Nephrogenic systemic fibrosis risk and liver disease.

Robert F Hanna,Mark R Escudero,Lee A Finkelstone,Vesselin Z Miloushev,Stephen M Lagana,Daniel S Chow,Martin R Prince

doi:10.1155/2014/679605

Abstract

Objective. Evaluate the incidence of nephrogenic systemic fibrosis (NSF) in patients with liver disease in the peritransplant period. Materials and Methods. This IRB approved study retrospectively reviewed patients requiring transplantation for cirrhosis, hepatocellular carcinoma (HCC), or both from 2003 to 2013. Records were reviewed identifying those having gadolinium enhanced MRI within 1 year of posttransplantation to document degree of liver disease, renal disease, and evidence for NSF. Results. Gadolinium-enhanced MRI was performed on 312 of 837 patients, including 23 with severe renal failure (GFR < 30 mL/min/1.73 cm2) and 289 with GFR > 30. Two of 23 patients with renal failure developed NSF compared to zero NSF cases in 289 patients with GFR > 30 (0/289; P < 0.003). High dose gadodiamide was used in the two NSF cases. There was no increased incidence of NSF with severe liver disease (1/71) compared to nonsevere liver disease (1/241; P = 0.412). Conclusion. Renal disease is a risk factor for NSF, but in our small sample our evidence suggests liver disease is not an additional risk factor, especially if a low-risk gadolinium agent is used. Noting that not all patients received high-risk gadolinium, a larger study focusing on patients receiving high-risk gadolinium is needed to further evaluate NSF risk in liver disease in the peritransplant period.

Highlights

Liver transplantation is the optimal treatment for patients with early-stage hepatocellular carcinoma (HCC) [1,2,3]
In the absence of data evaluating the association of liver disease with nephrogenic systemic fibrosis (NSF) while controlling for renal disease, the active European Medicines Agency (EMA) warning and historical Food and Drug Administration (FDA) warning may result in less imaging, suboptimal imaging, or imaging with modalities with higher radiation exposure
One study is a case-report describing a hepatitis C liver transplant patient who developed cyclosporine induced renal failure necessitating dialysis 11 years after transplant; a second study describes a patient with alpha1 antitrypsin related cirrhosis and end stage renal disease from membranous nephropathy; and a third study describes a patient with hepatitis B and C cirrhosis status after failed transplant for portal vein thrombosis with end stage renal disease requiring hemodialysis [19,20,21]

Summary

Introduction

Liver transplantation is the optimal treatment for patients with early-stage hepatocellular carcinoma (HCC) [1,2,3]. In a recent meta-analysis by Colli et al, gadoliniumenhanced MRI was suggested to be the superior imaging modality for diagnosing HCC [5]. Potential hepatic transplant patients with severe renal insufficiency may have the benefits of gadolinium-enhanced MRI withheld due to concerns for developing NSF. A recently revoked Food and Drug Administration (FDA) advisory and mandated package insert labeling on all gadolinium agents extended the risk from severe renal disease alone to patients with even mild or moderate renal disease if there is coexistent liver disease. In the absence of data evaluating the association of liver disease with NSF while controlling for renal disease, the active EMA warning and historical FDA warning may result in less imaging, suboptimal imaging, or imaging with modalities with higher radiation exposure

Methods

Results

Discussion

Conclusion