Reports of a previously rare condition entitled nephrogenic systemic fibrosis (NSF) have recently emerged in patients with advanced kidney disease. The risk of developing NSF is increased with larger doses of gadolinium (or multiple exposures) underlying pro-inflammatory states (in particular vascular endothelial dysfunction) and per-haps some currently unrecognized cofactors.
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gadolinium contrast toxicity in patients with kidney disease.pdf
Reports of a previously rare condition entitled nephrogenic systemic fibrosis (NSF) have recently emerged in patients with advanced kidney disease. The risk of developing NSF is increased with larger doses of gadolinium (or multiple exposures) underlying pro-inflammatory states (in particular vascular endothelial dysfunction) and per-haps some currently unrecognized cofactors.
Reports of a previously rare condition entitled nephrogenic systemic fibrosis (NSF) have recently emerged in patients with advanced kidney disease. The risk of developing NSF is increased with larger doses of gadolinium (or multiple exposures) underlying pro-inflammatory states (in particular vascular endothelial dysfunction) and per-haps some currently unrecognized cofactors.
Gadolinium-Contrast Toxicity in Patients with Kidney Disease: Nephro- toxicity and Nephrogenic Systemic Fibrosis Mark A. Perazella *
Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520- 8029, USA Abstract: Gadolinium is widely employed as a contrast agent for magnetic resonance imaging (MRI) and has generally been considered to be safe. As with iodinated radiocontrast, concern for contrast-induced nephropathy existed with gado- linium-contrast as it possessed many similar qualities (hyperosmolar, renal excretion via glomerular filtration). Early stud- ies in low risk patients suggested a benign renal profile, however, recent studies raise the possibility of nephrotoxicity. In addition, reports of a previously rare condition entitled nephrogenic systemic fibrosis (NSF) have recently emerged in pa- tients with advanced kidney disease and have been linked to exposure to gadolinium-contrast. Nephrogenic systemic fi- brosis is a debilitating disorder in which progressive and severe fibrosis of the skin and other systemic organs that leads to significant disability and is associated with increased mortality. Initially reported most commonly in end stage renal dis- ease (ESRD) patients receiving dialysis, it is also described in patients with severe acute kidney injury (AKI) and ad- vanced chronic kidney disease (stages 4 and 5) not requiring dialysis. In addition to underlying kidney disease, the risk of developing NSF is increased with larger doses of gadolinium (or multiple exposures), exposure to specific gadolinium chelates (non-ionic, linear), underlying pro-inflammatory states (in particular vascular endothelial dysfunction), and per- haps some currently unrecognized cofactors. No clearly effective therapies exist for NSF, although recovery from AKI and establishment of normal kidney function with renal transplantation appear to reverse or stabilize the disease in some cases. Avoidance of gadolinium exposure appears to be the best approach for patients who maintain risk factors. When gadolinium exposure occurs, aggressive hemodialysis following exposure may be useful as gadolinium is efficiently re- moved by this extracorporeal technique. Peritoneal dialysis clearance of gadolinium is poor, but aggressive peritoneal di- alysis prescriptions have not been studied for gadolinium removal. Keywords: Gadolinium, nephrotoxicity, nephrogenic systemic fibrosis, chronic kidney disease, end stage kidney disease, mag- netic resonance imaging, radiocontrast-induced nephropathy. INTRODUCTION Magnetic resonance imaging (MRI) is a commonly used imaging technique for numerous organ systems including the central nervous system, hepatic structures, and the vascula- ture. MR images are significantly enhanced by use of gado- linium-based contrast agents. They often provide images that are superior to those obtained with computed tomography (CT) scan and have the advantage of avoiding iodinated ra- diocontrast agents which have more overall toxicity (allergic and non-allergic reactions). Thus, MRI has been considered a relatively safe alternative to CT scan in situations where a contrast agent is thought required for enhanced image at- tainment. However, two complications of gadolinium- contrast (Gd-contrast) have come to light in recent times. First, concern for contrast-induced nephropathy from Gd- contrast has been raised as several studies over the past dec- ade demonstrate nephrotoxicity following Gd-contrast ad- ministration in patients with underlying kidney disease and other co-morbidities. Gd-contrast agents are hyperosmolar and completely eliminated from the body via renal excretion (glomerular filtration). Second, and even more concerning is
*Address correspondence to this author at the Section of Nephrology, De- partment of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8029, USA; Tel: 203-785-4184; Fax: 203-785-7068; E-mail: mark.perazella@yale.edu the recognition that Gd-contrast exposure in patients with significant kidney disease may trigger the development of nephrogenic systemic fibrosis (NSF), a debilitating and often devastating systemic fibrosing condition that is most clini- cally prominent in the skin [1-12]. This review will focus on these clinically important complications of Gd-contrast. GADOLINIUM CONTRAST: GENERAL PROPER- TIES AND PHARMACOKINETICS Gadolinium (Gd) is a metal of the lanthanide series (atomic number 64 on element chart) which has paramag- netic properties that disturb relaxation of water protons and by shortening relaxation times, increases signal intensity. This quality makes it extremely useful as an intravenous and/or intra-arterial contrast agent for MRI/MRA to enhance images of various body organs and tissues. As it is a metal, it must be in an ionic form to be soluble in water and allow it to be injected as a contrast agent that distributes throughout the body. However, gadolinium