What is the risk of nephrogenic systemic fibrosis associated with gadolinium (Gadolinium-based contrast agent) use in a post-lung transplant patient with Acute Kidney Injury (AKI)?

From the Guidelines

Gadolinium-based contrast agents can be used in post-lung transplant patients with acute kidney injury (AKI) when the diagnostic benefit outweighs the risk of nephrogenic systemic fibrosis (NSF), and group II gadolinium-based contrast media (GBCM) are preferred due to their lower risk of NSF 1. When considering the use of gadolinium-based contrast agents in post-lung transplant patients with AKI, it is essential to weigh the potential benefits against the risks. The risk of NSF is a significant concern, but the use of group II GBCM can minimize this risk.

Key Considerations

• The estimated glomerular filtration rate (eGFR) should be assessed before administration, but kidney function screening is optional for group II GBCM 1.
• Alternative imaging techniques without gadolinium should be considered when possible, such as non-contrast MRI sequences or other imaging modalities.
• If gadolinium must be used, the lowest possible dose should be administered, and prompt hemodialysis following the procedure may be considered for patients already on dialysis, though evidence for its effectiveness in preventing NSF is limited 1.
• The risk of NSF must be carefully weighed against the diagnostic benefit, with full documentation of the decision-making process and informed consent from the patient.

Recommendations

• Use group II GBCM, such as macrocyclic gadolinium agents (e.g., gadoterate meglumine, gadobutrol, or gadoteridol), at the lowest possible dose 1.
• Avoid using gadolinium-based contrast agents if eGFR is below 30 mL/min/1.73m², unless the diagnostic benefit outweighs the risk of NSF 1.
• Consider alternative imaging techniques without gadolinium when possible.
• Document the decision-making process and obtain informed consent from the patient.

From the FDA Drug Label

WARNING: RISK ASSOCIATED WITH INTRATHECAL USE and NEPHROGENIC SYSTEMIC FIBROSIS Nephrogenic Systemic Fibrosis GBCAs increase the risk for nephrogenic systemic fibrosis (NSF) among patients with impaired elimination of the drugs. Avoid use of Gadoteridol injection in these patients unless the diagnostic information is essential and not available with non-contrasted MRI or other modalities NSF may result in fatal or debilitating systemic fibrosis affecting the skin, muscle and internal organs. The risk for NSF appears highest among patients with: chronic, severe kidney disease (GFR less than 30 mL/min/1. 73 m 2), or acute kidney injury

The use of gadolinium contrast in a post-lung transplant patient with AKI (acute kidney injury) poses a risk of fibrosis, specifically nephrogenic systemic fibrosis (NSF).

• The patient's AKI increases the risk for NSF.
• Gadolinium-based contrast agents (GBCAs), such as gadoteridol, should be avoided in patients with impaired renal function unless essential and no alternative diagnostic methods are available 2. The risk of NSF is highest in patients with severe kidney disease or acute kidney injury, and the use of GBCAs in these patients may result in fatal or debilitating systemic fibrosis.

From the Research

Gadolinium Contrast in Post Lung Transplant Patient with AKI Risk of Fibrosis

• The use of gadolinium-based contrast agents in patients with renal impairment, such as those with acute kidney injury (AKI) after lung transplantation, is associated with an increased risk of nephrogenic systemic fibrosis (NSF) 3.
• NSF is a multisystem disease that can be severely debilitating and sometimes fatal, and its risk factors include renal impairment and proinflammatory conditions, such as major surgery and vascular events 3.
• The development of AKI after lung transplantation is a common complication, with an incidence of 42% reported in a Swedish nationwide study 4.
• AKI after lung transplantation is associated with increased mortality and morbidity, and its risk factors include preoperative factors such as higher body mass index, longer time on transplantation waiting list, re-transplantation, and moderate to severe tricuspid regurgitation 4.
• Intraoperative factors, such as the use of cardiopulmonary bypass, increasing number of transfused red blood cell units, and use of immunosuppressive therapy other than routine, are also independently associated with an increased incidence of AKI 4.
• The development of AKI is associated with negative clinical outcomes, including increased time to extubation, length of stay in the intensive care unit, and increased rate of primary graft dysfunction and 30-day mortality 4.
• Close monitoring of urine output and serum creatinine levels, as well as specific biomarkers, may promote early recognition of AKI and rapid nephrology intervention to improve outcomes 5.
• Combining renal protection strategies with the use of new biomarkers to develop early kidney risk identification and protection protocols is a promising idea that requires further investigation 5.