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Johns Hopkins MRI Policy in Relationship to Nephrogenic Systemic Fibrosis/Nephrogenic
Fibrosing Dermopathy
(NSF/NFD)
Background: NSF/NFD was first described in the
medical literature in 2000. The first case of NSF/NFD was seen in 1997.
The disease is seen in patients that have noticeably advanced renal
failure. The disease causes fibrosis of the skin and connective tissues
throughout the body. Patients develop skin thickening that may prevent
bending and extending joints, resulting in decreased mobility of joints.
In addition, patients may experience fibrosis that has spread to other
parts of the body such as the diaphragm, muscles in the thigh and lower
abdomen, and the interior areas of lung vessels. The clinical course of
NSF/NFD is progressive and may be fatal. The primary risk factor is
reduced renal function.
Creatinine/
eGFR is to be obtained for patients at risk for
reduced renal function, including:
- Age ≥ 65 years
- Diabetes
- History of renal disease/
renal transplantation
- History of liver
transplantation, hepato-renal syndrome
- Other medical conditions as
determined by attending radiologist
In acute renal failure, eGFR may be inaccurate and gadolinium use should be
avoided.
Patient on dialysis, or estimated GFR < 30
mL/min/1.73 m2:
1. Radiologist to determine if gadolinium use is
essential for diagnosis. Confirm that alternative tests are not
available.
2. Patient consent for gadolinium is obtained.
3. Maximum recommended dose is 0.1 mmol/kg
gadolinium.
4. If patient is on hemodialysis:
dialysis to be scheduled same day. Dialysis to be repeated 24 hours
later. For patients who are on dialysis, there must be
verification that the patient will receive dialysis as soon as possible
after the MRI. 2 dialysis sessions separated by 1 day are
recommended.
5. If patient is on peritoneal dialysis, use of
gadolinium contrast is strongly discouraged unless highly necessary for
diagnosis. Nephrology should be consulted to determine if hemodialysis can be performed.
Notes on estimated GFR (eGFR):
1. eGFR
by the Modification of Diet in Renal Disease (MDRD) formula* is based on
serum creatinine, age, gender and ethnicity.
2. For Hopkins
patients, eGFR is reported along with standard
lab values. Note the lab gives both values for African American and
non-African American.
3. eGFR
should be current (e.g., within the last month).
4. For outpatients who have a suspicion of
reduced renal function, patients should have POC or Express Testing, or a
phone call to a referring physician should be made to obtain serum creatinine.
eGFR calculator for Adults: http://www.nkdep.nih.gov/professionals/gfr_calculators/orig_con.htm
eGFR calculator for children: http://nkdep.nih.gov/professionals/gfr_calculators/gfr_children.htm
Consent
form language to be used:
Risks of gadolinium contrast:
- NSF/ NSD: a very rare fibrosing
condition of the skin and organs that has been reported in patients
receiving MRI with gadolinium. It can cause permanent disability
and death.
- Allergic reaction, with less than one in 300,000 chance that this will be severe.
- Metallic taste in the mouth, tingling in the arm,
nausea, or headache in less than 1% (less than 1 in 100) of people.
- Insertion of the needle (small plastic tube) may
also cause minor pain, bruising and/or infection at the injection
site.
Alternatives: In some
cases, a CT scan with iodine may be an alternative.
Researchers/ research subjections: http://irb.jhmi.edu/Guidelines/gadolinium.html
http://irb.jhmi.edu/Guidelines/mrilangguidance.html
For more information:
http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200705.htm
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