in this free ionic form (Gd 3+ ) is highly toxic to humans (and animals). It precipitates in several tissues including the liver, lymph nodes, and bones. Gd 3+ obstructs passage of calcium through ion channels of muscle cells and nerve tissue cells thereby reducing neuro- muscular transmission, and interferes with intracellular en- zymes and cell membranes. In order to avoid these toxic ef- fects, Gd 3+ must be sequestered by non-toxic substances [13]. This is achieved by binding Gd 3+ to another agent, 68 Current Drug Safety, 2008, Vol. 3, No. 1 Mark A. Perazella which is known generically as a chelate. Chelates are large organic molecules that form a stable complex with Gd 3+ , do not readily dissociate in vivo, and make the ion biochemi- cally inert [13,14]. The properties of the various Gd- chelates allow classification of Gd-contrast into four main categories based on their biochemical structure (linear versus macrocyclic) and their charge (ionic versus non-ionic). Mac- rocyclic chelates bind Gd 3+ more tightly than linear chelates, tend to be more stable both in vitro and in vivo, and possess lower dissociation rates [15]. Simply stated, macrocyclic chelates stick more tightly to Gd 3+ than do linear chelates; this has implications for possible toxicity. This aspect of chelate characteristics is important to prevent liberation of free Gd 3+ from its chelate, a process known as transmetala- tion. This phenomenon entails release of free Gd 3+ from its chelate ligand, which then binds with another endogenous metal such as zinc or copper, allowing free Gd 3+ to bind an endogenous ligand such as phosphorus. The commonly em- ployed Gd-contrasts approved by the Food and Administra- tion Drug (FDA) and their characteristics are noted in Table 1. The recommended dose of a Gd-contrast agent for a non- vascular MR study is 0.1 mmol/kg. When imaging of vascu- lar structures (MRA) is required, higher doses of Gd-contrast (0.3-0.4 mmol/kg) are often utilized. Until recently, Gd- contrast agents were FDA approved only for MRI studies at the 0.1 mmol/kg dose. Gadoteridol (macrocyclic chelate) is the only MR chelate approved at the higher 0.3 mmol/kg dose. Most MRA studies are often performed using Gd- contrasts at dose levels that are considered off-label. Following intravenous injection, Gd-contrasts are rapidly distributed into the extracellular space, quickly equilibrating between the plasma and interstitial compartments. The ma- jority are restricted to the extracellular space and have lim- ited protein binding. As a result of their exclusion from the intracellular compartment, Gd-contrasts have small volumes of distribution (Vd), approximately 0.26-0.28 L/kg body weight. They do not undergo biotransformation and are eliminated unchanged by the kidneys via glomerular filtra- tion without any contribution from tubular secretion. Renal clearance of Gd-contrasts ranges from 1.1 to 1.6 ml/min/kg in individuals with normal renal function (approximating the creatinine clearance). The Gd-contrasts maintain a mean terminal half-life (T 1/2 ) of approximately 1.6 hours. Over 95% of an injected dose is eliminated within 24 hours with less than 3% being eliminated in the feces [13,14,16]. The Vd for intravenous Gd-contrasts (gadobenate dimeglumine studied) is similar for patients with moderate (creatinine clearance [CrCl], 31-60 ml/min; n=15) and severe (CrCl, 15- 30 ml/min; n=17) kidney disease when compared with healthy subjects. However, the mean terminal T 1/2 is longer in moderate (5.6 hours) and severe (9.2 hours) kidney dis- ease than in healthy subjects (1.6 hours). Mean blood and renal clearance are both much lower in moderate (56 ml/min; 47 ml/min) and severe (31 ml/min; 22 ml/min) kidney dis- ease than in normal subjects (183 ml/min; 118 ml/min). Comparable pharmacokinetics of Gd-contrasts in patients with underlying kidney disease have been reported in other studies [17,18]. Thus, it is predictable that tissue gadolinium exposure is prolonged in the setting of decreased kidney function. The relatively small molecular weight (500 Da), small Vd (0.28 L/kg), and negligible protein binding charac- teristics of Gd-contrasts make them ideal for removal with an extracorporeal therapy such as hemodialysis. In one study, the T 1/2 of Gd-contrasts of non-dialyzed CKD stage 5 (CrCl =2-10 ml/min) patients was quite prolonged at 34.3 hours but decreased significantly to 2.6 hours following hemo- dialysis [19]. In another study the average Gd-contrast elimi- nation from serum using hemodialysis was 73.8% with one treatment, 92.4% with 2 treatments and 98.9% after the 3 rd
treatment [20,21]. Peritoneal dialysis on the other hand was an ineffective method of Gd-contrast removal (T 1/2 of 52.7 hours) [19]. This study suffers by the use of what is now considered an inadequate peritoneal dialysis prescription (2.0 liter volumes x 4 exchanges over a 24 hour period). GADOLINIUM-CONTRAST AND NEPHROTOXIC- ITY Iodinated radiocontrast-media induced nephrotoxicity is well described and common. However, the issue of Gd- contrast induced nephrotoxicity is somewhat controversial and generally overlooked. Initial pharmaceutical trials exam- ined the potential adverse renal effects of Gd-contrast. Since Gd-contrasts have characteristics very similar to those of iodinated radiocontrast, in particular hyperosmolality and renal clearance entirely dependent upon glomerular filtration, nephrotoxicity was an obvious concern of both manufactur- ers and physicians. Animal studies demonstrate nephrotoxic- ity with gadolinium contrast when given in high doses (0.6- 3.0 mmol/kg) to rats with normal kidney function [22]. Histopathology demonstrates vacuolization and necrosis of proximal tubular cells. The lower observed risk of Gd-based contrast as compared with iodinated radiocontrast may relate to mechanism of nephrotoxicity. Iodinated radiocontrast causes renal injury primarily through induction of vasocon- striction, whereas Gd-based contrast has not been shown to promote renal ischemia. Early studies in normal healthy sub- jects as well as small groups of patients with mild to moder- ate levels of underlying kidney disease suggested a reasona- Table 1. FDA Approved Gadolinium Contrast Agents
