How bad is the risk of nephrogenic systemic fibrosis (NSF) from gadolinium-based contrast agents (GBCAs) in different stages of chronic kidney disease (CKD)? A @radiology_rsna #MedEd #RadInTraining #tweetorial.

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Drs. Shankar and Davenport from @UMichRadiology answer this Q in a fantastic meta-analysis of 16 studies done with group II GBCAs in stage 4 versus 5 CKD patients, published as @radiology_rsna article at https://pubs.rsna.org/doi/full/10.1148/radiol.2020201492.

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The National Kidney Foundation specifically requested this stratified risk analysis (by CKD stage) of NSF after giving Group II GBCAs. The risk of NSF from Group I GBCAs, by the way, is already known to increase with decreased eGFR, especially in patients on dialysis.

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All 16 studies included in the meta-analysis had already specified the group II GBCA administered, stratified by CKD stage, and discussed whether the patient was on dialysis. All studies had also, of course, reported the incidence of NSF.

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Group II GBCAs include gadobenate dimeglumine (MultiHance), gadobutrol (Gadavist), gadoterate meglumine (Dotarem), and gadoteridol (ProHance).

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Results stratified by CKD stage for each of the GBCAs showed zero cases for NSF. Upper limits for the 95% confidence interval were calculated for each of the group II GBCAs based on the data analyzed, see table below.

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In this article, results showed that administering group II GBCAs in patients with stage 4 or 5 CKD confers a mean NSF risk that is:
a.always <100%
b.<10%, 95% of the time
c.<1%, 95% of the time
d.equal to zero

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Ans: C. Astounding. The authors concluded that the risk of NSF in patients receiving group II GBCA is very low, and that the safety profile of these group II GBCAs with respect to NSF is excellent.

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Take-Away #1: The authors’ preceding @JAMANetwork analysis showed group II GBCAs are safe (upper limit for 95% CI <0.07%) with low risk of NSF in stage 4-5 CKD. This analysis stratifies and affirms a low risk of NSF across all stages.

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Take-Away #2: The current recommendation to avoid group II GBCAs in patients with stage 4 or stage 5 CKD can now be appropriately weighed against the benefits of giving GBCAs. The authors encourage revising existing guidelines based on this evidence.

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Check out the full @radiology_rsna paper at https://pubs.rsna.org/doi/full/10.1148/radiol.2020201492. We encourage any thoughts or questions below! Thank you! #RadInTraining #MedEd #Tweetorial #radres

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