🧩Gadolinium (Gd) and The Nephrologists/ Current Status:
⚡️Nephrologists are concerned about Gadolinium due to the fear of "Nephrogenic Systemic Fibrosis" (NSF)
🌀🎯This is a Tweetorial to reconsider our fears about NSF
@RenalFellowNtwk
@NephJC
@AinuNephrology
@AnandhUrmila
⚡️Nephrologists are concerned about Gadolinium due to the fear of "Nephrogenic Systemic Fibrosis" (NSF)
🌀🎯This is a Tweetorial to reconsider our fears about NSF
@RenalFellowNtwk
@NephJC
@AinuNephrology
@AnandhUrmila
🔬 What is NSF(Nephrogenic systemic fibrosis):
🌟Almost exclusively described in patients with advanced kidney disease
⚡️NSF= Unusual skin thickening+cd34dermal fibroblasts+Multiple organ involvement
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🌟Almost exclusively described in patients with advanced kidney disease
⚡️NSF= Unusual skin thickening+cd34dermal fibroblasts+Multiple organ involvement
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Journey of NSF:
🎞Year 2000 to Year 2020
📋First described in 2000 as Scleromyxedema like cutaneous illness/ All the described 15 pts were renal/dialysis pts
💡2006: Causative role of Gadolinium(Gd) suspected
🥊2007: FDA isssued Boxed warning
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🎞Year 2000 to Year 2020
📋First described in 2000 as Scleromyxedema like cutaneous illness/ All the described 15 pts were renal/dialysis pts
💡2006: Causative role of Gadolinium(Gd) suspected
🥊2007: FDA isssued Boxed warning
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⁉️What is GBCA(Gadolinium Based Contrast Agent)
💉🧲GBCA=Gd+cheating agent, used as MR contrast
🔩Why Chelating Agent: To bind & stabilise Free Gd,which is toxic
☠️Why free Gd is toxic: bind to inorganic anion⛓🔜Precipitate in tissues🔜Fibrotic reaction
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💉🧲GBCA=Gd+cheating agent, used as MR contrast
🔩Why Chelating Agent: To bind & stabilise Free Gd,which is toxic
☠️Why free Gd is toxic: bind to inorganic anion⛓🔜Precipitate in tissues🔜Fibrotic reaction
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🟥🟩🟨 Does all GBCA created equal?
No. All are not equal with regard to their likelihood to cause NSF
📌There are 3 groups. Group 1 is notoriously associated with NSF. Group
2 has a good track record. Group3 are newcomers. Group 3=no data/ bad or good players ?
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No. All are not equal with regard to their likelihood to cause NSF
📌There are 3 groups. Group 1 is notoriously associated with NSF. Group
2 has a good track record. Group3 are newcomers. Group 3=no data/ bad or good players ?
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⁉️How common is NSF?
1️⃣Gr 1 GBCA usage in Renal Failure pts: Historically NSF was associated with 1-7%
>80% were dialysis Pts.
Only 3% in CKD/S 4-5ND
NSF in AKI: 12-20%
2️⃣Group 2 GBCA: Till now no confirmed cases of NSF🏅🏆
3️⃣Gr 3: Insufficient data🎭
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1️⃣Gr 1 GBCA usage in Renal Failure pts: Historically NSF was associated with 1-7%
>80% were dialysis Pts.
Only 3% in CKD/S 4-5ND
NSF in AKI: 12-20%
2️⃣Group 2 GBCA: Till now no confirmed cases of NSF🏅🏆
3️⃣Gr 3: Insufficient data🎭
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🎭Does the trend of NSF in the current era changed ?
✅Yes. ⚡️⬇️⬇️
🛑>70 fold ⬇️ from 2008 to 2019
In the meta analysis by Woolen et al, the pooled incidence of NSF was zero of 4931 patients
🎯So, it is the time to reconsider our fears about NSF due to GBCA in the current era
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✅Yes. ⚡️⬇️⬇️
🛑>70 fold ⬇️ from 2008 to 2019
In the meta analysis by Woolen et al, the pooled incidence of NSF was zero of 4931 patients
🎯So, it is the time to reconsider our fears about NSF due to GBCA in the current era
6/
🚨How to Prevent NSF in Renal failure Patients ?
(A)🚥Every time ask: Is there suitable alternative imaging modality ?
(B)❌Avoid Gr 1 & 3 GBCA ; Prefer Gr 2 GBCA
(C)💡To consider Hemodialysis if GBCA usage is planned
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(A)🚥Every time ask: Is there suitable alternative imaging modality ?
(B)❌Avoid Gr 1 & 3 GBCA ; Prefer Gr 2 GBCA
(C)💡To consider Hemodialysis if GBCA usage is planned
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🧩Are GBCAs dializable ?
👍Yes. Very well dializable as their MW is 500 to 1000 Dalton
🌟Negligible protein binding
❄️Minimal Lipid Binding
🌈4 Hour HD 🩸🌀🔆 = 78% clearance of Gr 1 GBCA & 97% clearance of Gr2 GBCA
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👍Yes. Very well dializable as their MW is 500 to 1000 Dalton
🌟Negligible protein binding
❄️Minimal Lipid Binding
🌈4 Hour HD 🩸🌀🔆 = 78% clearance of Gr 1 GBCA & 97% clearance of Gr2 GBCA
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🔥How to approach a Dialysis Pt who requires GBCA administration?
⚡️⚡️Plan HD at the earliest after Gd MR imaging🕚
⚡️⚡️First HD soon after MR imaging and another HD session after 24 Hours
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⚡️⚡️Plan HD at the earliest after Gd MR imaging🕚
⚡️⚡️First HD soon after MR imaging and another HD session after 24 Hours
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♨️Approach to a Pt of Stage 4-5 ND CKD and AKI not on Dialysis
💉Use Gr 2 GBCA exclusively
👍👍If Gr 2 GBCA are used, no need for prophylactic HD
🔥But, if administering Gr 1 or Gr 3 GBCA is the only choice, than two dialysis sessions on two consecutive days is mandatory
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💉Use Gr 2 GBCA exclusively
👍👍If Gr 2 GBCA are used, no need for prophylactic HD
🔥But, if administering Gr 1 or Gr 3 GBCA is the only choice, than two dialysis sessions on two consecutive days is mandatory
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♨️Approach in a Pt of CKD with eGFR > 30
✅Any Group of GBCA can be used
❇️No need to enforce any special precaution (ACR mentions that not even informed consent is needed but subject to local policies)
🆘🛑But, standard rules apply: Lowest dose/explore alternative Dx test
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✅Any Group of GBCA can be used
❇️No need to enforce any special precaution (ACR mentions that not even informed consent is needed but subject to local policies)
🆘🛑But, standard rules apply: Lowest dose/explore alternative Dx test
11/
Take Home Message:
🔰We need to reconsider our affinity for Gadolinium contrast..
But, the Age old rule applies:
🤝Trust not a new friend nor an old enemy.
🛑Same applies to newer Group 2 GBCA.
✅Use them but not without reservations.
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🔰We need to reconsider our affinity for Gadolinium contrast..
But, the Age old rule applies:
🤝Trust not a new friend nor an old enemy.
🛑Same applies to newer Group 2 GBCA.
✅Use them but not without reservations.
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