Gado Formulation Osmolality (mosm/l) Charge Molecular Structure Stability Con- stant Excess Chelate (mg/ml) Gado Market Share* (2006) Gadodiamide (Omniscan) 900 Non-ionic Linear 10 14.9 12 34% Gadopentetate (Magnevist) 1960 Ionic Linear 10 18.1 0.4 47% Gadoversetamide (OptiMARK) 1110 Non-ionic Linear 10 15 28.4 8% Gadobenate (MultiHance) 1970 Ionic Linear 10 18.4 0.1 6% Gadoteridol (Prohance) 630 Non-ionic Cyclic 10 17.1 0.23 5% Abbreviations: Gado, gadolinium. * Contrast Media Industry Guide data. Gadolinium-Contrast and Kidney Disease Current Drug Safety, 2008, Vol. 3, No. 1 69 bly favorable renal safety profile [23, 24]. Even up until re- cently, the Gd-contrasts were considered relatively safe for use in patients with kidney disease, even with the high doses required for renovascular imaging, where most other imaging techniques were inadequate (renal scans and ultrasonogra- phy) or were too risky (CT with iodinated contrast). The im- portance of this issue deserves emphasis. Numerous patients considered at high risk for radiocontrast-induced nephropa- thy (RCIN) from an iodinated radiocontrast study are ex- posed to a Gd-contrasts as a "renal safe" alternative. Critical review of the literature on this subject does not, unfortu- nately, allow a definitive answer to the question of Gd- contrast nephrotoxicity. Some but not all of the studies pub- lished on this subject over the past decade will be reviewed; recognizing that other negative studies were published prior to and during this time period. Gadolinium-Contrast Studies Supporting Renal Safety Several studies are available in this time period suggest- ing that Gd-contrast agents lack any significant nephrotoxic- ity (Table2). A retrospective study published in 1996 exam- ined a cohort of 64 patients with mild CKD as defined by baseline serum creatinine concentration of 2.0 1.4 mg/dl [25]. All patients received both Gd-contrast and iodinated contrast at separate times, thus serving as their own control. The rate of contrast-induced nephrotoxicity, as defined by a rise in serum creatinine concentration of 0.5 mg/dl following each exposure, was compared between the 2 different expo- sures. The dose of Gd-contrasts administered during the study ranged from 0.2 to 0.4 mmol/kg. No patient receiving Gd-contrasts developed nephrotoxicity as compared with 17% of patients receiving iodinated radiocontrast. A prospective study of 32 patients with moderate (CrCl, 31-60 ml/min) and severe (CrCl, 10-30 ml/min) kidney dis- ease was undertaken to examine Gd-contrast pharmacokinet- ics and renal safety [26]. Patients received 0.2 mmol/kg of intravenous gadobenate dimeglumine, which has an osmolal- ity of 1970 mosm/L. 24-hour urine CrCl before and at days 1, 2, 3, 5, and 7 following gadobenate dimeglumine exposure were measured. No patients received any form of contrast prophylaxis prior to or during the study. There was no sig- nificant change in CrCl at any time point in the study, sup- porting the absence of any clinically important nephrotoxic- ity. Patients with kidney disease (defined as a serum creatin- ine concentration greater than 1.5 mg/dl) were studied using gadopentetate dimeglumine (0.4 mmol/kg dose) as an alter- native imaging agent in patients who were allergic to iodi- nated radiocontrast [26]. 31 patients underwent 34 digital subtraction angiographies (DSAs) with this hyperosmolar agent (1960 mosm/L). Only one out of 34 studies was com- plicated by contrast-induced nephropathy, which was defined as an increase in serum creatinine concentration greater than 0.5 mg/dl. In 2000, a study in patients with CKD (serum creatinine greater than 1.5 mg/dl; mean =2.2 mg/dl; range =1.6-3.6 mg/dl) and peripheral vascular disease was undertaken to compare nephrotoxicity of nonionic radiocontrast with CO2 supplemented with either Gd-contrast (up to 0.4 mmol/kg of gadodiamide) or nonionic radiocontrast [27]. 40 patients un- derwent 42 lower extremity angiograms using one of the following contrast protocols: radiocontrast =15, gadodia- mide =20, CO2 =7. All received 300-5000 ml of normal saline prior to contrast exposure as prophylaxis. Contrast- induced nephropathy was defined as an increase in serum creatinine concentration greater than 0.5 mg/dl at 48 hours post procedure. Contrast-induced nephropathy developed in 6 out of 15 (40%) radiocontrast studies but only 1 out of 20 gadodiamide exposures (5%). Table 2. Studies Supporting Renal Safety of Gadolinium-Contrast Agents
Author (Year) Study Contrast Agent Dose (mmol/kg) Renal Function ([Cr] in mg/dl) Result Prince (1996) Retrospective, N=64 [Cr] 2d pre and 2d post, CIN 0.5 mg/dL Gadopentetate Gadodiamide Gadoteridol 0.2 - 0.4 [Cr] >1.5, Mean [Cr] =2.01.4
Hammer (1999) N =31, 34 DSAs, Mean age 53.1 CIN >0.5 mg/dL Gadopentetate 0.4 [Cr] >1.5
CIN: 1/34 (3%)
Spinosa (2000) N =40, LE angiograms 42 procedures RC- 15, Gado- 20 CIN 0.5 mg/dL at 48 hr Gadodiamide up to 0.4 [Cr] >1.5, Mean [Cr] =2.2, Range [Cr] =1.6-3.6 IC- 6/15 (40%) Gado- 1/20 (5%)
Spinosa (2001) Consecutive patients treated with Gado + CO2, CIN >0.5 mg/dL at 48 hr Gadodiamide <0.3 [Cr] >1.5, CIN: 3/95 (3%) Sancak (2001) N =16, IV Gado for upper extremity or SVC Gadodiamide 0.3 Mean [Cr] =1.5, Range [Cr] =1.2-1.8 Largest increase in [Cr] =0.2 mg/dL Rieger (2002) Prospective, N =29, 32 procedures (IA & IV) CIN >0.5 mg/dL at 72 hr Gadopentetate 0.34 0.06 [Cr] >1.5 Mean [Cr] 3.61.4 1/29 (atheroemboli)
