Presentation is loading. Please wait.

Presentation is loading. Please wait.

Welcome to IM Department Meeting!

Similar presentations

Presentation on theme: "Welcome to IM Department Meeting!"— Presentation transcript:

1 Welcome to IM Department Meeting!
Gadolinium Based Contrast Exposure and Risk of Nephrogenic Systemic Fibrosis Tonight’s Facilitators: Barbara Doerr, DO William Myers, DO Staci Smith, DO Michelle Cacek, DO

2 Nephrogenic Systemic Fibrosis (NSF)
originally named nephrogenic fibrosing dermopathy (NFD) manifestations initially thought to be confined to the skin systemic fibrosis on autopsy (NSF) skeletal muscles ,diaphragm ,pleura ,dura mater, pericardium & myocardium

3 Nephrogenic Systemic Fibrosis (NSF)
predominately in pts with acute kidney injury or severely impaired renal function CrCl less than 30 no predilection for age, race, gender ,or location typically middle aged pts reported in 8 yo children, as well as elderly

4 What’s the risk? risk of NSF estimated at 4.3 cases per 1,000 dialysis patients per year about 2.4 % for each time a CKD pt is exposed to gadolinium balancing benefit and risk majority of pts who receive Gd do not develop NSF

5 What’s the issue with NSF?
avoidance of GBCA’s limited radiological studies roadblocks to specific dx litigation opportunities

6 September 12, 2007

7 Boxed Warning Gadolinium based contrast agents increase risk of NSF in pts with: acute and chronic renal failure (GFR < 30) acute renal insuffciency of any severity due to hepatorenal syndrome or in perioperative liver transplant period

8 What is Gadolinium? nonionic, hyperosmolar (650 mosmol/kg) contrast agent metal with powerful magnetic properties contrast for MR imaging or MR angiography chelates are excreted exclusively by the kidney

9 Gadolinium Half Life 1.3 hrs if healthy
10 hrs at GFR of mL/min 34 hrs if ESRD hrs if HD follows administration

10 Gadolinium Based Contrast Agents
Omniscan launched in the U.S. in 1993 by GE Magnevist MultiHance OptiMARK ProHance

11 Risk factors for NSF renal impairment hypercoagulable state
thrombotic events recent vascular study transplant failure Hepatorenal syndrome, liver transplant

12 Signs and Symptoms of NSF
burning skin itchy skin swelling tight and hard skin red or dark skin patches contractures stiffness in joints trouble moving extremities pain deep in the bones muscle weakness “woody” feel of skin yellow scleral plaques

13 NSF Upper Extremity thick, hardened skin brawny hyperpigmentation
distinct papules subcutaneous nodules

14 NSF Upper Extremity soft-tissue swelling flexion contractures of hand

15 NSF slightly raised and erythematous nodular plaques
linear, confluent regions of fibrosis

16 Differential Diagnosis
scleroderma / systemic sclerosis eosinophilic fasciitis eosinophilia–myalgia syndrome

17 Differential Diagnosis
Unlike scleroderma NSF spares the face lacks the serologic markers of scleroderma symmetrical lesions prefers trunk and extremities

18 Punch Biopsy : Skin widening of subcutaneous septae w/ thick collagen bundles

19 Histological Findings and Pathogenesis
thick collagen bundles with surrounding clefts mucin deposition increased fibrocytes and elastic fibers increased factor XIIIa and mononucleated cells THICK AND WAVY BUNDLES!!

20 Topic Development: PICO
Patient Population I Intervention or Exposure C Comparison Intervention O Outcome

21 Question ??? What degree of kidney disease should we not use gadolinium based contrast agents ?

22 Article Nephrogenic Fibrosing Dermopathy/ Nephrogenic Systemic Fibrosis: Report of a New Case with Literature Review Daram, et al. AJKD, Vol 46, No 4, 2005, pp

23 Evidence Based Medicine
Nephrogenic Fibrosing Dermopathy /Nephrogenic Systemic Fibrosis: Report of a New Case with Literature Review Daram ,et al. AJKD 2005

24 Introduction- NSF: Report of a New Case
first cases of NSF recognized in 2000 renal dysfunction pts regardless of cause not just HD pts, PD pts as well other associations: vascular sx vascular thrombosis scleral plaques

25 The Patient: NSF: Report of a New Case
39 yo AAM ESRD on HD d/t HTN for 8 yrs multiple medical problems antiphospholipid ab syndrome no other rheumatologic history 3 yrs before hospital admission stiff fingers and arms thickening skin on calves and thighs rapid progression to contractures

26 The Patient- NSF: Report of a New Case
pt’s lab data -p 755 fibrosis around translumbar HD cath pt expired after 45 min of ACLS autopsy results extensive fibrosis plaque like changes across chest, extremities contractures thickened pleura dense collagenous bands fibrotic cardiac tissue

27 NSF: Report of a New Case
taut, waxy appearance cobblestone pattern fig 1B

28 NSF: Report of a New Case
chest wall w/thick dermis dense white fibrous bands in septa

29 NSF: Report of a New Case
haphazardly arranged collagen bundles w/ clefts

30 NSF: Report of a New Case
diaphragm section fibrous bands fibroblast like cells

31 NSF: Report of a New Case
dendritic projections on CD34 cells CD45 RO cells

32 Discussion- NSF: Report of a New Case
NFD is not merely a cutaneous disease systemic manifestations muscle, pleura, diaphragm, myo and pericardium initiating factors in NSF tissue injury hypercoagulable state

33 Discussion - NSF: Report of a New Case
NSF involves aberrant fibrocyte recruitment decrease EPO due to fibrogenic properties NO consistent treatment proven effective

34 Article Nephrogenic Systemic Fibrosis After Exposure to Gadolinium in Patients with Renal Failure Othersen, J. et al, Nephrology Dialysis Transplantation, Sept 21, 2007, p 1-7.

