NSF and kidney

Q: Patients with a history of a kidney transplant are at risk for nephrogenic systemic fibrosis (NSF) when exposed to gadolinium-based contrast agents (GBCA).

A) True

B) False

Answer: B

Although NSF is a true dreaded complication of GBCA, in various ways, it has been blown out of proportion in clinical practice. Deciding to have GBCA during MRI for patients with kidney dysfunction is always based on clinical judgement for risks vs benefits. Few patients are definitely at high risk and require a nephrologist's consent. In descending order, risk is highest in:

• End-stage kidney disease (ESRD) patients on dialysis of any type
• Acute kidney injury (AKI) 
• eGFR less than 30 mL/min per 1.73 m2

One important point that is often missed is that although a single dose of GBCA can induce NSF, it's usually multiple, cumulative, or higher-than-usual doses of GBCA that are responsible for NSF.

Prior kidney transplant, hepatorenal syndrome, perioperative liver transplantation, exposure to lanthanum carbonate, high-dose erythropoietin treatment, metabolic acidosis, proinflammatory conditions, and elevated iron or phosphate levels were proposed in the past as risk factors for NSF but were found to be unproven.

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#dermatology

References:

1. Shabana WM, Cohan RH, Ellis JH, et al. Nephrogenic systemic fibrosis: a report of 29 cases. AJR Am J Roentgenol 2008; 190:736.

2. Prince MR, Zhang HL, Roditi GH, et al. Risk factors for NSF: a literature review. J Magn Reson Imaging 2009; 30:1298.

3. Abu-Alfa AK. Nephrogenic systemic fibrosis and gadolinium-based contrast agents. Adv Chronic Kidney Dis 2011; 18:188.

4. Malikova H. Nephrogenic systemic fibrosis: the end of the story? Quant Imaging Med Surg. 2019 Aug;9(8):1470-1474. doi: 10.21037/qims.2019.07.11. PMID: 31559176; PMCID: PMC6732068.