Abbreviations: Gado, gadolinium; RC, iodinated radiocontrast; CrCl, creatinine clearance; [Cr], serumcreatinine concentration; CIN, contrast-induced nephropathy; ref, reference; DSA, digital subtraction angiogram; LE, lower extremity; SVC, superior vena cava; IV, intravenous; IA, intra-arterial. 70 Current Drug Safety, 2008, Vol. 3, No. 1 Mark A. Perazella The same authors published another study again support- ing Gd-contrast safety in patients with CKD and ischemic nephropathy [28]. 146 consecutive patients with a serum creatinine concentration greater than 1.5 mg/dl underwent renal angiography using a combination of CO 2 and gadodia- mide. Contrast-induced nephropathy was defined as an in- crease in serum creatinine concentration greater than 1.5 mg/dl at 48 hours; 95 patients had data available for study. Three patients (3.2%) developed nephrotoxicity, less than what is commonly seen in similar patients exposed to iodi- nated radiocontrast. In 2001, 16 patients with mild CKD (mean serum creatin- ine concentration =1.5 mg/dl; range =1.2-1.8 mg/dl) un- derwent intravenous studies with gadodiamide at a dose of 0.3 mmol/kg [29]. No patient developed clinically significant kidney dysfunction. The largest increase in serum creatinine concentration was 0.2 mg/dl. Lastly, a study published in 2002 prospectively examined 29 patients with chronic kidney disease (mean serum creatin- ine concentration of 3.6 mg/dl; range, 1.6-7.0 mg/dl) who received 0.34 mmol/kg (range, 0.23-0.44 mmol/kg) of gadopenetate dimeglumine [30]. In contrast to other studies, intravenous saline was employed as Gd-contrast prophy- laxis. A total of 32 procedures were performed on these patients. None of the patients developed Gd-contrast neph- roxicity as defined as an increase in serum creatinine concen- tration >0.5 mg/dl, over a 3 day period of observation [30]. One patient developed acute kidney injury; however, this was attributed to renal atheroemboli rather than Gd-contrast injury. Gadolinium-Contrast Studies Supporting Nephrotoxicity In contrast to the prior reports supporting renal safety, four studies suggest that Gd-contrast agents exhibit variable degrees of nephrotoxicity (Table 3). An uncontrolled retro- spective study published in 2003 examined the effect of both intra-arterial (n=42) and intravenous (n=153) gadopentetate dimeglumine (1960 mOsm/L) on kidney function in patients with underlying CKD [31]. The average dose of high osmo- lality gadopenetate dimeglumine was 0.28 mmol/kg and no contrast prophylaxis was provided. Patients who received intravenous and intra-arterial gadopentetate dimeglumine had mean baseline serum creatinine concentrations of 2.1 mg/dl (estimated CrCl =61 ml/min) and 2.6 mg/dl (esti- mated CrCl = 40 ml/min), respectively. Contrast-induced nephropathy, defined as an increase in serum creatinine con- centration >1.0 mg/dl within 48 hours developed in 3.5% (7/195) of the entire population: 1.9% (3/153) with intrave- nous and 9.5% (4/42) with intra-arterial administration. In the 7 patients who developed nephrotoxicity, the average baseline serum creatinine concentration was 2.5 mg/dl (esti- mated CrCl =33 ml/min); 4 had diabetes and 5 hypertension suggesting that these may be risk factors for Gd-contrast related nephrotoxicity. Although this study was uncontrolled, the high rate of acute kidney injury seen in this population was evidence for Gd-contrast nephrotoxicity. While en- hanced nephrotoxicity from intra-arterial use of Gd-contrast is likely, complications (i.e., atheroemboli) from the artery manipulation by the procedure confounds the study results. In a prospective study, 21 CKD patients with a serum creatinine concentration greater than 1.5 mg/dl (eGFR <50 ml/min/m 2 ) were randomized to either high dose gadobutrol (1603 mosm/L, 0.34 to 0.90 mmol/kg) or iohexol (820 mOsm/L iodinated radiocontrast) for digital subtraction an- giography [32]. Ten patients receiving gadobutrol had a baseline eGFR of 34 ml/min and 60% had diabetes while the iohexol group (n =11) had an eGFR of 29 ml/min with 36% of the patients having diabetes; both groups received intrave- nous fluids prior to contrast. Contrast-induced nephropathy (50% decrease in eGFR within 48 hours) developed in 45% of iohexol patients and 50% of gadobutrol patients; none of which required renal replacement therapy. In a retrospective study, 91 patients with CKD stage 3 (n =50) and 4 (n =41) were examined for nephrotoxicity (in- crease in serum creatinine concentration of 0.5 mg/dl within 24-72 hours) of Gd-contrast exposure [33]. The patients re- ceived one of three different Gd-contrast preparations (2 with high-osmolality, 1 with low-osmolality) at 0.2 mmol/kg. Contrast prophylaxis was not employed. Approximately 20% of patients had diabetes and 80% hypertension. Eleven pa- tients (12.1%) developed contrast-induced nephropathy, Table 3. Studies Supporting Nephrotoxicity of Gadolinium-Contrast Agents
Author (Year) Study Contrast Agent Dose (mmol/kg) Renal Function ([Cr] in mg/dl) Result Sam (2003) N =195 with CKD No control group CIN >1.0 mg/d at 48 hr with oligoanuria Gadopentetate 0.28 CrCl <80 ml/min, CrCl =38.216 ml/min CIN: 7/195 MRA: 3/153 (1.9%) DSA: 4/42 (9.5%) Erley (2004) Randomized prospective N =21 CIN >50% decrease in GFR Gadobutrol =10 Iohexol =11 0.570.17 [Cr] >1.5 or CrCl <50 ml/min/1.73m 2
CIN: Gado: 5/10 (50%) RC: 5/11 (45%) Briguori (2006) Retrospective, N =25, (historical controls, N =32) CIN 0.5 mg/dL within 48 hr or dialysis within 5 days Gadodiamide =8 Gadobutrol =17 3: 1 mixture with RC 0.60.3 0.28-1.23 [Cr] >2 mg/dL or CrCl <40 ml/min CIN: Gado: 7/25 (28%) RC: 2/32 (6.5%) Ergun (2006) Retrospective, N =91 [Cr] measured pre-Gado, days 1, 3, and 7, and 1 mo, CIN 0.5 mg/dL within 72 hr Gadopentetate Gadodiamide Dotarem 0.2
Stage 3 and 4 CKD Mean [Cr] =33 ml/min Range CrCl =15-58 CIN: 11/91 (12.1%) CKD Stage 4: 9/11 with CIN Abbreviations: CKD, chronic kidney disease; Gado, gadolinium; RC, iodinated radiocontrast; CIN, contrast-induced nephropathy; [Cr], serumcreatinine concentration; MRA, mag- netic resonance angiography; DSA, digital subtraction angiography; CrCl, creatinine clearance; mo, month; hr, hours; GFR, glomerular filtration rate. Gadolinium-Contrast and Kidney Disease Current Drug Safety, 2008, Vol. 3, No. 1 71 again suggesting that Gd-contrasts can be nephrotoxic. Six of these patients had diabetes mellitus and 9 had stage 4 CKD. The type of Gd-contrast (i.e., high versus low osmolality) administered to the patients who developed RCIN was not noted. No patient required renal replacement therapy for acute kidney injury. A prospective study in 25 patients with CKD (mean se- rum creatinine concentration of 2.3 mg/dl) and a matched historical control (n =32) examined the nephrotoxicity of 2 different Gd-contrast agents administered during cardiac catheterization (34). Contrast prophylaxis with 0.45% saline and N-acetylcysteine was provided to all patients. In the Gd- contrast group, a contrast mixture that contained 0.6 mmol/kg of Gd-contrast and 0.4 ml/kg of iso-osmolar non- ionic radiocontrast was compared with the same iso-osmolar radiocontrast agent alone in the historical control group. The 2 contrast protocols are considered equivalent based on the concept of "X-ray attenuating doses". In the Gd-contrast/iso- osmolar contrast group, 28% of patients developed an in- crease in serum creatinine concentration of 0.5 mg/dl within 48 hours as compared with 6.5% in the radiocontrast alone historical control group [34]. Gadolinium-Contrast Nephrotoxicity: What Should We Conclude? Drawing a conclusion from the information reviewed above is difficult. The majority of studies suggest safety, but clearly Gd-contrast-induced nephrotoxicity can develop. One is hampered by data from studies that use variable designs with small numbers, patients with varying levels of kidney function, wide ranges of Gd-contrast osmolality and dose, non-uniform measures of kidney function, erratic use of con- trast prophylaxis, and poor controls or lack of control groups altogether. Clearly, better studies are required that employ adequate numbers of high-risk patients (CKD 3 and 4, dia- betic nephropathy) and the use of appropriate contrast pro- phylaxis (intravenous fluids, N-acetylcysteine). That being said, there appears to be adequate data to suggest that Gd- contrast agents have enough of a nephrotoxic potential that caution should be exercised in their use in patients with stage 4/5 CKD, and possibly even more so in patients with ad- vanced CKD and diabetes. Non-contrast studies (ultrasound, CO 2 ) may be preferred. If this is not possible, it would seem reasonable to consider some form(s) of contrast prophylaxis in higher-risk patients receiving Gd-contrasts. Higher doses (>0.3-0.4 mmol/kg) and arterial injection of Gd-contrast agents appear to enhance risk. Whether the use of higher osmolality Gd-contrast agents increase the nephrotoxicity is uncertain since the nephrotoxic potential of Gd-contrasts at different osmolalities have not been systematically exam- ined. Regardless, it is prudent to employ the lowest dose of Gd-contrast possible to achieve adequate image quality in higher-risk patients. There is no evidence that these maneu- vers would be efficacious, but the similarities of Gd-contrast nephrotoxicity to that of typical iodinated radiocontrast- induced nephropathy make these suggestions reasonable. GADOLINIUM-CONTRAST AND NEPHROGENIC SYSTEMIC FIBROSIS In 1997, several renal transplant recipients with failed allografts requiring chronic dialysis (n =9), ESRD patients on chronic dialysis (n =5), and one patient with AKI were noted to develop a previously unrecognized fibrosing disor- der of the skin [7]. This new disease entity was descriptively coined nephrogenic fibrosing dermopathy (NFD) after de- tailed examination of the clinical and histopathologic data of 14 cases by Cowper and colleagues [7]. A case control study of 8 patients with NSF undertaken by the Centers for Disease Control and Prevention (CDC) and California Department of Health could not identify a specific etiology or trigger, but found advanced kidney dysfunction as a common thread. Following the subsequent recognition that fibrosis also oc- curred in systemic organs and the role of the circulating fi- brocyte in the fibrosing reaction, the name was changed to nephrogenic systemic fibrosis (NSF). This process symmet- rically affects the extremities more so than the trunk, the face is always spared. Initial signs and symptoms include sharp pain and burning associated with redness and swelling of the skin. These changes progress over a matter of weeks to months to extensive dermal fibrosis (entire limbs), often pro- ducing severe joint contractures and marked limitations in mobility. This may lead to a wheelchair dependent or bed bound state [6]. Involvement of systemic organs such as the liver, heart, lungs, diaphragm, esophagus and skeletal muscle has also been reported and may be associated with fatal con- sequences [6,7]. Literature Review on the Gadolinium-NSF Link After the initial report of cases in 2000, the NSF literature consisted predominantly of case reports/case series with the cause being ascribed to any of a number of potential agents or associations. Included were exposure to high-dose erythropoietin, presence of anti-phospholipid antibodies (and other hypercoaguable states), vascular injury and vascular surgical procedures, ischemia, and liver failure (in particular hepatorenal syndrome and liver transplantation). Despite this, no unifying agent or risk factor except for underlying kidney disease was identified. A major breakthrough oc- curred in 2006 when Grobner reported the development of NSF in 5 ESRD patients exposed to gadodiamide in the set- ting of metabolic acidosis [2]. Subsequent to this report, a number of centers have replicated this association. Marck- mann and colleagues described 13 patients in Denmark who developed symptoms of NSF within 2 to 75 days post expo- sure to gadodiamide [3]. Eight patients had ESRD (one on peritoneal dialysis), while 5 had advanced (stage 5) CKD not yet on dialysis. All had courses complicated by vascular in- jury and none had acidosis. A small case control study from Connecticut noted NSF in 3 patients exposed to gadolinium contrast (2 gadodiamide, 1 gadopentetate) demonstrating an incidence of 4.3 cases per 1000 patient years [35]. This was associated with an absolute risk of 3.4% for development of NSF in an exposed patient. In California, another 12 patients were noted to develop NSF following gadodiamide exposure (2-11 weeks), with an odds ratio of 22.3 [4]. Four patients were suffering from AKI, eight had ESRD on dialysis, and 33% of the patients had some form of vascular injury. Another 6 patients with variable levels of kidney disease were described in Texas to develop