then appropriate prophylactic steps and use of contrast agents with the lowest risk of complication should be used after obtaining informed consent. This will allow one to maximize the diagnostic efficiency while also limiting the adverse effects.

The use of gadolinium for arterial interventions

BACKGROUND

Gadolinium (Gd) has been traditionally used as a non-nephrotoxic alternative to iodinated contrast for digital subtraction angiography (DSA) in patients with chronic renal insufficiency. However, its use has been questioned on the basis of reports of nephrotoxicity and its recent association with nephrogenic systemic fibrosis (NSF), a potentially lethal complication. Recently available data are conflicting with respect to the true safety profile of intra-arterial Gd. The purpose of this study was to examine the risk of contrast nephropathy and NSF after Gd exposure in a large population of azotemic patients undergoing DSA.

METHODS

A comprehensive database encompassing data on all patients who underwent DSA between June 2003 and December 2007 at the New York Presbyterian Hospital was retrospectively reviewed. Patients receiving Gd either alone or in combination with iodinated contrast during DSA were identified and further analyzed. Acute renal failure (ARF) was defined as an elevation in serum creatinine (Cr) by >0.5 mg/dL within 48 hours of exposure. Clinical follow-up was conducted through chart reviewing as well as telephonic interviews with patients and their primary care physicians.

RESULTS

A total of 153 patients underwent 179 exposures to Gd either alone (33%) or in combination (67%) with iodinated contrast. Mean follow-up duration was 27.1 months. The mean Cr level was 1.94 ± 0.78 mg/dL and 1.96 ± 1.1 mg/dL before and after DSA, respectively. There were 20 (11.2%) instances of ARF. The mean Cr level before DSA was higher in patients who developed ARF versus those in the non-ARF group (2.7 ± 1.1 mg/dL vs. 1.9 ± 0.7 mg/dL, p = 0.004). In the ARF group, 12 patients had a return to baseline renal function, four experienced irreversible renal deterioration, and four needed dialysis (4.5% incidence of irreversible renal failure). There were 19 deaths at the time of this study (12.4%). The highest risk for the development of ARF after Gd exposure occurred in patients with Cr levels of >3.0 mg/dL before DSA and in those receiving >0.4 mmol/kg of Gd. For patients who received iodinated contrast in combination with Gd, there was a trend toward a higher risk for developing ARF as compared with those receiving only Gd. Finally, there were no instances of NSF identified in any of the patients who received intra-arterial Gd.

CONCLUSIONS

Although Gd has the potential to cause kidney injury similar to iodinated contrast, the risk of irreversible renal failure and the requirement for dialysis is low. Life- or limb-threatening interventions should not be avoided in this patient cohort because of preexisting elevations in Cr. These data should help guide the use of Gd in patients with chronic renal insufficiency.

Emerging MRI methods in rheumatoid arthritis

New MRI techniques have been developed to assess not only the static anatomy of synovial hyperplasia, bone changes and cartilage degradation in patients with rheumatoid arthritis (RA), but also the activity of the physiological events that cause these changes. This enables an estimation of the rate of change in the synovium, bone and cartilage as a result of disease activity or in response to therapy. Typical MRI signs of RA in the pre-erosive phase include synovitis, bone marrow edema and subchondral cyst formation. Synovitis can be assessed by T2-weighted imaging, dynamic contrast-enhanced MRI or diffusion tensor imaging. Bone marrow edema can be detected on fluid-sensitive sequences such as short-tau inversion recovery or T2-weighted fast-spin echo sequences. Detection of small bone erosions in the early erosive phase using T1-weighted MRI has sensitivity comparable to CT. Numerous MRI techniques have been developed for quantitative assessment of potentially pathologic changes in cartilage composition that occur before frank morphologic changes. In this Review, we summarize the advances and new directions in the field of MRI, with an emphasis on their current state of development and application in RA.

Responses of human skin in organ culture and human skin fibroblasts to a gadolinium-based MRI contrast agent: comparison of skin from patients with end-stage renal disease and skin from healthy subjects

OBJECTIVE

Nephrogenic systemic fibrosis is a clinical syndrome occurring in a small subset of patients with end-stage renal disease (ESRD). Exposure to certain of the gadolinium-based contrast agents during magnetic resonance imaging appears to be a trigger. The pathogenesis of the disease is largely unknown. The present study addresses potential pathophysiologic mechanisms.

MATERIALS AND METHODS

We have compared responses in organ-cultured skin and skin fibroblasts from individuals with ESRD to responses of healthy control subjects to Omniscan treatment.

RESULTS

Treatment of skin from ESRD patients with Omniscan stimulated production of matrix metalloproteinase-1 and tissue inhibitor of metalloproteinases-1, but not type I procollagen. The same treatment also stimulated an increase in hyaluronan production. Similar results were seen with skin from normal controls but basal levels were higher in ESRD patients. Fibroblasts in monolayer culture gave the same responses, but there were no differences based on whether the cells were isolated from the skin of healthy subjects or those with ESRD.

CONCLUSION

These data indicate that Omniscan exposure alters an enzyme/inhibitor system responsible for regulating collagen turnover in the skin and directly stimulates hyaluronan production. The higher basal levels of type I procollagen, matrix metalloproteinase-1, tissue inhibitor of metalloproteinases-1, and hyaluronan in the skin from ESRD patients could contribute to the sensitivity of this patient population to fibrotic changes, which might be induced by exposure to some of the gadolinium-based contrast agents.

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.