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Gadolinium Toxicity – Status and Direction – August 2018
The two of us, Sharon Williams and Hubbs Grimm, have been working together on gadolinium toxicity related issues since 2012 and this website since 2014. Since it affects us and our many new friends personally, coming to agreement on our “message” has not always been easy but we have done it.
Recently, out of frustration with lack of progress on matters related to gadolinium toxicity from MRI contrast agents, we wanted to do a post that was both reflective of where the medical community has been on this issue and where we believe it ought to go. While we had similar ideas, we differed in how we wanted to convey the message. So, we each worked on our own editorial and then we helped each other with the final copy as we have done many times in the past.
Tomorrow we will be posting two editorials about Gadolinium Toxicity. While our approaches are different, this is not a dispute between us or an attempt to decide which is right and which is wrong. Instead, it is two people, working together with great respect for each other, expressing their thoughts in an important discussion about something that affects countless other people. We invite industry representatives to contribute to this discussion.
We hope you will read both editorials and take time to consider the important points we make.
Sharon’s editorial is titled, “Gadolinium Toxicity: If not NSF, then what is it?”
Hubbs’ editorial is titled, “Gadolinium Toxicity – Let’s not make the same mistake again”
Sharon Williams and Hubbs Grimm
Coauthors of The Lighthouse Project
Study finds more Gadolinium in Bone than Brain Tissue
A recent study by Murata et al, “Macrocyclic and Other Non-Group 1 Gadolinium Contrast Agents Deposit Low Levels of Gadolinium in Brain and Bone Tissue: Preliminary Results from 9 Patients with Normal Renal Function”, adds to the mounting evidence of gadolinium deposition and retention in patients with normal renal function. The study, published online ahead of print in Investigative Radiology, found that “Gadolinium deposition in normal brain and bone tissue occurs with macrocyclic and linear protein interacting agents in patients with normal renal function”. The authors noted that, “Deposition of Gd in cortical bone occurs at much higher levels compared with brain tissue and shows a notable correlation between the two”.
The linear gadolinium-based contrast agents (GBCAs) most frequently associated with NSF were designated as Group 1 agents by the FDA in 2010. Those agents are gadodiamide (Omniscan), gadoversetamide (OptiMARK), and gadopentetate (Magnevist). The linear protein binding agents include gadobenate dimeglumine (MultiHance), gadoexetate (Eovist), and gadofosveset (Ablavar). (more…)
Toxicity of Gadolinium Deposition from MRI Contrast Agents
A recent review article by Ramalho et al summarizes the literature on gadolinium-based contrast agents or GBCAs that are administered for contrast-enhanced MRIs, and it ties together information on agent stability, and animal and human studies. The article, “Gadolinium-Based Contrast Agent Accumulation and Toxicity: An Update”, also emphasizes that the low-stability agents are the ones most often associated with brain deposition of gadolinium that has been reported in the literature since 2014.
Since the article has Open Access at AJNR.org, I will not go into all of the details of it. However, there are some facts contained in the paper that I want to present here that are relevant to why GadoliniumToxicity.com exists. In 2014, Hubbs Grimm and I created this website as a way to alert people to a problem that was not yet recognized by the FDA and medical industry. That problem was gadolinium retention in patients with normal renal function. We knew the facts were in the published literature, but they just had not been seen by the right people yet. Thankfully, that has now begun to change.
Nephrogenic Systemic Fibrosis (NSF)
No review of GBCAs would be complete without some background information on NSF.
In 2006, the association between the administration of GBCAs and the development of Nephrogenic Systemic Fibrosis (NSF) in patients with severe renal disease was reported by Grobner and then by Marckmann et al. NSF predominantly involves the skin, but it is a systemic disease that may also affect other organs such as the lungs, liver, heart, and muscles. The exact pathophysiology of NSF remains unknown, but as the review states, the dissociation of gadolinium ions from their chelating ligands has been accepted as the primary etiology. That is more likely to occur in patients with renal failure than in those with normal renal function since the excretion rate is reduced in those with renal failure. The article indicates that most cases of NSF reported in the literature have been associated with the administration of nonionic, linear gadodiamide (Omniscan, GE Healthcare), nonionic, linear gadoversetamide (OptiMARK, Covidien), and with ionic, linear gadopentetate dimeglumine (Magnevist, Bayer HealthCare Pharmaceuticals).
After limiting the use of GBCAs in patients with renal failure and using more stable GBCAs, there have been no new cases of NSF reported since mid-2009. According to the paper, from 2009 to 2014, confidence in the safety of GBCAs had been largely restored. However, since 2014, numerous studies have been published that reported finding evidence of gadolinium deposition in neural tissues in patients with normal renal function. (more…)
Gadolinium Deposition in Humans is Not Something New
Since early 2014, there have been numerous articles published that report finding evidence of gadolinium deposition in the brain within the dentate nucleus (DN) and globus pallidus (GP) in patients with normal renal function. The findings seem to have come as a surprise to some radiologists, but a review article by Huckle et al indicates that no one should be surprised by the findings. The article, Gadolinium Deposition in Humans – When did we learn that Gadolinium was deposited in vivo?, takes a retrospective look back at gadolinium-based contrast agents (GBCAs) to describe the historical evidence of gadolinium (Gd) deposition in vivo. According to the authors, it “shows that deposition in the basal ganglia should come as no surprise”.
The article notes that deposition of gadolinium in animals with normal renal function has been described in the peer-reviewed literature since at least 1984 when Weinmann et al reported that although gadolinium elimination in rats was largely complete 7 days after administration of Gd-DTPA, a small fraction (0.3%) was retained. Other animal studies confirmed gadolinium retention that was proportional to the dose. Gadolinium was found in bone, skin, and other organs in animals.
The higher stability of macrocyclic GBCAs compared to the linear agents has been confirmed in published animal studies. However, while higher levels of gadolinium were detected in the skin and bones of animals injected with linear agents, the studies demonstrated that “quantifiable levels of gadolinium” are deposited after administration of all GBCAs – linear and macrocyclic agents.
Gadolinium Toxicity 