Nephrogenic systemic fibrosis

Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy, is a complication of gadolinium-based contrast agents used in imaging studies.

It is characterised by "firm, erythematous, and indurated plaques of the skin associated with subcutaneous oedema" 1. Eventually, flexure contractures develop, with restriction to movement, pain and pruritus. Although the skin is primarily involved, many solid organs (e.g. lungs, heart, diaphragm, liver, and kidneys) can also be involved, eventually leading to death.

Screening

Patients should be screened for the possible risk of developing NSF by using institutional screening questionnaires and calculating the eGFR 2:

  • renal transplant (20% develop NSF): should have eGFR checked
  • liver failure patients: should have eGFR checked
  • outpatient screening (not on dialysis): eGFR use is controversial as they rarely develop NSF
Recommendations

Avoid gadolinium-containing contrast agents in patients whose:

  • eGFR is <30 mL/min/1.73 m2
  • eGFR is <60 mL/min/1.73 m2 (probably) 1

"When contrast-enhanced MR imaging is requested for a patient with renal insufficiency who is hospitalised due to major surgery, major infection, or a thrombotic vascular event, alternative imaging is indicated to avoid the use of gadolinium-based contrast agents; this decision should be made after consultation with the referring service and the patient" 1.

In cases where contrast still needs to be given 2:

  • if eGFR <30 ml/min
    • take informed consent (risk of NSF <1/10,000 patients with eGFR <30 ml/min)
    • maximum dose of 0.1mmol/kg
    • adequate hydration must be provided
  • if the patient is on dialysis: (inpatient)
    • MRI should be done just before dialysis as the contrast can be removed by subsequent dialysis
    • some centres consider dialysis a strict contraindication
  • typically presents weeks to months after administration of Gd
  • typically involves the dermis in the extremities symmetrically, less commonly the trunk with the face spared, typically sparing the antecubital and popliteal fossae
  • presentation resembles scleromyxoedema or eosinophilic fasciitis
  • skin lesions: hyperpigmented, thickened brawny induration
  • joint contractures
  • pain, pruritus, skin tightness or burning sensation

The development of NSF with exposure to gadolinium-containing MRI contrast agents has been strongly reported in patients with moderate to end-stage renal impairment. This could be due to transmetallation, which is replacement of the gadolinium from the chelate and forming a free gadolinium ion, free gadolinium ions may then deposit in different tissues and result in inflammation and fibrosis. Low stability gadolinium contrast media show the strongest association with NSF 3. Additional positive risk modifiers (increase risk) include:

  • concurrent infectious/inflammatory condition
  • concurrent infarcted/ischaemic tissue (e.g. peripheral arterial thromboembolism)
  • recent surgery/trauma
Histology
  • deep dermal biopsy required
  • however findings are non-specific: thickened collagen bundle, mucin deposition, spindle cell proliferation, CD3 + fibroblasts
Contrast agents

The medical literature review has shown that ~78% of all unconfounded, single-agent cases of NSF have been associated with Omniscan® (gadodiamide), while ~20% have been associated with Magnevist® (gadopentetate dimeglumine), and less than 2%, with OptiMARK® (gadoversetamide) 4.

  • diffuse soft tissue tracer uptake on bone scans
  • skin thickening and subcutaneous stranding on multiple modalities
  • skin and muscle activity on PET
  • no consistently effective therapy
  • improved renal function: renal transplant, recovery from ARF
  • physical therapy
  • extracorporeal photopheresis, plasmapheresis, Ig therapy, steroids and other immunosuppression
MRI physics
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Article information

rID: 1719
Section: Pathology
Synonyms or Alternate Spellings:
  • NSF
  • Gadolinium and nephrogenic systemic fibrosis

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