NSF following gadodiamide [5]. The onset of symp- toms ranged form 19 days to 2 months. The CDC published their findings in MMWR (3/5/07) of a case control study of 72 Current Drug Safety, 2008, Vol. 3, No. 1 Mark A. Perazella 19 patients with confirmed NSF from 2 St. Louis area hospi- tals [36]. Of these patients, 11 were maintained on hemo- dialysis, 6 on peritoneal dialysis, and 2 had temporary hemo- dialysis for AKI. The attack rate for peritoneal dialysis (4.6 cases/100 patients) was much higher than for hemodialysis (0.61/100 patients), suggesting worse clearance of Gd- contrast with peritoneal dialysis. The type and dose of Gd- contrast was not noted, but hypothyroidism, edema and deep venous thrombosis were significant risk factors for develop- ment of NSF. In one case; however, they could not document exposure to Gd-contrast. Physicians from Wisconsin re- ported another 13 cases of NSF following gadodiamide ad- ministration noting that an underlying pro-inflammatory state (major surgery, infection, vascular event or thrombosis) was an important risk factor [37]. They also confirmed the high mortality (31%) associated with this disease state. They, however, incorrectly classified 2 patients with AKI as CKD stage 3. Most recently, a case control study of 19 patients with NSF from the Denmark group described that high cu- mulative gadodiamide dose, elevated serum calcium and phosphate concentrations and high dose epoietin- (trend) increase the risk of developing NSF [38]. It is notable that NSF has been reported in most European countries including Denmark, United Kingdom, Austria, Belgium, the Nether- lands, Norway, Sweden, and Switzerland [1,39]. The FDA has also linked NSF to Gd-contrast exposure and has released two Public Health Advisories, one in 6/06 reporting NSF in 25 ESRD patients after Gd-contrast expo- sure[10], and an update in 12/06 increasing this number to 90 patients[11]. An NSF registry was created in 2001 to col- lect data on all cases of NSF [7] and to date greater than 95% of 239 cases of NSF (where data are available) have been linked to exposure to gadolinium [25]. Gadodiamide has been implicated in approximately 85% of these cases and gadopentetate in 15%. The vast majority of patients that de- velop NSF are dialysis-dependent (~90%), although it has also been described in patients with advanced CKD not yet on dialysis, patients with a poorly functioning renal trans- plant and those with acute kidney injury [6,7]. Further evidence of the importance of Gd-contrast agents as a trigger for NSF was provided by documentation of Gd 3+
within the tissues of patients with NSF using scanning elec- tron microscopy and energy dispersive X-ray spectroscopy [40,41]. In addition to this qualitative evidence, High and coworkers quantified the concentration of Gd 3+ in tissues of the NSF patients previously examined [42]. They found that the NSF tissues contained 35-150 fold higher amounts (5- 106 parts per million [ppm]) than the tissues of healthy sub- jects (0.477-1.77 ppm) exposed to Gd-contrast. The authors speculate that phagocytosis of Gd 3+ retained in tissues by macrophages results in production of profibrotic cytokines that eventuate in dermal and/or systemic fibrosis. Animal Research Examining Gadolinium-NSF Link An obvious area of research to examine the potential for gadolinium-contrast agents to promote the development of NSF is studies in animals. Interestingly, rats exposed to daily, high dose gadolinium-contrast for 28 days developed numerous skin lesions that included hair loss, erythema, thickening, ulceration and crusting. These lesions were at- tributed to zinc deficiency from transmetalation of zinc by the gadolinium chelate [22]. Recently, an abstract was pre- sented at the International Society of Nephrology/World Congress of Nephrology in Rio de J aniero, Brazil [43]. 40 rats with normal kidney function were exposed to 2 types of high dose gadolinium (2.5 mmol/kg of either gadodiamide or gadopentetate), gadodiamide (2.5 mmol/kg) without its ex- cess sodium caldiamide chelate, or saline control daily for 28 days. Rats exposed to gadodiamide without excess chelate developed NSF-like skin lesions within 6 days, those ex- posed to gadodiamide with excess chelate developed NSF- like skin lesions at 16 days, while the gadopentetate and sa- line exposed rats did not develop skin lesions. Although histopathology was note reported, higher gadolinium concen- trations were found in the tissues of the 2 groups of rats that developed NSF. This experiment suggests that gadodiamide, due to the process of transmetalation with release of gadolin- ium, is more likely to cause NSF than gadopentetate, at least in rats. In the 7 published reports (total of 58 patients) where the specific MR contrast agent was identified, the Gd-contrast administered was gadodiamide in all but one, which was gadopentetate [2-5, 36-38]. While the initial inclination is to ascribe NSF to this particular agent, care must be taken be- fore gadodiamide is blamed as specifically responsible for NSF since this agent is one of the more commonly used Gd- contrasts. In fact, gadodiamide and gadopentetate are the most commonly used Gd-contrast agents claiming 81% of the market share for 2006 per the Contrast Media Industry Guide (CMIG) report. Also, according to the FDA Med- Watch reporting system, as of 1/07 there have been more than 100 cases of NSF in which 85 were associated with ex- posure to gadodiamide (Omniscan), 21 with gadopentetate (Magnevist), 6 with gadoversetamide (OptiMARK), and one with gadobenate (MultiHance), although this patient also received gadodiamide. More recently (3/07), Bayer Health Care stated that they were aware of 42 cases of NSF associ- ated with exposure to gadopentetate (Magnevist) [44]. As noted above, the NSF registry implicates gadodiamide in approximately 85% of these cases and gadopentetate in 15% [7]. Each of these NSF associated preparations is a linear Gd-contrast agent. To date, there are no reports of NSF asso- ciated with gadoteridol (ProHance), a cyclic Gd-contrast. Gadodiamide and NSF If gadodiamide is more likely to cause NSF than the other Gd-contrast agents, what factors make it unique in this re- gard? One theory relates to its stability, its ability to bind to and sequester Gd +3 . Gadodiamide has the lowest stability constant and highest dissociation rate of the five Gd-contrast preparations available in the United States (Table 1). Be- cause of this decreased stability, the Gd +3 ion of
