Review
Pathobiochemistry of gadolinium
Class | Net Charge | Trade Name | Short Names | Log K(therm) | Log K(cond7.4) | Kinetic Stabiltiy |
---|---|---|---|---|---|---|
Linear | Non-ionic | Omniscan | Gadodiamide | 16.9 | 14.9 | Low |
Non-ionic | Optimark | Gadoversetamide | 16.8 | 15.0 | Low | |
Ionic | Magnevist | Gadopentetate | 22.5 | 18.4 | Medium | |
Ionic | Multihance | Gadobenate | 22.6 | 18.4 | Medium | |
Ionic | Primovist | Gadoxetate | 23.5 | 18.7 | Medium | |
Ionic | Vasovist | Gadofosvescet | 22.1 | 18.9 | Medium | |
Macrocyclic | Non-ionic | Gadovist | Gadobutrol | 21.8 | 15.5 | High |
Non-ionic | Prohance | Gadoteridol | 23.8 | 17.2 | High | |
Ionic | Dotarem | Gadoterate | 25.6 | 19.3 | High |
Pathogenesis of nephrogenic systemic fibrosis
Symptoms, diagnosis and differential diagnosis
Incidence and prevalence
Treatment of nephrogenic systemic fibrosis
Established therapies | Physical Therapy |
Pain control (opoids, NSARs, steroids, antidepressants) | |
Renal Transplantation | |
Based on case reports | Extracorporal photopheresis |
Plasmapheresis | |
UV- A1 therapy | |
High dose iv. Immunoglobulines | |
Imatinib Mesylate | |
Rabamycine | |
Pentoxifylline | |
Anecdotal | Topical dovonex |
Cytoxan | |
Thalidomide | |
Immunosuppression via Steroids |
Present guidelines in Europe and the USA - European Medicines Agency (2010), European Society of Urogenital Radiology (2008), FDA (2010) and American College of Radiology (2010)
FDA 2006 | FDA 2007 | FDA 2010 |
---|---|---|
Boxed Warning for GBCAs | Change in labeling for GBCAs | |
Patients at risk: | Patients at risk: | Patients at risk: |
Moderate to end stage kidney disease (GFR < 60 ml/min/1.73 m²) | Acute or chronic severe renal insufficiency (GFR < 30 ml/min/1.73 m²) Acute renal insufficiency due to hepatorenal syndrome or in the perioperative phase of a liver transplant | Highest risk for patients with GFR < 30 ml/min/1.73 m² |
Repeated or high dosage GBCA enhanced procedures | ||
NO RISK: patients with normal kidney function | ||
Screen all patients for renal dysfunction (history and/or lab tests) | Screen all patients for renal dysfunction (history for assessment of acute kidney failure, lab tests for patients at risk for chronic renal failure) Risk factors are Diabetes, Hypertension, heart disease, smoking, obesity, high cholesterol, family history of kidney disease, age 65 or older, urinary tract infections/obstructions, systemic infections or autoimmune diseases [91] | |
Measures: | Measures: | Measures: |
Carefully weigh pros and cons of GBCA enhanced imaging | avoid GBCA unless absolutely necessary | Gadodiamide, Gadoversetamid, Gadopentet Acid are contraindicated for highest risk patients |
Use alternative imaging if possible | do not exceed recommended dose | |
take the elimination half life into account and allow enough time for GBCA elimination before rescanning the patient | ||
Avoid GBCAs in patients with impaired (known/suspected) drug elimination unless absolutely necessary | ||
Consider prompt dialysis in all patients with impaired renal function | Consider prompt dialysis in patients that are already on dialysis treatment | Consider prompt dialysis in patients that are already on dialysis treatment |
Monitor patients after GBCA administration, good documentation, no repeat GBCA imaging procedures until GBCA is eliminated from the body |
Patients with severely impaired renal function | high risk GBCAs are contraindicated |
medium and low risk GBCAs: use lowest possible dose, pause at least 7d between two GBCA enhanced procedures | |
Patients with moderately impaired renal function | High risk GBCAs: use single injection of minimum dose, pause of 7d between two GBCA enhanced procedures |
Medium and low risk GBCAs: use minimum dose, pause of 7d between two GBCA enhanced procedures | |
Toddlers < 1yo | High, medium and low risk GBCAs: use single injection of minimum dose, pause of 7d between two GBCA enhanced procedures |
Infants < 4wks | high risk GBCAs are contraindicated |
medium and low risk GBCAs: use lowest possible dose, pause at least 7d between two GBCA enhanced procedures | |
Breast feeding | High risk GBCAs: pause for 24 h |
Medium and low risk GBCAs: consider pause for 24 h | |
Perioperative phase of liver transplants | high risk GBCAs are contraindicated |
medium and low risk GBCAs: use lowest possible dose, pause at least 7d between two GBCA enhanced procedures |
Guidelines of the American College for Radiology (2010)
Chronic Kidney Disease Stage 1 or 2 | No special measures |
(eGFR 60 to 119 ml/min/1.73 m2) | |
Chronic Kidney Disease Stage 3a | Lowest possible dose of GBCA for diagnostic studies. If possible, avoid high risk GBCAs |
(eGFR 45- 59 ml/min/1.73 m2) | |
Chronic Kidney Disease Stage 3b | GBCA use should be safe if dosage is restricted to 0.1 mmol/kg or less. Apply same safety measures as in the following group |
(eGFR 30- 44 ml/min/1.73 m2) | |
Chronic Kidney Disease Stage 4 or 5 not on chronic dialysis | If feasible, avoid all contrast media. If usage is not avoidable, use lowest possible dose, avoid high risk GBCAs, avoid readministration of GBCAs for a week |
(eGFR <30 ml/min/1.73 m2) | |
End-stage renal disease with chronic dialysis | Consider change of imaging modality. Avoid high risk GBCAs, use lowest possible dose. Schedule the imaging study as close as possible before the next routine hemodialysis session. |
(eGFR 45- 59 ml/min/1.73 m2) | |
Acute kidney injury | If possible avoid any GBCA administration, regardless of eGFR. If GBCA use is necessary, avoid high risk GBCAs, use lowest possible dose. |
Pregnancy | If possible, avoid use of GBCA, unless such an imaging study is absolutely necessary. |
Pediatrics | Use similar safety measures as in adults. Neonates can have an eGFR of less than 30 ml/min/1.73 m³ but is not considered an absolute contraindication. |
Gadoteridol | 0.1 mmol/kg or 0.2 ml/kg |
Gadoversetamide | 0.1 mmol/kg or 0.2 ml/kg |
Gadodiamide | CNS: 0.1 mmol/kg or 0.2 ml/kg |
Body: 0.05 mmol/kg or 0.1 ml/kg | |
Intrathoracic/intraabdominal/pelvic: 0.1 mmol/kg or 0.2 ml/kg | |
Gadobenate dimeglumine | 0.1 mmol/kg or 0.2 ml/kg |
Gadopentetate dimeglumine | 0.1 mmol/kg or 0.2 ml/kg |
Gadofosveset | 0.12 mmol/kg or 0.03 ml/kg |
Gadoxetate disodium | 0.025 mmol/kg or 0.1 ml/kg |
Gadoterate meglumine | 0.1 mmol/kg or 0.2 ml/kg |
Gadobutrol | 0.1 mmol/kg or 0.1 ml/kg |