Synopsis
Dialysis patients had 3 times the signal increase on
unenhanced T1-weighted images compared to a control population with near normal
renal function undergoing the identical number of GBCA administrations. Although any clinical consequence to GBCA
administration would be expected to be magnified in dialysis patients, no
clinical effect of receiving GBCA could be identified in the
nephrologist/nursing notes recorded 3 times a week in the 30 days following
GBCA administration. Purpose
To determine if poor renal function affects the amount
of signal change in the dentate nucleus following GBCA administration.
Introduction
Increased
signal on unenhanced T1 weighted images (1-8) has been observed
along with detection of Gd (9,10) in deep brain nuclei including
dentate nucleus and globus palidus following multiple doses of gadolinium based
contrast agents (GBCA) with a linear chelate structure. This increased signal has not been detected
with macrocyclic GBCA suggesting that chelate stability may be a factor. Since
GBCA are eliminated via renal excretion, patients with renal dysfunction have
longer exposures to the administered GBCA.
If high chelator stability protects against Gd accumulation in deep
brain nuclei then the T1 signal change would be expected to be greater or to
occur with fewer GBCA doses in patients with renal dysfunction.
Methods
The Radiology PACS was searched during the period of 2000 to
2007 when GBCA was freely administered to patients on dialysis without
precautions. Four patient groups were
identified as follows: Group 1 - on dialysis at the time of GBCA administration
with a brain MRI scan including unenhanced T1-weighted images prior to any GBCA
administration and at least one brain MRI scan following GBCA exposure. Group 2 is a control group receiving the same
number of linear GBCA administrations with near normal renal function. Group 3 included patients on dialysis who
underwent brain MRI scans without GBCA.
Groups 4 consists of patients with near normal renal function who
underwent at least 2 brain MRI scans without GBCA exposure.
Pre and post GBCA unenhanced T1 weighted images were
analyzed independently by four radiologists blinded to all clinical
information. Using ROI analysis, the
signal intensity of the right dentate nucleus, cerebellar peduncle, pons,
globus palidus and thalamus were measured. In patients for whom brain tumor or
artifact interfered with measurement of these structures on the right side,
they were measured on the left side.
From the ROI measurements, the dentate to cerebellar peduncle (DCP)
ratio, the dentate to pons (DNP) ratio,= and globous palidus to thalamus (GPT)
ratio were calculated, After evaluating
inter-observer agreement, the average of the 4 reviewers was used for further
analyses.
Each
dialysis patient was evaluated by a nurse and a nephrologist at each dialysis
visit and any new symptoms or findings were recorded in the dialysis
charting system. These dialysis notes
and any other patient records available within the electronic medical record
were reviewed for the 30 days following each GBCA exposure and compared to
notes made on 30 consecutive days prior to GBCA exposure.
Results
19 patients received GBCA while on chronic
hemodialysis and had pre-GBCA T1 images as well as a subsequent brain MRI with
un-enhanced T1-weighted images. For the
3 groups of control patients (dialysis – no GBCA, near normal renal function
receiving GBCA and near normal renal function – no GBCA), no signal intensity
increase on unenhanced T1 weighted images were noted visually in dentate
nucleus. In the dialysis patients,
however, a signal intensity increase on unenhanced T1 weighted images was noted
in choroid plexus, substantia nigra and red nucleus in addition to dentate
nucleus and globus palidus in some patients.
With reference to the cerebellar peduncle, dialysis patients
showed more than 3 times the dentate signal increase observed in GBCA matched controls (p=0.003) see Table 2. With reference to the pons, no significant
increase was noted which may reflect greater variability in pons signal which
can have a greater distance from the coil and also can take up GBCA (10).
A review of notes for
the dialysis sessions from 30 days prior to and 30 days following each GBCA
exposure identified 67 issues raised
prior to GBCA enhanced MRI and 33 post GBCA enhanced MRI, Table 3. No issue could be attributed to the GBCA
exposure.
Discussion/Conclusion
These data in 16 dialysis patients and control
subjects with normal or near normal renal function demonstrate 3 times the
dentate T1 signal increase occurring in dialysis. However, no clinical effect of the GBCA could be identified in any of the patients in spite of physician/nurse evaluations occurring following GBCA administration at their regular, 3 times per week dialysis appointments.
Acknowledgements
No acknowledgement found.References
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