gadodiamide is more likely to dissociate from its stabilizing chelate moi- ety than other Gd-contrast agents. Because of this fact, ex- cess chelate (12 mg/ml of sodium calcium diamide) is added to the commercial formulations of gadodiamide in an attempt to diminish freely circulating Gd 3+ [14,15]. The stability con- stant of gadoversetamide is essentially the same as gadodia- mide, however the excess chelate in this preparation is even greater at 28.4 mg/ml (sodium calcium versetamide), and is tempting to use this as an explanation for the decreased cases of NSF associated with gadoversetamide compared to Gadolinium-Contrast and Kidney Disease Current Drug Safety, 2008, Vol. 3, No. 1 73 gadodiamide. However, the stability constant of gadopen- tetate is 1000 times greater than either gadodiamide or gado- versetamide and this agent is now the second most common Gd-contrast associated with NSF. This may relate to its more widespread use, but it still calls into question the concept of relative toxicity being related to chelate stability. At the pre- sent time, it is risky to blame this disease on specific agents and I agree with the FDA [11] that it must be assumed to be a class effect until more data are available. The dose of Gd-contrast utilized appears to be impor- tantly associated with the development of NSF. A typical non-vascular MRI examination employs 0.1 mmol/kg while an MRA often utilizes up to 0.3 mmol/kg of Gd-contrast. In the 5 cases reported from Austria, the dose of Gd-contrast was approximately 0.26 mmol/kg if one assumes a 70 kg body weight [2]. The 13 cases reported from Denmark re- ported an average contrast volume of 18.5 mmol, which would be 0.26 mmol/kg for a 70 kg individual [3]. Only one patient received less than a 10 mmol dose. In the study by Broome, gadodiamide was administered at double dose (0.2 mmol/kg) in each of the patients in whom NSF subse- quently developed [4]. During the six-year period of this report, 559 MRI examinations (301 with gadolinium-contrast and 258 without contrast) were performed on 168 patients with advanced kidney disease receiving dialysis. Since there were no cases of NSF in the patients receiving an MR study performed without Gd-contrast, the calculated odds ratio for gadolinium causing NSF was 22.3. Of the 301 MR studies utilizing Gd-contrast, 207 were performed using a dose of 0.2 mmol/kg while the remaining 94 received 0.1 mmol/kg. Since none of the cases of NSF occurred in patients receiving 0.1 mmol/l of Gd-contrast, the odds ratio of developing NSF with the higher dose of Gd-contrast was 12.1 [4]. Review of all of the published literature generally supports the en- hanced risk with higher Gd-contrast dose. The NSF registry also supports this contention as the majority of patients with NSF were exposed to high doses of and multiple exposures to Gd-contrast. These data suggest that the risk of NSF is significantly correlated to the dose of Gd-contrast adminis- tered and patients would therefore be at much higher risk if receiving an MRA as opposed to a typical non-vascular MRI study. Why should Gd-contrast have the potential to trigger the development of NSF in patients with underlying kidney dis- ease? Certainly, reduced kidney function increases the T 1/2 of Gd-contrast considerably as it is slowly excreted by the kid- neys in acute kidney injury, advanced stages of chronic kid- ney disease (CKD stages 4 and 5), and dialysis-dependent ESRD where it requires three hemodialysis treatments to remove >95% of the administered dose. Thus, significant renal impairment is associated with increased time for trans- metalation and prolonged tissue exposure, which may pro- mote deposition of toxic Gd 3+ leading to fibrosis. In addition, the association of higher doses Gd-contrast increasing the risk of developing NSF also supports this hypothesis as these higher doses would further increase and prolong tissue expo- sure in the setting of impaired excretion. Compared with other conditions and complications that afflict ESRD patients, NSF appears to be a relatively rare condition occurring in only 5% of patients receiving gadodiamide in the report from Denmark [3]. There are nu- merous patients in the United States alone with ESRD and advanced CKD, most of which have significant co- morbidities that require radiographic imaging. It is very likely that MR studies are commonly used in this population to assess vascular disease and other end organ pathology. If therefore seems reasonable to assume that many patients with advanced kidney disease that have received an MR study with gadolinium have been spared this abysmal com- plication. Thus a combination of risk factors or cofactors are likely required for NSF to occur. Clearly, advanced kidney disease is a requisite. The dose of Gd-contrast appears to play a role and the specific Gd-contrast (gadodiamide) util- ized may also be a factor. All of the published studies and the data from the NSF registry describe the presence of vas- cular/endothelial injury (hypercoaguable states, venous thrombosis, vascular surgery) and perhaps a proinflamma- tory state (infection, major surgery) in NSF patients. A num- ber of other cofactors may also be important including meta- bolic acidosis, intravenous iron dosing, increased serum cal- cium and phosphate concentrations, and high dose erythro- poietin, but they are hardly confirmed. Fig. (1) demonstrates the factors potentially responsible for the development of NSF following Gd-contrast exposure. Prevention and Treatment of NSF Currently, there is no effective therapy for NSF. Physical therapy plays an important role in increasing and maintaining the mobility of affected limbs and joints. Renal transplanta- tion has anecdotally improved