To The Editor:
We read with great interest the article by Pei and Xie in the January 2009 issue of Academic Radiology . The authors suggest evaluating patients with chronic kidney disease using gadolinium-enhanced perfusion magnetic resonance (MR) imaging. In their study, the authors used gadolinium diethylenetriamine penta-acetic acid (Gd-DTPA). Pei and Xie state in the introduction that “Gd-DTPA is not contraindicated in patients with impaired renal function , and it is therefore possible to study renal perfusion and excretion in patients with chronic renal dysfunction using dynamic MRI.” The quoted source, by Haustein et al , focuses on the evolution of serum creatinine level in the 5 days after gadolinium injection. It is worth noting that this study was published in 1992, 14 years before the discovery of a possible link between gadolinium injection and nephrogenic systemic fibrosis . Today, Gd-DTPA is known to be one of the gadolinium contrast agents that may induce nephrogenic systemic fibrosis. Furthermore, chronic kidney disease is known to be a major risk factor for this very severe disease, whose first signs may occur as late as 3 months after the injection.
Guidelines from the European Society of Uroradiology recommend avoiding the use of Gd-DTPA, gadodiamide, and gadoversetamide in at-risk patients. In patients with chronic kidney disease, other gadolinium contrast agents, preferably cyclic, must be used, at the lowest dose possible to achieve a diagnostic examination.
At the beginning of MR renography, Gd-DTPA was the most commonly used gadolinium contrast agent, under the assumption that it would have similar pharmacokinetics as 99m Technetium-DTPA. However, it has been recently proved that Gd-DTPA is filtered much faster than 99m Technetium-DTPA .
Furthermore, several studies have shown the advantages and the feasibility of MR renography with low doses of gadolinium contrast agents (0.025 mmol/L or 2–4 mL) in adults. These doses help avoid the susceptibility effects associated with high concentrations of gadolinium contrast agents in the renal medulla and collecting system.
In our opinion, the choice of Gd-DTPA and the rationale for a 20-mL injection should be more discussed.
References
1. Pei X.L., Xie J.X.: Functional MRI: evaluation of chronic kidney disease with perfusion imaging. Acad Radiol 2009; 16: pp. 88-95.
2. Haustein J., Niendorf H.P., Krestin G., et. al.: Renal tolerance of gadolinium-DTPA/dimeglumine in patients with chronic renal failure. Invest Radiol 1992; 27: pp. 153-156.
3. Grobner T.: Gadolinium—a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis?. Nephrol Dial Transplant 2006; 21: pp. 1104-1108.
4. Thomsen H.S.: ESUR guideline: gadolinium-based contrast media and nephrogenic systemic fibrosis. Eur Radiol 2007; 17: pp. 2692-2696.
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8. Teh H.S., Ang E.S., Wong W.C., et. al.: MR renography using a dynamic gradient-echo sequence and low-dose gadopentetate dimeglumine as an alternative to radionuclide renography. AJR Am J Roentgenol 2003; 181: pp. 441-450.
9. Lee V.S., Rusinek H., Johnson G., Rofsky N.M., Krinsky G.A., Weinreb J.C.: MR renography with low-dose gadopentetate dimeglumine: feasibility. Radiology 2001; 221: pp. 371-379.