Medios de contraste intravascular en tomografía computada y resonancia magnética: lo que el clínico necesita saber / Intravascular contrast media in computed tomography and magnetic resonance imaging: what the clinician needs to know

Introducción: los medios de contraste en radiología se utilizan para mejorar la visibilidad de los tejidos normales y patológicos, lo que permite distinguirlos entre sí mediante la modificación de las características de imagen de los tejidos. Permite no solo una mejor evaluación morfológica de las lesiones, sino también una evaluación cinética funcional y de contraste. Objetivos: presentar una revisión actualizada sobre los medios de contraste intravascular en radiología, con énfasis en los conceptos que el médico clínico no radiólogo debe tener presente al momento de su indicación. Métodos: se realizó una revisión bibliográfica de literatura radiológica relevante sobre medios de contraste intravascular: clasificación, indicaciones, contraindicaciones y precauciones que debe adoptar el médico clínico. Resultados: aunque los medios de contraste en radiología tienen un excelente perfil de seguridad, su uso no está exento de riesgos y debe basarse en criterios apropiados después de una evaluación clínica exhaustiva, ponderando riesgos y beneficios para cada paciente individual. Conclusión: la comunicación entre médicos tratantes, nefrólogos y radiólogos es funda-mental para evaluar casos clínicos complejos o que requieran consideraciones especiales al momento de indicar la administración de un medio de contraste intravascular.

Introduction: Imaging contrast media are used to enhance the visibility of normal and pathologic tissues, allowing distinction of one another by modifying tissue imaging characteristics. This allows both enhanced morphologic assessment of lesions and also contrast kinetics evaluation. Objectives: To present an updated review on intravascular imaging contrast media. Emphasis will be put on useful concepts that general physicians must take into account when indicating contrast-enhanced imaging studies.Methodology: A bibliographic review of relevant imaging literature on intravascular contrast media was performed: classification, appropriate indications, contraindications, and tips for proper use by the general physician. Results: Although imaging contrast media have an excellent safety profile, its use is not risk-free and must be based on appropriateness criteria applied after a thorough clinical evaluation, balancing the risks and benefits for each patient. In particular, intravascular contrast media, such as those based on iodine for computed tomography and gadolinium chelates for magnetic resonance imaging, must be used with caution. Conclusion: Effective communication between radiologists and referring physicians is key in the evaluation of complex cases that require protocol adjustments when considering the use of intravascular contrast media for imaging studies.

In vivo Imaging Biodistribution Profile of a New Macrocyclic Gadolinium Chelate as a Highly Stable Multifunctional MRI Contrast Agent

Gadolinium contrast agents (CAs) are integral components of clinical magnetic resonance imaging (MRI). However, safety concerns have arisen regarding the use of gadolinium CAs, due to their association with nephrogenic systemic fibrosis (NSF). Furthermore, recently the long-term retention of Gd²⁺-based CAs in brains patients with normal renal function raised another possible safety issue. The safety concerns of Gd²⁺-based CAs have been based on the ligand structure of Gd²⁺-based CAs, and findings that Gd²⁺-based CAs with linear ligand structures showed much higher incidences of NSF and brain retention of CAs than Gd²⁺-based CAs with macrocyclic ligand structure. In the current study, we report the in vivo biodistribution profile of a new highly stable multifunctional Gd²⁺-based CA, with macrocyclic ligand structure (HNP-2006). MR imaging using HNP-2006 demonstrated a significant contrast enhancement in many different organs. Furthermore, the contrast enhanced tumor imaging using HNP-2006 confirmed that this new macrocyclic CA can be used for detecting tumor in the central nervous system. Therefore, this new multifunctional HNP-2006 with macrocyclic ligand structure shows great promise for whole-body clinical application.