or stabilized NSF in patients who have excellent graft function. Extracorporeal photo- pheresis has shown some hope while others with variable response include steroids, pentoxyphylline, plasmapheresis, and intravenous sodium thiosulfate [45,46]. Since NSF is still relatively rare and sporadic, none of these maneuvers have been tested in a controlled clinical trial. What recommendations can be made regarding the use of Gd-contrast-based MR studies in high-risk patients? The vast majority of cases of NSF occur in patients with ESRD receiving hemodialysis or peritoneal dialysis. However, ap- proximately 10% of the cases develop in patients with acute kidney injury (many requiring dialysis), patients with ad- vanced CKD stage 4 (estimated GFR 15-30 ml/min) and in patients with CKD stage 5 not receiving renal replacement therapy (estimated GFR <15 ml/min). Thus, for the time being, it would seem reasonable to try to avoid administra- tion of all types of Gd-contrast to patients with these charac- teristics. This recommendation is even stronger when con- sidering an MRA in this population, as the higher contrast dose required with those studies appears to significantly in- crease the risk of NSF. Alternative imaging modalities (ul- trasonography, PET scan, CO 2 angiography, MRI without contrast, CT scan without contrast) should be employed in these patients whenever possible, including studies using iodinated radiocontrast when necessary. Using iodinated radiocontrast in patients with advanced CKD not on dialysis puts patients at risk for radiocontrast-induced nephropathy and may tip them over into a situation that may require temporary or permanent dialysis. Iodinated radiocontrast- induced nephropathy is more likely to occur than is NSF induced by Gd-contrast exposure in this group of patients. However, since radiocontrast-induced nephropathy is poten- 74 Current Drug Safety, 2008, Vol. 3, No. 1 Mark A. Perazella tially reversible while NSF is not, a Gd-contrast-based study may be a better choice in this group. If an MR study with contrast (especially MRA) were felt to be absolutely required in a patient with ESRD or CKD 4 or 5 not on dialysis, the lowest possible dose of Gd-contrast should be used and if feasible, a Gd-contrast other than gadodiamide. Also, until further data are available on this topic, it would seem prudent to perform hemodialysis both immediately following, and again the day after the MR study to accelerate Gd-contrast elimination, in patients already receiving hemodialysis. This maneuver should also be entertained for CKD patients (not currently on chronic dialysis) and patients maintained on chronic peritoneal dialysis who receive a Gd-contrast (MRA) study. This is obviously a very inconvenient strategy, but this aggressive approach underscores the concern over, and un- certainty surrounding, the development of this devastating condition. Obviously, these are difficult decisions that can only be made utilizing input from the physician requesting the MR study, the nephrologist and the radiologist. There will be situations that Gd-contrast administration cannot be avoided in a high-risk patient. CONCLUSION In conclusion, Gd-contrast agents can no longer be as- sumed to be as safe as they have traditionally been consid- ered when administered to patients with underlying kidney disease. Although the toxicity profile of the Gd-contrast agents may be narrower than that associated with iodinated radiocontrast agents, they are clearly not entirely benign. Nephrotoxicity can occur in high risk patients who receive a large dose (>0.3-0.4 mmol/kg) and intra-arterial injection of Gd-contrast. NSF can be a catastrophic complication of Gd- contrast exposure and we should make a concerted effort to avoid this dreaded condition. There is strong evidence that NSF is related to a tissue response to the toxic effects of gadolinium. Hopefully, future work in this field will provide more clearly identifiable risk factors and preventative ma- neuvers that will allow us to give advice beyond simple avoidance altogether. This will be important information as MR Gd-contrast studies play an important role in the diagno- sis, treatment and follow-up of a vast array of medical condi- tions in patients with kidney disease. REFERENCES [1] Perazella MA, Rodby RA. Gadoliniumuse in patients with kidney disease: A cause for concern. Semin Dial 2007; 20: 179-84. [2] Grobner T. Gadolinium-a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibro- sis? Nephrol Dial Transplant 2006; 21: 1104-08. [3] Marckmann P, Skov L, Rossen, et al. Nephrogenic systemic fibro- sis: suspected etiological role of gadodiamide used for contrast- enhanced magnetic resonance imaging. J Am Soc Nephrol 2006; 17: 2359-62. [4] Broome DR, Girguis MS, Baron PW, et al. Gadodiamide- associated nephrogenic systemic fibrosis: Why radiologists should be concerned. Am J Roentgenol 2007; 188(2): 586-92. [5] Khurana A, Runge VM, Narayanan M, et al. 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Fig. (1). Speculative mechanism by which gadolinium might trigger nephrogenic systemic fibrosis. In the setting of kidney disease (1), im- paired renal excretion of high dose gadolinium prolongs the T 1/2 and enhances the chance for dissociation of gadolinium from its chelate (2), allowing increased tissue exposure. Pro-inflammatory conditions (3), vascular trauma and endothelial dysfunction allows free Gd 3+ to more easily enter tissues, where macrophages phagocytose the metal and produce local profibrotic cytokines as well as signals that attract circulat- ing fibrocytes to the tissues. Other co-factors (4), such as increased serum calcium and phosphorus, metabolic acidosis, intravenous iron ther- apy and high dose intravenous erythropoietin may also enhance the development of NSF through various effects. Once in tissues, circulating fibrocytes and perhaps Gd 3+ (through direct effects on collagen) induce a fibrosing process that is indistinguishable from normal scar forma- tion. 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Received: J une 1, 2007 Revised: J uly 10, 2007 Accepted: J uly 11, 2007