C-Reactive Protein Levels and Clinical Symptoms Following Gadolinium Administration in Hemodialysis Patients

Background

Until recently, gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) has increasingly replaced iodinated contrast agent examinations in dialysis patients, although only limited data existed about the clinical safety of Gd contrast agents in these patients. Specific clinical adverse events (AEs), including nephrogenic systemic fibrosis, were linked to Gd exposure in dialysis patients. An inflammatory reaction or transmetallation may be involved.

Study Design

Secondary analysis of a 5-day observational study in a parent cardiovascular study with repetitive cardiac MRI (32 patients) and patients undergoing Gd-enhanced MRI for clinical indications (6 patients). Clinical information and samples were obtained according to parent protocol.

Setting & Participants

Dialysis patients at a university-based dialysis unit.

Predictor

Gd-chelate complex. 37 of 38 patients underwent 64 MRI studies with Gd-diethylenetriamine penta-acetic acid (Gd-DTPA). 25 of these patients underwent additional MRI studies with gadobutrol (n = 10), 0.9% saline (n = 7), or both (n = 8), and 1 patient received gadobutrol only.

Outcomes

Clinical adverse events; C-reactive protein (CRP) levels on days 1, 3, and 5 after MRI; Gd levels in blood and urine after MRI.

Results

CRP levels increased 10-fold on day 3 after MRI in 87% of MRI studies with Gd-DTPA (+59.3 ± 57.9 mg/L [P < 0.001] versus −0.9 ± 3.7 mg/L with gadobutrol versus −0.9 ± 8.5 mg/L with 0.9% saline). 77 mild to moderate and 3 serious AEs were observed in 24 patients. CRP levels and adverse events did not correlate with Gd blood concentrations. CRP level increase or AEs were not observed after MRI with gadobutrol or 0.9% saline.

Limitations

Observational study without randomization, risk of bias because of multiple MRI studies in a limited patient cohort.

Conclusion

Gd-DTPA, but not gadobutrol, induces an acute-phase reaction and clinical AEs in dialysis patients. Additional investigations have to analyze the underlying pathomechanism.

Index Words: Gadolinium, Gd-DTPA, gadobutrol, adverse event, hemodialysis, C-reactive protein, magnetic resonance imaging