Gadolinium Deposition in the Brain: Current Updates

Gadolinium-based contrast agents (GBCAs) are commonly used for enhancement in MR imaging and have long been considered safe when administered at recommended doses. However, since the report that nephrogenic systemic fibrosis is linked to the use of GBCAs in subjects with severe renal diseases, accumulating evidence has suggested that GBCAs are not cleared entirely from our bodies; some GBCAs are deposited in our tissues, including the brain. GBCA deposition in the brain is mostly linked to the specific chelate structure of the GBCA: linear GBCAs were responsible for brain deposition in almost all reported studies. This review aimed to summarize the current knowledge about GBCA brain deposition and discuss its clinical implications.

Imágenes del depósito de gadolinio en el sistema nervioso central / Images of gadolinio deposit in the central nervous system Abstract

Magnetic resonance imaging has been shown to be very useful in the diagnosis and monitoring of multiple diseases affecting the central nervous system. Gadolinium has been used extensively worldwide. It has been estimated that since its introduction more than two hundred million doses of GBCA have been administered globally. Gadolinium-based contrast agents (GBCAs) were long considered medicines with a high safety profile, the literature reports incidences of immediate adverse effects such as headache, dizziness, and altered sense of taste. Studies performed a few years after the introduction of GBCA showed that there were gadolinium deposits in the tissues but their clinical significance was not known. It wasn’t until 2006 when the first reports were published that associated the gadolinium ion tissue deposits from GBCA with a systemic inflammatory entity of the connective tissue similar to scleroderma known as Nephrogenic Systemic Fibrosis (NSF), in patients with chronic renal failure. In 2013, the association between the use of GBCAs and the progressive increase in the signal intensity of the dentate nucleus and the globus pallidus in T1-weighted MRI images without contrast medium, was described for the first time. This review describes the most relevant aspects of the pathophysiology of these findings taking into account their differential diagnosis.

Las imágenes por resonancia magnética han mostrado ser de gran utilidad en el diagnóstico y seguimiento de múltiples enfermedades que afectan el sistema nervioso central. El gadolinio se ha utilizado ampliamente a nivel mundial. Se estima que desde su introducción se han administrado más de doscientos millones de dosis de MCBG en el mundo. Los medios de contraste basados en Gadolinio (MCBG) fueron considerados por mucho tiempo medicamentos con un alto perfil de seguridad, la literatura reporta incidencia de efectos adversos inmediatos como cefalea, mareo y alteración del sentido del gusto. Estudios realizados pocos años después de la introducción de los MCBG mostraron que había depósitos de gadolinio en los tejidos, pero no se conocía su significancia clínica Fue hasta 2006 cuando se publicaron los primeros reportes que asociaban el depósito tisular del ion gadolinio proveniente de los MCBG con una entidad inflamatoria sistémica del tejido conectivo similar a la escleroderma conocida como Fibrosis Sistémica Nefrogénica (FSN) en pacientes con falla renal crónica. En 2013 se describió por primera vez la asociación entre el uso de los MCBG y el aumento progresivo de la intensidad de señal del núcleo dentado y los globos pálidos en las imágenes de RM ponderadas en T1 sin medio de contraste. En esta revisión se describen los aspectos más relevantes de la fisiopatología de estos hallazgos considerando su diagnóstico diferencial.

Análisis de costo efectividad del ácido gadotérico frente a otros medios de contraste basados en gadolinio / Analysis of Cost Effectiveness of Gadoteric Acid versus Other Contrast Agents Gadolinium-Based

