Nephrogenic systemic fibrosis: a nephrologist's perspective

Nephrogenic systemic fibrosis (NSF) is a debilitating disorder that affects patients with renal insufficiency. Recent evidence suggests that the development of NSF may be related to the administration of gadolinium-based contrast media (GBCM) in the setting of magnetic resonance imaging. As no treatment has consistently been effective in the management of NSF, strategies to prevent the development of this condition appear to be the best therapy. Identification of patients at greatest risk for developing NSF after exposure to GBCM is crucial. Risk factors include advanced chronic kidney disease (stages 4 and 5) and acute or chronic inflammatory events. The United States Food and Drug Administration has updated its public health advisory to include patients with moderate renal insufficiency (chronic kidney disease stage 3) as being at risk for developing NSF. However, these data require further verification and the vast majority of affected patients are already on renal replacement therapy. Another strategy in prevention may include consultation with a radiologist for imaging alternatives. If GBCM must be administered, immediate hemodialysis may be protective in patients already on hemodialysis; however, given the lack of data to support this, we do not recommend routine dialysis for patients not yet on dialysis or who are currently being treated with peritoneal dialysis. Decisions such as this should be made on a case by case basis after evaluating additional risk factors.