Gadolinium Arteriography Complicated by Acute Pancreatitis and Acute Renal Failure

Abstract

Editor: Several studies have supported the intravenous use of gadolinium as a paramagnetic contrast agent with a favorable safety profile (1,2). The relative safety of gadolinium-based contrast agents over iodine-based contrast agents in patients with renal insufficiency is also well established (3–5). Recently, however, reports of severe adverse reactions to standard doses of gadolinium have surfaced (6,7). Adding to this growing body of literature, we report a case of acute pancreatitis and acute renal failure after the administration of a gadoliniumbased contrast agent for iliac arteriography in a patient with diabetes mellitus and chronic renal insufficiency. A 68-year-old woman with long-standing bilateral lower extremity claudication was admitted to the interventional radiology service for right iliac artery stent placement. Preoperative MR angiography demonstrated a 90% ostial stenosis of the right common iliac artery and occlusion of the left common iliac artery. The patient also had a history of hypertension, hyperlipidemia, diabetes mellitus, and chronic renal insufficiency (creatinine 5 3.8 mg/dL). Given the patient’s baseline renal insufficiency and the attendant risk of nephrotoxicity from an iodine-based contrast agent, arteriography was performed with a gadolinium contrast agent, gadodiamide (Omniscan; Nycomed-Amersham, Princeton, NJ). Arteriography confirmed the presence of a critical (90%) ostial stenosis of the right common iliac artery. The patient received intravenous conscious sedation consisting of 1 mg of midazolam and 100 mg of fentanyl citrate. A total of 6,000 U of intravenous heparin was given to induce systemic anticoagulation before intervention. Subsequently, angioplasty and stent placement across the ostial lesion of the right common iliac artery were performed without immediate complication. Six hours after the procedure, the patient reported nausea, mild epigastric pain radiating to the back, and two episodes of vomiting. The patient received 10 mg of intravenous perchlorperazine, with transient improvement. Eleven hours after the procedure, the patient again reported epigastric discomfort and received 80 mg of oral simethicone, with minimal relief. Amylase and lipase levels at this time were noted to be 246 U/L and 1,314 U/L, respectively (laboratory normal ranges: amylase, 0–140 U/L; lipase, 0–200 U/L). Laboratory measurements obtained the next morning showed an increase in amylase and lipase to 684 U/L and 1,646 U/L. Results of liver function tests were within the reference range. A right upper quadrant ultrasound scan yielded findings that were within normal limits. The patient subsequently developed superimposed acute renal failure, electrolyte imbalance, and pulmonary edema, necessitating transfer to the intensive care unit. Microscopic urinalysis on the second postoperative day demonstrated muddy brown casts consistent with acute tubular necrosis. The patient’s respiratory status improved rapidly after aggressive diuresis, and she was stable for transfer to the renal service on the fifth postoperative day. With conservative management, her renal function improved and she never required dialysis. Her pancreatitis also resolved, without any further complications, and she was discharged from the hospital on the tenth postoperative day. In view of its relative safety in the setting of renal insufficiency, gadolinium is increasingly being used as an alternative contrast agent in interventional radiology. Despite its safety, however, there have been several recent reports of adverse events associated with gadolinium administration. Specifically, case reports of acute renal failure after gadoteridol intraarterially and acute pancreatitis after intravenous gadolinium-DTPA have surfaced (6,7). This case adds to a growing body of evidence that pancreatitis and renal failure are potential complications associated with gadolinium administration. To our knowledge, this is the first report of both acute pancreatitis and acute renal failure occurring in the same patient after a single administration of intraarterial gadolinium. While this case offers no definitive answers, it does suggest that further study of gadolinium dosing and adverse reactions in both animals and humans is necessary. There is currently no recommendation for the maximum safe dose of gadolinium, nor is there a minimum recommended creatinine clearance below which gadolinium should not be administered. Until such limits are established, care should be taken when administering large doses of gadolinium compounds.