Objetivo: Hacer una análisis de costo-efectividad en el uso del ácido gadotérico en resonancia magnética para pacientes con insuficiencia renal crónica tipo 4 y 5, en comparación con otros medios de contraste gadolínicos. Métodos: Mediante un modelo de árbol de decisión, desde la perspectiva del tercero pagador, se compararon diferentes medios de contraste gadolínicos. El desenlace de análisis fue sobrevida medida en años de vida ganados, para una esperanza de vida de 64,5 años y una edad promedio de 60 años. Se manejaron los precios del mercado obtenidos del Sistema de Información de Precios de Medicamentos, en pesos colombianos de 2013. Se evaluó el costo de las tecnologías para una presentación de 15 ml. Resultado: La efectividad de medios de contraste se evaluó en términos de seguridad. La principal complicación se encontró en la fibrosis sistémica nefrogénica luego del uso de estos medios de contraste en pacientes con enfermedad renal avanzada, siendo letal en más del 56 % de los casos. Se encontró que no se informan casos de fibrosis sistémica nefrogénica con el uso de ácido gadotérico y de gadobutrol. El primero mostró un promedio de años de vida de 1,706 y fue el menos costoso de todos. En el análisis tipo Montecarlo con variaciones de ±50 %, mantiene su dominancia en el 100 % de las iteraciones. Conclusiones: El ácido gadotérico es la opción más favorable por su dominancia y mejor o igual en efectividad frente a los demás medios de contraste gadolínicos.

Objective: To evaluate the cost - effectiveness of the use of gadoteric acid in magnetic resonance in patients with type 4 and 5 chronic renal failure, versus other gadolinic contrast media methods. Methods: From the perspective of a third party payer, different gadolinic contrast media were compared using a decision tree model. The analysis outcome was survival measured in years of life gained, for a life expectancy of 64.5 years an average age of 60 years. Market prices obtained from the Information System on Drug Prices for Colombia were handled in Colombian pesos (2013). The technology costs for a 15 ml presentation were evaluated. Result: The effectiveness of contrast media was assessed in terms of security. The main complication was nephrogenic systemic fibrosis in the use of these contrast media in patients with advanced renal disease. It was lethal in over 56% of cases. We found no cases of nephrogenic systemic fibrosis reported using gadoteric acid and gadobutrol. The first showed an average life of 1,706 years; and was the least expensive compared to all the analyzed ones. In the Monte Carlo analysis with variations of + / -50 %, it maintains its dominance in 100% of iterations. Conclusions: Gadoteric acid is the most favorable option due to its dominance. Its effectiveness is greater than or equal to the effectiveness of other contrast media.

Prevention of Nephrogenic Systemic Fibrosis / 대한내과학회지

Gadolinium is widely used as a contrast agent for magnetic resonance imaging (MRI). In patients with radiocontrast media-induced nephrotoxicity, MRI has generally been considered to be a safe substitute for computed tomography (CT). However, recent studies have described the potential emergence of gadolinium-related nephrogenic systemic fibrosis (NSF) in patients with advanced kidney disease. NSF is a fibrosing disorder seen only in patients with moderate to severe kidney failure; it is particularly common in patients on dialysis. Skin involvement occurs in all patients and is characterized by plaques, papules, nodules, thickening, and hardening of the skin overlying the extremities and trunk. Histopathologic examination of an incisional or punch biopsy of affected skin reveals marked expansion and fibrosis of the dermis with proliferation of CD34+ fibrocytes and long dendritic processes. There is no proven medical treatment for NSF other than recovery of renal function. Therefore, the currently recommended preventive measure for NSF in patients with advanced kidney failure is avoidance of gadolinium. Gadolinium-containing contrast agents, especially at high doses, should be used only if clearly necessary. Prompt commencement of hemodialysis may be necessary after gadolinium administration.

Fibrosis sistémica nefrogénica: la pandemia que no fue / Causal relationship between the use of gadolinium based contrast media and nephrogenic systemic fibrosis

Nephrogenic systemic fibrosis (NSF) is a severe iatrogenic disease that affect patients with impaired renal function exposed to gadolinium-based contrast agents. Clinically, symptoms develop within days or weeks after the exposure and mimic a scleromyxedema. The causal relationship between use of gadolinium-based contrast agents and NSF led to develop clinical guidelines aiming to limit the use of this contrast medium in high risk patients. These guidelines decreased the incidence of NSF in the last years. Unfortunately there is no specific treatment for NSF yet. Thus, strict adherence to current guidelines is key to prevent new cases. Renal dysfunction is increasingly common in our population. Therefore, practicing physicians should be aware of this potential complication of the use of gadolinium based contrast media.

