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A TIMELY REMINDER ABOUT AN EVOLVING CLINICAL ENTITY: NEPHROGENIC SYSTEMIC FIBROSIS AND GADOLINIUM USE IN CKD

To the Editor: I read with great interest the letter by Hedley et al. The authors should be congratulated for providing a timely reminder regarding this new clinical entity of nephrogenic systemic fibrosis (NSF) and its possible relation to the use of Gadolinium (Gd). Presently there seems to be little awareness regarding this entity. Gadolinium is almost entirely eliminated by the kidneys with a half-life of 70–90 min in people with normal renal function. In people with chronic kidney disease (CKD) Gd has a prolonged half-life and is likely to accumulate in skin and soft tissues eliciting an inflammatory response, leading to NSF. High et al. demonstrated Gd in four out of 13 skin and soft tissue biopsies of seven patients with NSF up to 11 months after Gd exposure. Strong epidemiologic associations are emerging, linking NSF to the exposure to Gd. A population-based study calculated the incidence of NSF in patients with CKD to be 2.4% per Gd-based contrast study. The International NSF registry at Yale University has around 217 patients in its database. A survey by it revealed that around 95% of the 100 patients studied until now had a history of exposure to Gd-based contrast agent for magnetic resonance imaging studies within 2–3 months of the diagnosis. Given the permanent and progressive nature of NSF and the debilitating consequences, it is hoped that ANZSN will soon come out with recommendations/ guidelines regarding the use of Gd-based contrast agents in the CKD population. While prompt and intensive dialysis after Gd exposure may be logical for those already on dialysis treatment, the vexed issue of managing predialysis patients remains.