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On May 5, 2015, an editorial by Emanuel Kanal, MD, Director of Magnetic Resonance Services and Professor of Radiology and Neuroradiology at the University of Pittsburgh Medical Center, and Michael F. Tweedle, PhD, Professor and Stefanie Spielman Chair in Cancer Imaging at The Ohio State University Medical School, was published online ahead of print. The editorial, “Residual or Retained Gadolinium: Practical Implications for Radiologists and Our Patients”, is in the June 2015 issue of Radiology. It addresses the issue of gadolinium retention in patients with normal renal function, as evidenced by published findings by Kanda et al, Errante et al, Quattrocchi et al, McDonald et al, and Radbruch et al.
In December of 2013, a study by Kanda et al first brought attention to what appeared to be evidence of residual gadolinium within the brain tissues of patients without severe renal disease. The evidence of gadolinium in the brain started with reports of abnormal signals in the globus pallidus and the dentate nuclei on unenhanced T1-weighted MR images after repeated prior administration of certain gadolinium-based contrast agents or GBCAs. Other studies found measureable concentrations of gadolinium in normal brain tissues from patients with normal renal (kidney) function. In their editorial, Kanal and Tweedle said, “These provocative findings cause us to reconsider what we know and what we need to learn to better care for our patients”.
The authors said, “We now have clear evidence that the administration of various GBCAs results in notably varied levels of accumulation of residual gadolinium in the brain and bones of patients, even those with normal renal function. What we still do not know is the clinical significance, if any, of this observation.” (more…)
Reports of Gadolinium Retention in brain tissues of patients with normal renal function raise safety concerns
Several recent studies that involve Gadolinium-based Contrast Agents used for enhanced MRIs have gotten the attention of the radiology community. The findings of all the studies indicate that Gadolinium-based Contrast Agents, or GBCAs, might not work exactly as everyone thought they did. The recent Mayo Clinic study by McDonald et al appears to confirm that at least some gadolinium from the intravenously administered GBCA can remain in brain tissues of patients – including in patients with normal renal function. Based on reports of increasing T1 signal intensity on unenhanced magnetic resonance images (MRI) in patients who had multiple MRIs with a GBCA, it appears that once deposited, gadolinium accumulates in the brain tissue. (Recent studies cited at end.)
Prior to the publication of these studies, patients with normal renal function had been told that their unexplained, chronic symptoms could not be from retained gadolinium; however, the findings of the recent studies cast serious doubt on that. The findings seem to support what patients with normal renal function have been saying for years now – they are retaining gadolinium from the GBCA administered for their MRIs and they are experiencing troubling symptoms because of it.
Recently I had the opportunity to provide some information for a story about GBCA safety that John Hocter, managing editor of Health Imaging, was writing. The recent publication of his article brought the plight of patients with normal renal function to a broader and more public audience. Also contributing to the article was Tobias Gilk, a leading MRI Patient-Safety advocate and member of the newly formed American Board of MR Safety. (more…)
MRI safety recently took a step forward with the formation of the American Board of Magnetic Resonance Safety (ABMRS). According to its website, the not-for-profit corporation’s purpose is to improve the safety of medical and research magnetic resonance (MR) environments. That includes the safety of MR facilities and the certification and qualification of the professionals who oversee the physical and operational safety of the MR equipment, environment, and processes.
The leadership of the founding Board of Directors includes the following:
- Chair: Emanuel Kanal, MD, Director of MR Services at the University of Pittsburgh Medical Center
- Vice Chair: Max Amurao, Phd, Director of Radiation Safety for Clinical Programs at Columbia University/New York Presbyterian Hospitals
- Secretary/Treasure: Tobias Gilk, MArch, Sr. Vice President of Radiology-Planning and Founder of Gilk Radiology Consulting
While doing research in early 2012, I came across a 2007 article written by J.F.M. Wetzels of The Netherlands that really caused me to pause and think about the problems associated with Gadolinium-Based Contrast Agents. The title was “Thorotrast toxicity: the safety of Gadolinium compounds”. Thorotrast was a radiocontrast agent used from 1930 to 1960. It wasn’t until the late 1940’s that the first “Thorotrast-related malignancies” were described in the literature and the problem came to light.
Thorotrast particles had been deposited in cells in the liver, spleen, bone marrow, and lymph nodes where they stayed and continually exposed the surrounding tissue to radiation. The problems created by Thorotrast had such a long-latency period that malignancies might not show up for 45 years or more later.
Wetzels described what was happening with Gadolinium and NSF through 2006. He said that because Gadolinium is a toxic, heavy metal, “Gadolinium-Based Contrast Agents are all chelates, which must ensure that no free Gadolinium is present in the circulation”. Wetzels closed by saying, “we must keep in mind that toxic effects may occur less frequently, later, and only after repeated exposure in patients with less severe renal dysfunction”. When I read that, I thought of what might be happening to patients with normal renal function. (more…)