DOI:10.2214/AJR.07.0101
AJR 2007; 188:W581
© American Roentgen Ray Society
Reply
Dale R. Broome and
Mark S. Girguis
Loma Linda University Medical Center Loma Linda, CA 92354
WEB—This is a Web exclusive article.
We thank Drs. Thomsen and Morcos for their letter to the editor regarding
our article about gadodiamide-associated nephrogenic systemic fibrosis
[1]. They provided an excellent
summary of the current U.S. Food and Drug Administration (FDA) and
international reporting of this association and further evidence of a causal
relation between gadolinium-based contrast media and nephrogenic systemic
fibrosis. On the basis of this reported information and the limited data in
our study, we agree with their recommendations that the window of caution for
gadodiamide administration should be extended to patients with moderate and
severe renal insufficiency with a glomerular filtration rate (GFR) of < 60
mL/min. We had one patient in our study
[1] and an additional patient
since that report who developed nephrogenic systemic fibrosis after
gadodiamide administration when their estimated GFR values were between 15 and
30 mL/min (severe renal insufficiency).
Whether this recommendation should be extended to all gadolinium-based
contrast media is a more controversial matter because the various
gadolinium-based contrast media differ in their concentrations of excess
chelate and thermodynamic stability constants that may affect the likelihood
of nephrogenic systemic fibrosis development. Assuming that chelate
instability is the predisposing factor for nephrogenic systemic fibrosis
development, the ionic linear gadolinium chelates (gadodiamide and
gadoversetamide) would seem to be associated with the highest risk.
Because of the smaller number of reported nephrogenic systemic fibrosis
cases with other gadolinium-based contrast media, it may not be necessary to
restrict so tightly their use in patients with renal insufficiency. For these
other contrast media, it may be sufficient to avoid administration of these
agents only in patients with end-stage renal disease and those with severe
renal insufficiency (GFR < 30 mL/min), particularly if the contrast dose
can be minimized.
Restricting or cautioning against the use of gadolinium-based contrast
media in patients with moderate and severe renal insufficiency would have a
significant impact on clinical MRI because contrast-enhanced MRI has become
the primary imaging technique for many conditions in the renal-insufficient
patient for whom iodinated contrast media are relatively contraindicated.
Restricting the use of gadolinium-based contrast media would also require
greater screening of MRI patients for renal insufficiency because 11% of the
U.S. population more than 65 years old have a GFR of < 60 mL/min without
any underlying diabetes or hypertension
[1]. To detect at-risk
renal-insufficient patients, serum creatinine levels would need to be checked
on many patients before MRI, including patients with known kidney disease,
diabetes, and hypertension and probably all patients over the age of 60
years.
References
- Broome DR, Girguis MS, Baron PW, Cottrell AC, Kjellin I, Kirk GA.
Gadodiamide-associated nephrogenic systemic fibrosis: why radiologists should
be concerned. AJR 2007;188
: 586–592[Abstract/Free Full Text]
- Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of
chronic kidney disease and decreased kidney function in the adult US
population: Third National Health and Nutrition Examination Survey.
Am J Kidney Dis 2003;41
: 1–12[Medline]
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