In two studies, dialysis patients with NSF were significantly more likely than those without NSF to have been exposed to gadolinium.
Nephrogenic systemic fibrosis (NSF), also called nephrogenic fibrosing dermopathy, is a recently described syndrome that occurs mainly in patients with chronic renal failure who have undergone contrast-enhanced magnetic resonance imaging with gadolinium. The syndrome presents with swelling, tightening, and hyperpigmentation of skin (usually in the extremities) and may limit joint mobility.
In a retrospective study from Scotland, researchers identified 14 NSF cases (0.8%) among 1826 patients with chronic renal failure who underwent dialysis between 2000 and 2006. Previous exposure to gadolinium-enhanced MRI was documented in 93% of patients with NSF, in contrast to 23% of those without NSF. Among exposed patients, the cumulative gadolinium dose was significantly higher in patients with NSF than in those without.
In a cross-sectional study from Boston, researchers systematically examined 186 hemodialysis patients and found skin manifestations of NSF in 25 (13%). Among 90 patients for whom data were available, gadolinium exposure was documented in 94% of patients with NSF, in contrast to 52% of patients without NSF. During 2 years of follow-up, mortality was significantly higher in patients with NSF than in patients without.
Comment: These reports suggest that nephrogenic systemic fibrosis is not vanishingly rare among patients on dialysis. The retrospective study might have
underestimated the prevalence because there was no systematic effort to diagnose NSF in that cohort; the cross-sectional study might have overestimated the prevalence if examiners too liberally labeled skin abnormalities as NSF.
In a recent FDA alert, clinicians were urged to avoid gadolinium-enhanced MRI for patients with advanced renal failure whenever possible. In my institution, patients are now asked about renal disease before they receive gadolinium. When compelling indications exist for gadolinium-enhanced MRI in a hemodialysis patient, the FDA suggests performing dialysis promptly after the MRI.
Published in Journal Watch General Medicine October 16, 2007
Collidge TA et al. Gadolinium-enhanced MR imaging and nephrogenic systemic fibrosis: Retrospective study of a renal replacement therapy cohort. Radiology 2007 Oct; 245:168.