Revisiting the risks of MRI with Gadolinium based contrast agents—review of literature and guidelines

Insights into Imaging, Aug 2015

Aurang Z. Khawaja, Deirdre B. Cassidy, Julien Al Shakarchi, Damian G. McGrogan, Nicholas G. Inston, Robert G. Jones

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://link.springer.com/content/pdf/10.1007%2Fs13244-015-0420-2.pdf

Revisiting the risks of MRI with Gadolinium based contrast agents—review of literature and guidelines

Revisiting the risks of MRI with Gadolinium based contrast agents-review of literature and guidelines Aurang Z. Khawaja 0 1 2 3 Deirdre B. Cassidy 0 1 2 3 Julien Al Shakarchi 0 1 2 3 Damian G. McGrogan 0 1 2 3 Nicholas G. Inston 0 1 2 3 Robert G. Jones 0 1 2 3 0 Present address: Division of Diabetes and Cardiovascular Medicine, University of Dundee , Dundee DD19SY , UK 1 Department of Renal Transplant Surgery & Vascular Access, Queen Elizabeth Hospital, University Hospitals Birmingham , Mindelsohn Way, Birmingham B15 2GW, West Midlands , UK 2 Aurang Z. Khawaja 3 Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham , Mindelsohn Way, Birmingham B15 2GW, West Midlands , UK Gadolinium based contrast agents (GBCA) have been linked to the occurrence of nephrogenic systemic fibrosis (NSF) in renal impaired patients. The exact interaction between the various different available formulations and occurrence of NSF is not completely understood, but has been postulated. This association has triggered public health advisory bodies to issue guidelines and best practice recommendations on its use. As a result, the reported incidence of NSF, as well as the published use of GBCA-enhanced magnetic resonance imaging in renal impairment, has seen a decline. Understanding of the events that led to these recommendations can increase clinical awareness and the implications of their usage. We present a review of published literature and a brief overview of practice recommendations, guidelines and manuals on contrast safety to aide everyday imaging practice. Teaching Points Low risk gadolinium based contrast agents should be the choice in renal insufficiency. Higher doses have been linked to NSF development. Doses should be as low as possible. Clear documentation of date, dose and type of formulation used should be noted. Magnetic resonance imaging; Contrast media; Gadolinium/adverse effects; Nephrogenic fibrosing dermopathy; Renal insufficiency - Gadolinium-based contrast agents (GBCA) have been linked to the occurrence of nephrogenic systemic fibrosis (NSF) in renal impaired patients. The majority of studies that report on their use in the renal impaired population were published prior to the publications that prompted the alert on NSF [1–3]. This association has triggered public health advisory bodies to issue guidelines and best practice recommendations on its use in renal insufficiency. Since then, this has all but halted the rapid progression and uptake of contrast-enhanced magnetic resonance imaging (MRI) in this population that was seen in the early to mid 2000s. Understanding of the events that led to these recommendations can increase clinical awareness and the implications of the use of GBCAs in daily imaging practice. We conducted an electronic database search [PubMed/ Medline, EMBASE] to collate the evidence in published literature on the occurance of NSF in the renal impaired. We also carried out a forward citation and bibliographic search of identified studies. Published studies were reviewed for reported pathophysiological and clinical manifestations, proposed diagnostic pathway, treatments options and reported incidence. We also reviewed practice recommendations, guidelines and published manuals on contrast safety. Background and incidence In the year 2000, 15 patients with chronic kidney disease were identified presenting with scleromyxoedema-like cutaneous manifestations yet having significant clinical and histo-pathological differences; the term nephrogenic fibrosing dermopathy was initially proposed. These clinical findings are now recognized as characteristic of NSF [4]. Following this, case reports of similar findings and also significant systemic involvement found on autopsy were reported [5, 6]. Patients with end-stage renal disease were reported to develop symptoms as early as two to four weeks after exposure to GBCAs for MRI [1]. Exact pathogenesis remains unclear; however, postulation of likely early dermal manifestation of this gadolinium toxicity is proposed [7]. A strong association is observed in the presence of both acute renal impairment and chronic dialysis dependent renal insufficiency and other influencing co-factors that may play a role, such as a background inflammatory process [8, 9]. As the evidence in published literature increased, the United States Food and Drug Administration (FDA), followed by the European Medicines Agency (EMA) issued an alert on the use of GBCAs in patients with renal insufficiency [10, 11]. Since then, public health and practice guideline bodies have published recommendations on its use [12–14]. A 2008 multicentre retrospective review reported 15 cases of NSF in a total population of 83,121 (0.02 % incidence), all of whom received at least one administration of a GBCA. All 15 of these cases of NSF were found in patients who had received a higher than standard dose, increasing the incidence to 0.17 % (15 of 8997 patients). A hig (...truncated)


This is a preview of a remote PDF: https://link.springer.com/content/pdf/10.1007%2Fs13244-015-0420-2.pdf

Aurang Z. Khawaja, Deirdre B. Cassidy, Julien Al Shakarchi, Damian G. McGrogan, Nicholas G. Inston, Robert G. Jones. Revisiting the risks of MRI with Gadolinium based contrast agents—review of literature and guidelines, Insights into Imaging, 2015, pp. 553-558, Volume 6, Issue 5, DOI: 10.1007/s13244-015-0420-2