35 Evidence Based Medicine
Nephrogenic Systemic Fibrosis After Exposure to Gadolinium in Patients with Renal Failure

36 NSF After Gadolinium Exposure
Purpose: analyze NSF incidence association of NSF with gadolinium exposure in CKD pts both pre-dialysis and dialysis pts determine if increased gadolinium exposure increases NSF

37 NSF After Gadolinium Exposure
Methods: 849 total pts in 5 yr time span ( ) Nephrology at Medical University of SC discussed with Dermatology stratified by gadolinium exposure 0, 1, or greater than 1 statistical association between NSF rate and gad exposure statistical association of increasing gad exposure and NSF occurrence

38 NSF After Gadolinium Exposure
Methods: CKD pts NOT on dialysis 592 pts or 4% had CKD 3 – 4 6,636 total pts received gad from skin bx w/ immunoperoxidase staining for CD 34

39 NSF After Gadolinium Exposure
Results: 849 total pts 261 had 354 MRI scans w/ gadolinium (Omniscan) 1 time exposure in 191 pts 2 exposures in 53 3 exposures in 13 4 exposures in 5

40 NSF After Gadolinium Exposure
NSF Incidence Never 0% One time 1.1% Greater than one time 2.9%

41 NSF After Gadolinium Exposure
Results: Pts on Dialysis overall NSF rate 0.5% (4 of 261) 1.5% risk of NSF after one gad exposure 98.5% did not develop NSF odds ratio 6.67 w/ one exposure 44.5 odds ratio with multiple exposures skin lesions appeared within 2-3 mo strong statistical association with NSF and gadolinium exposure

42 NSF After Gadolinium Exposure
Results : CKD 3 – 4 pts no patients discovered to have NSF incidence estimated at <0.2% possibly due to only 4% have CKD 3-4

43 NSF After Gadolinium Exposure
Conclusions: NSF incidence is very low increased exposure leads to increased risk higher Ca, Phos, and Epo may be associated with increased NSF incidence NO need for gad restriction in CKD 3- 4 monitor skin for 4-6 mo if gad is used consider dialysis immediately after exposure kidney transplant therapy in future

44 Concluding Points A Academic Detailing R Reminders E Enticements Audit

45 Concluding Points: Academic Details
Academic Detailing: Medical knowledge NSF Patient care Communication OMM/OPP Systems based practice Physician interacts with healthcare system Practice based learning Physicians maintain knowledge and skills to provide ongoing pt care

46 Osteopathic Considerations
myofascial release indirect techniques whole body approach

47 Osteopathy in Action NSF registry CDC FDA
collects info about NSF pts from all over the world General Clinical Research Center at Yale University CDC FDA 1-800-FDA-1088

48 Systems Based Practice
acute NSF: 58089 chronic NSF: 5829 include CKD staging: 585.- principal procedure MRI imaging: 8897

49 Systems Based Practice
Cerebral a. occlusion w/ cerebral infarction DRG: 43491 $5,246.24 Medicare Cerebral a. occlusion w/ cerebral infarction plus acute NSF DRG: 43491, 58089 $7,877.25 Medicare

50 Reminders Carepath in future screening baseline kidney fxn / size
acute kidney injury vs CKD CrCl –when not to use gadolinium follow-up labs after gadolinium use when to dialyze ESRD pts if GBCA used

51 Enticements/ Systems Based Practice
MRI imaging: DRG 8897 MRI brain w/ contrast: $3,692 MRI brain w/o contrast: $2,255 MRI thoracic/lumbar spine w/ contrast : $2,465 MRI thoracic/lumbar w/o contrast: $2,144

52 Audit How can we measure outcomes and progress?
Practice habits changed in the future?

53 Conclusions : Take Home Points
interest of pt safety balance benefits and risks of GBCA’s screen all pts with labs and history GBCA’s should NOT be used if CrCl <30 careful consideration if CrCl <60 alternative imaging methods

54 Conclusions: Take Home Points
monitor for skin manifestations after GBCA follow labs after administration do not exceed recommended dose mmol/kg allow time for elimination before readministration

55 Please Join Us Next Month
IM Journal Club presented by Dr. Bryan laryngeal reflux and proton pump inhibitors

56 References Nephrogenic Fibrosing Dermopathy /Nephrogenic Systemic Fibrosis: Report of a New Case with Literature Review.Daram ,et al. AJKD 2005. Nephrogenic Systemic Fibrosis After Exposure to Gadolinium in Patients with Renal Failure. Othersen, J. et al, Nephrology Dialysis Transplantation, Sept 21, 2007, p 1-7.

57 Happy Halloween !! Trick or treat

58 References
Gadodiamide-Associated Nephrogenic Systemic Fibrosis: Why Radiologists Should Be Concerned . Dale R. Broome et al. AJR 2007; 188: Adverse Reactions to Gadolinium Contrast Media: A Review of 36 Cases. Murphy,et al. AJR, Oct 1996:

Download ppt "Welcome to IM Department Meeting!"

Similar presentations

Ads by Google