From The Board: Contrast This!

From the Board

Kenneth Liss, DO

Hypertension and Nephrology Associates

Just when I think I am going to contribute to academe and scribe something about the latest nephrologic innovation or controversy, something in real life brings me to my senses and I have to vent. The latest 3 am phone call from an even more exhausted sounding surgical resident was the impetus this time.

Apparently, the local neighborhood “skin popper” had run out of IV sites to satisfy his cravings. This unseemly behavior brought him to the emergency department (ED) with a rather foul smelling and deeply seeded wound. Doing their due diligence, the ED ran some routine laboratory studies and found that the patient had a serum creatinine of 3.4 mgs/dL. This was confirmed to be a chronic value for at least the past 18 months prior. Being concerned about the possible diagnosis of necrotizing fasciitis and wanting to eschew iodinated contrast, the surgical resident wisely decided to order an MRI study with gadolinium. This brings me to my part in the story. The surgical resident apologized for having to call me but was informed by the department head in radiology that the gadolinium would only be administered if “renal” gave its blessing.”

The last time I checked I was not ordained to approve or disapprove of anything. I can make recommendations, but I am not the final arbiter of any medical test or procedure. I am also not a surgeon, but I know that necrotizing fasciitis carries with it tremendously high morbidity and mortality. I am compensated to be concerned about the nephrologic ramifications of contrast agents, but with the exception of anaphylaxis they rarely are lethal.

Granted iodinated contrast administered to a volume depleted, septic patient with a GFR of <25 has significant renal risk, but in this immediate case, the risk of not making the proper diagnosis paled in comparison with the contrast risk. More germane, however, was the risk of gadolinium administration in this setting compared with leaving this potentially fatal disease inappropriately managed. The Yale Registry of reported nephrogenic systemic fibrosis (NSF) cases continues to demonstrate that, although this disease is real and often quite dangerous, it remains exceedingly rare1. I will even concede that the onset of this disease likely parallels the use of gadolinium as a medical contrast agent and that the incidence has decreased markedly since our knowledge of gadolinium as a causative agent has grown2.

Physicians need tools such as chemotherapy, antihypertensives, anti-glycemics, robotic prostatectomies, and renal replacement therapy in order to help our patients. Let’s all agree that adriamycin, renal transplantation, renin angiotensin system blocking agents, and even metformin have all been associated with significant patient morbidity and even mortality but I never get awakened at 3 am to give consent to use them. While I advocate continued research to find safer contrast agents, less dangerous chemotherapeutic drugs, more precise surgical techniques, and drugs that are not associated with lactic acidosis, I would never advocate eliminating what is currently a crucial part of our medical therapeutic armamentarium. Until such time that the need for gadolinium has become obsolete, I encourage our radiologic colleagues to formulate a substantive position paper recognizing that the potential benefit of gadolinium, even in patients at risk for NSF, generally outweighs the risk of this rare condition.

 

References

  1. The International center for Nephrogenic Fibrosing Dermopathy Research. icndfr.org
  2. Igreja ACdSM, Mesquita KdC, Cowper SE, Costa IMC. Nephrogenic systemic fibrosis: concepts and perspective. An Bras Dermatol. 2012; 87(4): 597-607.