NSF caught the nephrologist community by surprise with its initial identification in 1997 and had a formal description as a unique entity in 2001. The cause of NSF eluded diagnosis, but it happened only in patients with kidney disease and the culprit was the magnetic resonance contrast enhancing imaging agent. Gadolinium(Gd) has paramagnetic properties that disturb relaxation of water protons and by shortening relaxation it increases signal intensity, making it an excellent contrast agent. For safe use of the contrast-enhancing benefits of Gd, the metal must be sequestered by an organic ligand. In general, there are two major categories of ligand, linear and macrocyclic, are based on biochemical structure. And based on the animal data, linear based agents tend to have significantly higher tissue concentration and hence long term retention in comparison to macrocyclic based agents. Renal clearance of Gd approximates creatinine clearance in normal individuals. and have a terminal half life of 1.3 to 1.6 hours. The terminal half life increases in patients with CKD stage 3 (4-8hrs) and stage 4(18-34hrs). Agents with a component of liver clearance have a terminal half life of 6.1 to 9.5 hrs with stage 3 and 4 CKD respectively.
Gd serum elimination using hemodialysis is approximately 74% with 1 treatment, 92% with 2 treatments and 99% after 3 treatments. PD is relatively ineffective in Gd removal
Who is at Maximum risk? - Notably, no cases in stage 1-3 CKD have been confirmed in the published literature so far. In the HALT-PKD and CRISP studies, patients with ADPKD stages I through 3 CKD underwent 1111 Gd exposures with no occurrence of NSF. A total of 592 patients who had stages 3 through 4 CKD were exposed to Gd also did not develop NSF. 88 patients who had stages 1 through 4 CKD underwent 94 Gd exposures, including 34 patients with stage 4 CKD did not develop NSF. Finally, none of 2053 patients ( Stage 3 44.7%, stage 4 23.9%, stage 5 5.7%) who were exposed to 2278 MRIs developed NSF during 29 months of follow-up. The literature suggests that dialysis dependent patients with ESRD, stage 5 CKD and AKI maintain the highest risk.
Imaging with Gadolinium of high risk patients. On the basis of current knowledge, the following statements on patient risk for NSF can be made:
1. Use only macrocyclic gadolinium based contrast agents.
2. Use the lowest dosage required to obtain quality images.
3. Avoid IV iron and high dose ESA's before and after anticipated exposure.
4. Patients with stages I through 3 CKD do not seem to maintain risk for NSF after gadolinium exposure.
5. Patients with stage 4 CKD maintain modest risk and the risk increases in the presence of other factors like pro-inflammatory states, metabolic acidosis, hypercalcemia hyperphosphatemia and liver failure. Hence optimize metabolic status before anticipated exposure.
6. Arrange HD for patients with CKD stage 5, AKI and those dependent on dialysis.
- ► 2018 (57)
- ► 2017 (52)
- ► 2016 (45)
- ► 2015 (63)
- ► 2014 (95)
- ► 2013 (133)
- ► 2012 (201)
- ► 2011 (370)
- Virtual Grand Rounds in Nephrology- E nephrology
- ASN's review on the ESRD bundling
- TOPIC DISCUSSION: EFFECT OF PROTEINURIA on combina...
- Poem from Pediatric Nephrologist
- TOPIC DISCUSSION: ACE induce angioedema replaced b...
- Nephsap review: Chronic Kidney Disease : CKD patie...
- Nephsap review: Chronic Kidney Disease: Troponin T...
- Bundled Payment for ESRD
- 2010 North American Dialysis and Transplantation (...
- Hematuria and Donation?
- TOPIC DISCUSSION: Do Peritoneal Dialysis patients ...
- Renal Fellow Network: Deciphering the pathologists...
- TOPIC DISCUSSION: TIDAL PD
- TOPIC DISCUSSION: DEXA SCAN in TRANSPLANT PATIENTS...
- CLINICAL CASE 21, ANSWERS AND SUMMARY
- Plagiarism In Application Essays????
- Micro RNAs and Transplantation
- IN THE NEWS: Anabolic Steroids and FSGS
- CLINICAL CASE 20, ANSWERS AND SUMMARY
- Pediatrics Grand rounds continue
- CONSULT ROUNDS: Severe Pre eclampsia
- Milk and CKD
- Transplant/Immunology Quiz 3 answers
- Rituximab and Cyclophosphamide: A Tale of Two Trea...
- CONSULT ROUNDS: HUS/TTP During Pregnancy
- IN THE NEWS: FACTOR H REPLETION in Atypical HUS
- Leflunomide and liver failure
- TOPIC DISCUSSION: Gadolinium and NSF- How to image...
- Lupus Nephritis Post Transplant
- Why do Internal Medicine Residents Choose Nephrolo...
- TOPIC DISCUSSION: TTP/HUS
- CONSULT ROUND: Hypercalcemia and Lithium
- CONSULT ROUND: ATHEROEMBOLIC DISEASE
- CONSULT ROUNDS:Rare and Interesting Cause of Hyper...
- TOPIC DISCUSSION: URR and Kt/V
- Organ Trading Discussion
- Dietary Management of Hypertension
- Chronic Dialysis: Now or Later?
- Photopheresis therapy for renal allograft rejectio...
- IN THE NEWS --->google as a diagnostician
- Live Donor Nephrectomy with vaginal extraction
- CLINICAL CASE 19, ANSWER AND SUMMARY
- IN THE NEWS- HYPOMAGNESEMIA AND PPI?
- JOB MARKET for RENAL FELLOWS
- Nephron Power: NYSN Fellows Boot camp
- NYSN Fellows Boot camp
- TOPIC DISCUSSION: captopril and stones?
- Topic Discussion: D-Lactate vs D-lactic acid
- ▼ July (48)