NDT Advance Access originally published online on November 28, 2008
Nephrology Dialysis Transplantation 2009 24(4):1274-1277; doi:10.1093/ndt/gfn655
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Acute phase reaction to gadolinium-DTPA in dialysis patients
1 Division of Cardiology, Department of Internal Medicine 2 Division of Nephrology, University of Heidelberg, Heidelberg 3 kfh-Nierenzentrum Würzburg, Germany
Correspondence and offprint requests to: Vedat Schwenger, Division of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120 Heidelberg, Germany. Tel: +49-6221-9112-0; Fax: +49-6221-9112-229; E-mail: vedat.schwenger{at}med.uni-heidelberg.de
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Abstract |
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Background. Several late sequelae of the administration of gadolinium (Gd)-containing MRI contrast agents have been described in patients with advanced renal failure. In an observational series, we found a remarkable frequency of peracute reactions after administration of Gd-DTPA used for cardiovascular evaluation before renal transplantation.
Methods. In a 26-month observational period, 13 of 136 haemodialyzed or CAPD patients exhibited onset of fever, chills and nausea within hours after administration of Gd-DTPA peracute. A minority showed persistent cessation of residual diuresis. We performed blood cultures in most patients and evaluated white blood cell (WBC) counts, eosinophils, CRP, heart rate and blood pressure.
Results. Within an average of 12 h (range 12–36 h) after Gd administration, the 13 patients (9 males, 4 females; median age 61 years, range 47–79) developed consistent symptomatology with fever (median 39.0°C, range 37.5–39.5), chills, malaise, hypotension, vomiting, dyspnoea—initially raising suspicion of septicaemia. Subsequent blood cultures on bacterial contamination of the injected product remained negative throughout; bacterial or endotoxin contamination of the reagent was excluded. Steroids were tried in the first two patients without a noticeable effect. In all subsequent patients, symptoms were attenuated during the first 5 h dialysis (F60HPS with 280 ml/min blood flow) and disappeared within 72 h. CRP levels remained markedly elevated up to 14 days. Lymphopenia was seen in all patients, and polymorphic neutrophils (PMN) remained normal. Two polyuric patients developed persistent anuria. After a median of 16 months, none of these patients developed nephrogenic systemic fibrosis.
Conclusion. This series with unusually severe acute phase reactions was caused by one specific preparation. Such peracute reactions may be relevant for the so-far largely unresolved pathogenesis of the skin reaction to some Gd products in end-stage renal disease (ESRD) patients. It remains unresolved whether the reaction observed with Gd-DTPA do in principle also occur with other Gd reagents.
Keywords: acute phase reaction; acute renal failure; dialysis; gadolinium; lymphopenia
Received for publication: 29. 7.07
Accepted in revised form: 31.10.08
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