Nephrogenic systemic fibrosis: concepts and perspectives / Fibrose nefrogênica sistêmica: conceitos e perspectivas

Nephrogenic systemic fibrosis is a chronic, progressive condition that develops in some patients with renal impairment after exposure to gadolinium-based contrast agents used in magnetic resonance imaging. Thickening of the skin is typical, usually affecting the extremities. Visceral organs can also be affected. The diagnosis of the disease requires careful clinicopathological correlation. Treatment aims at restoring renal function, which is associated with delayed progression and, eventually, remission of skin changes. Reduction and prevention of nephrogenic systemic fibrosis cases are based on limiting the use of gadolinium-based contrast agents in patients with kidney disorders (especially in patients with advanced renal failure at stages 4 and 5), and restricting their use to situations in which they are essential to diagnosis/follow-up. Other than limiting exposure to gadolinium based contrast agents, no effective preventive methods have been reported. Due to increased awareness about the disease among radiologists and nephrologists, the incidence of nephrogenic systemic fibrosis is declining.

Fibrose nefrogênica sistêmica é condição crônica, progressiva, desenvolvida caracteristicamente em pacientes nefropatas após exposição a contrastes radiológicos que contenham gadolínio. O espessamento cutâneo é aspecto típico, envolvendo predominantemente as extremidades. Envolvimento visceral pode ocorrer. O diagnóstico da doença requer cuidadosa correlação clínico-patológica. O tratamento visa à restauração da função renal, que se associa ao retardo da progressão e, eventualmente, remissão das alterações cutâneas. A prevenção da ocorrência e redução da incidência baseiam-se na limitação do uso de contrastes à base de gadolínio em nefropatas (especialmente na insuficiência renal avançada em estágios 4 e 5), restringindo-os às condições nas quais seja imprescindível ao diagnóstico/acompanhamento. À exceção da restrição de exposição aos agentes de contraste a base de gadolínio, não há métodos preventivos efetivos relatados. Devido à ampla divulgação da doença entre radiologistas e nefrologistas, a incidência da fibrose nefrogênica sistêmica está em declínio.

Gadolinio y fibrosis sistémica nefrogénica / Gadolinium and nephrogenic systemic fibrosis

Inicialmente llamada dermopatía fibrosante nefrogénica, la fibrosis sistémica nefrogénica (FSN) está fuertemente ligada a la inyección endovenosa de medios de contraste -basados en gadolinio- en pacientes con insuficiencia renal. En esta revisión corta se analiza la fisiopatología y la clínica, la responsabilidad del radiólogo en la prevención a través de la puesta en práctica de las reglamentaciones vigentes y, por último, se mencionan algunos conceptos sobre el tratamiento de los pacientes con insuficiencia renal crónica que deben exponerse a la inyección de gadolinio...

Contrast Enhanced US in the Abdomen

Contrast enhanced ultrasound, which was introduced in 1996, has been widely used in Europe and Eastern Asia. Ultrasound contrast agent can be classified as first generation and second generation, depending on the gas within the microbubble. With the first generation contrast agent, the high MI technique was used, and only intermittent scanning was possible due to destruction of the microbubble during scanning. Use of the second generation contrast agent with the low MI technique makes continuous scanning possible. Contrast enhanced US can be used in detection and differentiation of focal liver lesions. It is also helpful for monitoring of radiofrequency ablation and for targeting of US guided biopsy. Currently, because morphologic criteria alone may not reflect the response of the tumor to treatment, new criteria are needed for treatment evaluation after administration of anti-angiogenic agents. Contrast enhanced US could provide quantitative markers for evaluation of the response to treatment via use of dynamic contrast enhanced US. Due to cost-effectiveness, contrast enhanced US is not yet widely used in Korea; however, considering recent issues regarding contrast agent related adverse reaction, such as contrast induced nephropathy and nephrogenic systemic fibrosis, and radiation exposure, contrast enhanced US might be more widely used in Korea, as an alternative imaging modality in the future.

