As 2010 Ends, Can’t We Please Let Go Of NSF?

Make no mistake, Nephrogenic Systemic Fibrosis (NSF), a horrible (and thankfully very rare) disease which can afflict persons with significantly impaired kidney function who receive certain gadolinium based MRI contrast agents. Over the past few years, tremendous resources have been poured into the identification of patients, research on the specific mechanisms of disease, and effective means of prevention. NSF has run into a problem, however, which has dramatically curtailed further research… we’ve darn-near eliminated this disease!

In about 4 years, NSF was identified (originally called Nephrogenic Fibrosing Dermopathy), the culprit identified, the population-specific susceptibility deduced, and effective screening protocols developed and deployed. Yes, it is still possible to develop NSF today, but we also have the tools requisite to interdict the agents that trigger the disease, and an industry-wide awareness of the preventative steps which are effective in doing so.

This is a testament to an international confederation of radiologists, nephrologists, pharmacologists and pathologists who collaborated on the challenge of this disease. It is worthy of a self-congratulatory pat on the back for radiology that we were able to sleuth-out the cause, and disciplined enough to execute effective prevention, in such a short time. But lest we spend too much time singing our own accolades, we should remember that more than 92% of MR accidents studied (selected based on the availability of information on causation), were made up burns, projectiles and hearing damage. These aren’t clinical problems, per se, rather they’re operational in nature.

Perhaps that accounts for the disparity in response. MR is a clinical instrument, and NSF was in the clinical wheelhouse. Yes, it extended well beyond radiology, but it was (and still is) essentially a clinical issue.

More often than not you will never find a radiologist actually in an MRI suite, so they are unfamiliar with – and often uncomfortable with – operational concerns. There are, of course, exceptions to this but those are… well… exceptional.

If NSF can be identified, studied, researched, and ultimately almost universally prevented in the course of a handful of years, how is it that we continue to see alarming year-over-year growth in combined burns, projectiles and hearing damage? If we can study a brand new disease and prevent it with nearly 100% effectiveness, why can’t we make sure insulating pads are used, or that ferromagnetic detectors are part of every MRI center, or that we make sure that hearing protection is used (and used properly)?

For these injuries there is no direct-causation mystery. We don’t need expensive animal trials, or chemical analysis of different contrast agents. We don’t need an international interdisciplinary clinical team. We need pads, ferromagnetic detectors, and earmuffs.

So my appeal, made plain in the headline, is for us to let NSF go. Let us not dwell in an anachronistic state of fear, nor linger any longer in self-congratulation. We have other tasks to help make MRI as safe as we know it can be, and we need to redirect our attention to that job ahead of us.

Tobias Gilk,
President & MRI Safety Director — Mednovus, Inc.
Sr. Vice President —

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4 thoughts on “As 2010 Ends, Can’t We Please Let Go Of NSF?

  1. Annie

    Question for you regarding another patient safety issue. If a patient has had CT contrast, do you know of any recommended waiting period before having an MRI. Not because of kidney function, but because of possible opacification from the CT contrast on the MR images causing unsure diagnosis. Can there be false positives or false negatives if an MRI is performed with IV CT contrast still within the patients system. I have not been able to find any research on this and wondered if you knew of any recommendations. I have had Radiologist’s prefer to wait 12 to 24 hours after administration of CT IV contrast if an MRI is requested for vascular imaging or question of lesion. Again, not due to kidney function, only for imaging purposes. As patient care is a priority, just wondering if you could offer some insight.

    Thank you for your time.

  2. Tobias Gilk Post author

    This is a great question, Annie! Great both because it’s very interesting (we’ve known for years that Gadolinium based contrast agents, used for MRI, are slightly radio-opaque and show up in X-rays, but I’ve never even considered the inverse… iodinated contrast showing up in MR), and because I don’t have an answer for you.

    I would speculate (and it’s just speculation) that because I’ve not heard of this as a concern before, if there is an image artifact from CT contrast in MR imaging, it must be fairly small.

    I have a very well regarded radiologist friend who, I suspect, will be able to answer this question with authority. Next time I speak with him, I’ll see if I can’t get you a definitive answer.

  3. Deborah

    We, along with the FDA, know for certain both chelated and very toxic free gadolinium is retained in normal renal functioning patients. How much gadolinium retention is considered to cause adverse health effects? Once that is determined, GDD (gadolinium deposition disease) will become an important topic anyone receiving a gadolinium based, and very toxic, MRI with contrast should be discussing.

    It is past time the drug makers are allowed to use toxic metals in MRI contrasts.

  4. Tobias Gilk Post author


    Yes, it is known that very small quantities of gadolinium are indeed retained by patients who receive these contrast agents. Whether or not they remain chelated is believed to be of critical importance to the potential health effects, so it’s important to differentiate whether the retained gadolinium is in its original chelated state, or has dissociated. The different agents have very different propensities / resistance to dechelation.

    It’s not known what the triggers for NSF or gadolinium toxicity are. NSF is defined as requiring renal impairment, but it is unclear as to whether there are other peculiar conditions to the patients who develop NSF (and, so goes the thinking, other toxic responses to gadolinium based contrast agents).

    This is already a very important and widely discussed topic, and I’m sure will continue to be. For the discussions it will continue to be vital to both identify risk profiles (and mitigation steps that can be taken) as well as the vital role that contrast agents serve in the diagnosis of disease.

    Thank you for your comment.

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