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Will Dialysis Prevent the Development of Nephrogenic Systemic Fibrosis After Gadolinium-Based Contrast Administration?

University of Missouri–Columbia School of Medicine Columbia, MO
Yale University School of Medicine New Haven, CT

 
WEB—This is a Web exclusive article.

Note—G. Saab has been a speaker for Bracco Diagnostics.

We read with interest the recent manuscript by Broome and colleagues [1], "Gadodiamide-Associated Nephrogenic Systemic Fibrosis: Why Radiologists Should Be Concerned." We found it to be quite informative, adding to the current body of evidence suggesting a link between the administration of gadolinium-based contrast media, in this case gadodiamide, and the development of nephrogenic systemic fibrosis (NSF). As nephrologists, we found it most interesting, yet concerning at the same time, that hemodialysis after gadolinium-based contrast media administration on the day of exposure and on consecutive days thereafter did not prevent the development of NSF.

That gadodiamide is cleared by dialysis [2] could suggest that once the gadolinium-based contrast media (or free gadolinium ion) deposits in the extravascular tissues, back-diffusion out of the tissues into plasma occurs very slowly or not at all. Indeed, Joffe and colleagues [2] documented that, although the serum concentration of gadodiamide decreased progressively throughout a hemodialysis session, there did not appear to be an appreciable increase in the serum levels between dialysis sessions.

Although the Joffe et al. [2] study did not directly assess the removal of free gadolinium ions, animal studies suggest a significantly higher residual concentration of gadolinium in tissue after administration of gadodiamide compared with other agents [3]. It is also important to note that studies documenting the removal of gadolinium-based contrast media with dialysis only measure the reduction in serum levels and not the mass transfer or total amount of contrast material extracted. Thus, although serum levels are reduced, there is no information regarding residual tissue amounts.

Thus, it appears that timing of dialysis could be of the essence in preventing the redistribution of gadolinium into the extravascular space and ultimately the development of NSF, especially given the recent documentation of gadolinium detection in the skin biopsies from patients with NSF [4]. It would be helpful to nephrologists if the authors could provide more details regarding the dialytic therapy each of the three patients received. Of utmost importance would be the elapsed time between contrast administration and the initiation of dialysis and specific information regarding the dialysis prescription (continuous vs intermittent, membrane characteristics, blood and dialysate flow rates, bath used, and so on).

In conclusion, we found the manuscript by Broome and colleagues [1] to be a significant addition to the literature regarding NSF. It would, however, be extremely informative if the authors would elaborate further regarding the dialysis treatment provided to the patients.

References

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1. 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 : 586-892[Abstract/Free Full Text]
2. Joffe P, Thomsen HS, Meusel M. Pharmacokinetics of gadodiamide injection in patients with severe renal insufficiency and patients undergoing hemodialysis or continuous ambulatory peritoneal dialysis. Acad Radiol 1998; 5:491 -502[CrossRef][Medline]
3. Tweedle MF, Wedeking P, Kumar K. Biodistribution of radiolabeled, formulated gadopentetate, gadoteridol, gadoterate, and gadodiamide in mice and rats. Invest Radiol 1995;30 : 372-380[CrossRef][Medline]
4. High WA, Ayers RA, Chandler J, Zito G, Cowper SE. Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis. J Am Acad Dermatol 2007;56 : 21-26[CrossRef][Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Saab, G. Articles by Abu-Alfa, A. Search for Related Content PubMed PubMed Citation Articles by Saab, G. Articles by Abu-Alfa, A. Social Bookmarking                      What's this?