A Case of Delayed Onset Nephrogenic Systemic Fibrosis After Gadolinium Based Contrast Injection

Nephrogenic systemic fibrosis (NSF) is a rare fibrosing disorder of the skin and joints that occurs in patients with advanced renal insufficiency. This condition is progressive and can be seriously disabling. Gadolinium based contrast agent (GBCA) has been identified as a potential cause of this condition. A 56-years-old man in hemodialysis developed stiffness and contracture of the whole limbs eight years after frequent GBCA exposure for cervical magnetic resonance imaging. For the first time in Korea, we report late-onset nephrogenic systemic fibrosis after GBCA exposure and performed an electrophysiologic study of this condition.

CO2 Angiography-1 / 대한혈관외과학회지

CO2 was firstly used as an intravenous contrast medium in the early 1950s for diagnosing pericardial effusion. In the 1970s Cho and Hawkins pioneered the intraarterial use of CO2. In 1980, with the appearance of digital subtraction angiography (DSA), excellent imaging of "low density" contrast material was available. CO2 can be used very safely not only in patients with contrast allergies and renal failure, but also in patients undergoing routine angiographic evaluations and many interventional procedures. Nowadays, conventional invasive vascular imaging is being replaced by high-technology imaging modalities, including ultrasound, computed tomography, and magnetic resonance angiography (MRA): however, angiography continues to be the gold common procedure. Gadodiamide has been proposed to replace iodinated contrast material in high-risk patients with contrast allergy and renal insuffieciency. Neither nonionic iodinated contrast medium nor gadolinium-based contrast medium is safe, because these contrast medium may cause allergic reactions or nephrotoxicity. In recent years, its gadolinium-containing contrast agents have been shown to cause nephrogenic systemic fibrosis in patients with end-stage renal disease. Therefore, the use of carbon dioxide as a contrast agent has increased significantly with its wide clinical applications, including the use of carbon dioxide during peripheral vascular stenting and abdominal aortic stent graft placement. Familiarity with the physical properties of carbon dioxide, avoidance of air contamination, catheterization techniques, vascular anatomy, physiologic monitoring, and radiation safety is essential for the safe and effective performance of carbon dioxide angiography. Recently, CO2 has been reported as a "black blood" contrast agent for MRA. Today, carbon dioxide is used worldwide as a contrast agent for numerous vascular and nonvascular procedures in various organs and arterial circulation below the diagram, as well as in the venous circulation. There are over 200 publications proving that CO2 is not nephrotoxic and is without any kind of allergy. For safe and reliable utilization, one must understand the principles of CO2 delivery in the vascular system. A very safe and inexpensive plastic bag delivery system (CO2 Plastic Bag Delivery System(TM), AngioDynamics, Inc., USA) has been used during the over past 20 years. High-resolution DSA 1024x1024 systems with high frame rates have produce images nearly comparable to those with iodinated contrast material.

Nephrogenic Systemic Fibrosis / 대한신장학회지

No abstract available.

MRI contrast media: What clinicians need to know.

Magnetic resonance imaging (MRI) is an imaging modality that uses the differential spinning of protons (hydrogen) in the body when exposed to an external magnetic field, to produce crosssectional images of the body. The advent of MRI is a boon to mankind as it does not involve ionizing radiation and provides superior soft tissue contrast even without administration of contrast media. The contrast media used in MRI were developed many years after MRI was already in use, the first being gadopentetate dimeglumine—a non-specific extracellular gadolinium chelate. Extracellular agents are the most widely used, although tissue-specific agents have been developed and are used as problem-solving tools in specific conditions. Tolerance to gadolinium-based contrast agents is excellent. The tissue-specific agents do have some adverse effects, though none of them are life-threatening. However, identification of a condition called nephrogenic systemic fibrosis has forced a rethink about the liberal usage of MRI contrast agents.

