What Nephrologists Need to Know About Gadolinium: Conclusions

Conclusions

Over time, the number of indications for, and doses of, gadolinium chelates have increased beyond those originally approved by the FDA. Although these increases have probably not compromised the safety of patients with normal renal function, for those with a reduced GFR the risk of developing NSF is now a concern. A strong association between NSF and gadolinium-based agents has emerged from retrospective analyses. Gadolinium has been detected in affected tissue, but there is as yet no definitive proof that gadolinium is the cause of NSF. Treating an animal model such as a 5/6 nephrectomized rat with gadolinium chelates might provide some insight into causal relationships. Until more data become available, it is advisable to avoid using gadolinium chelates (particularly gadodiamide) whenever possible in people with severe kidney disease to ESRD. As gadolinium chelates can be nephrotoxic, their use should no longer be considered 'safe' in terms of CIN. If a gadolinium chelate is administered, the physician should be familiar with associated laboratory artifacts so that unnecessary treatment is not initiated on the basis of erroneous values.

Key Points

• Originally thought to be safe contrast agents, gadolinium chelates have recently been shown to be associated with the development of nephrogenic systemic fibrosis (NSF) in patients with impaired renal function
  
  
• NSF, previously known as nephrogenic fibrosing dermopathy, occurs only in patients with kidney dysfunction, is characterized by waxy thickening of the skin of the extremities and torso, and commonly leads to joint contractures and immobility
  
  
• The proposed, but not yet proven, etiology of NSF is tissue deposition of free gadolinium that is liberated from chelates, secondary to prolonged gadolinium clearance time due to impaired renal function
  
  
• Treatments for NSF have only been tested informally; the condition has been shown to improve in response to recovery of kidney function
  
  
• Several authorities have issued recommendations for use of gadolinium chelates; most advise caution when considering use of these agents in patients with renal dysfunction

Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape accredited continuing medical education activity associated with this article.

Reprint Address

Correspondence: Jeffrey G. Penfield, Veterans Affairs North Texas Health Care System, 4500 S Lancaster Road, Dallas, TX 75216, USA Email: [email protected]