NSF rare with newer gadolinium-based contrast agents, review finds

Researchers advised caution when using newer gadolinium-based contrast agents in patients with impaired kidney function and suggested that more research on nephrogenic systemic fibrosis (NSF) is needed in this population.

Nephrogenic systemic fibrosis (NSF) occurs rarely with newer gadolinium-based contrast agents (GBCAs), but there's little evidence on the rate among patients with acute kidney injury or risk factors for chronic kidney disease (CKD), a study found.

Researchers reviewed 32 published articles to synthesize evidence about NSF risk with newer versus older GBCAs across the spectrum of kidney function. Twenty articles looked at NFS risk after exposure to newer GBCAs and 12 allowed comparison of NSF risk between newer and older GBCAs. The systematic review and evidence synthesis were published June 23 by Annals of Internal Medicine.

In the 20 studies (n=83,291) analyzed to determine the occurrence of NSF per index exposure to newer GBCAs, no NSF cases developed (exact 95% CI, 0.0001 to 0.0258 case). Among the 12 studies (n=118,844) analyzed to compare the occurrence of NSF per index exposure to newer versus older GBCAs, 37 NSF cases developed after exposure to older GBCAs (exact 95% CI, 0.0001 to 0.0523 case) and four occurred (three confounded) after exposure to newer GBCAs (exact 95% CI, 0.0018 to 0.0204 case). Data were scant for patients with acute kidney injury or those at risk for CKD.

The authors wrote that although the review suggests that development of NSF after exposure to newer GBCAs is very rare, the available evidence in patient populations with mild kidney disease is too limited. They also noted that study heterogeneity prevented meta-analysis, and the risk of bias was high in most studies because of inadequate exposure and outcome ascertainment. They urged caution using GBCAs in patients with severely impaired kidney function and acute kidney injury because the exact clinical factors contributing to risk in these subpopulations remain unknown.

“Limited evidence suggests that additional studies in patient populations with mild kidney disease would substantially change these conclusions,” the authors wrote. “However, considering the scarcity of data about the use of newer and seemingly safer GBCAs among patients with advanced CKD, CKD risk factors, or acute kidney injury, further investigations in these populations are warranted and will require particular attention to comprehensive exposure and outcome assessment (such as documentation of all GBCA exposures and use of standardized diagnostic criteria for NSF).”

Read more about contrast agents and acute kidney injury in the March ACP Hospitalist.