Nephrogenic systemic fibrosis following acute kidney injury and exposure to gadolinium.

Nephrogenic systemic fibrosis (NSF) is a scleroderma-like systemic fibrosing condition of unknown etiology described in patients with renal insufficiency. Gadolinium exposure has been strongly associated with the development of NSF though the mechanism of such injury is not known. There are only few reported cases of NSF in the setting of acute renal failure and fewer reported cases where skin lesions developed after kidney function had returned to normal. We report a case of NSF in a young Hispanic woman with lupus nephritis but normal creatinine, who received gadolinium during a brief episode of prerenal acute kidney injury not requiring dialysis, secondary to sepsis.

A case of nephrogenic systemic fibrosis following gadolinium exposure in a peritoneal dialysis patient / 대한내과학회지

Nephrogenic systemic fibrosis is a systemic illness that only affects patients with kidney failure. Exposure to gadolinium-based contrast agents has been associated with the subsequent development of nephrogenic systemic fibrosis in patients with decreased renal function. Nephrogenic systemic fibrosis is characterized by skin induration after swelling and limited joint movement through a loss in flexibility that preferentially affects the extremities. A 58-year-old man in peritoneal dialysis developed swelling and stiffness of the lower limbs following gadolinium exposure for brain magnetic resonance imaging. This patient was diagnosed with nephrogenic systemic fibrosis by CD34 immunoreactivity of subcutaneous fibroblasts in a skin biopsy. We report, for the first time in Korea, that nephrogenic systemic fibrosis developed after gadolinium exposure in a peritoneal dialysis patient.

A case of nephrogenic systemic fibrosis after gadolinium-based contrast agent injection / 대한내과학회지

Nephrogenic systemic fibrosis is a rare multisystemic disorder mainly affecting the skin and joints in patients with underlying renal insufficiency exposed to gadolinium-based contrast. We report a patient who had renal insufficiency caused by multiple myeloma and developed nephrogenic systemic fibrosis after exposure to gadolinium-based contrast for the first time in Korea.

Nephrogenic Fibrosing Dermopathy Improved after Renal Transplantation / 대한피부과학회지

Nephrogenic fibrosing dermopathy (NFD) is a rare cutaneous fibrosing disorder that primarily affects patients with a history of renal disease. NFD manifests with induration, thickening and hardening of the skin with brawny hyperpigmentation. Lesions are typically symmetrical and usually develop on the limbs and trunk. Flexion contractures of the joints may be a feature of the disease. Histopathological features of NFD include proliferation of dermal fibroblasts and dendritic cells, thickened collagen bundles, increased elastic fibers and focal mucin deposition. Although the pathogenesis remains largely unknown, some of the factors implicated in the pathogenesis include renal dysfunction, circulating fibrocytes, vascular injury, and gadolinium which is a contrast material used in magnetic resonance imaging. Currently, no definitive or uniformly effective therapies are available for the treatment of NFD. We herein describe the case of a 44-year-old female NFD patient who undergoes significant improvement of skin lesions and associated joint contracture after renal transplantation.

Nephrogenic systemic fibrosis: A review of the new conundrum.

Nephrogenic systemic fibrosis is an idiopathic, sclerosing condition that occurs only in patients who have impaired renal function. Although its most conspicuous manifestation is in the skin, the condition involves multiple organ systems and is potentially fatal. Its postulated association with gadolinium-based magnetic resonance contrast agents has attracted attention. The distinctive clinical features of this entity include a prodromal systemic inflammatory syndrome followed by a chronic course of fibrosis that has a predilection for the skin and subcutaneous tissues of the extremities. The progressive systemic fibrosing process involves multiple organs and contributes to the morbidity and the increased mortality. Appropriate preventive action, prompt recognition and timely reporting of cases may enable better management of this condition.