For patients with advanced CKD, low risk of nephrogenic systemic fibrosis with group II GBCAs


Background: With more than 500 cases of NSF reported during 1997-2007, a black box warning advises against use of all GBCAs in at-risk CKD patients. However, newer literature has shown that group II GBCAs may have lower risks of causing NSF. The risk to patients with CKD IV and V is not clear.

Dr. Monica Midha

Study design: Systematic review and meta-analysis.

Setting: 2,700 citations were screened for eligibility, of which 16 studies were selected.

Synopsis: The authors evaluated 4,931 administrations of group II GBCAs in patients with CKD stages IV and V to determine the pooled incidence of NSF in this population. The pooled incidence of NSF was 0% (0 out of 4,931) with an upper bound of the 95% confidence interval of 0.07%. The analysis did not examine sequential group II GBCA exposures or the use of group II GBCAs in the setting of acute kidney injury. The authors advocate that the harms of withholding group II GBCAs in patients with advanced CKD (e.g., underdiagnosis or delay in diagnosis) may outweigh the risk of group II GBCA administration in this population.

Bottom line: The risk of NSF with use of group II GBCAs in patients with advanced CKD is likely less than 0.7%.

Citation: Woolen SA et al. Risk of nephrogenic systemic fibrosis in patients with stage 4 or 5 chronic kidney disease receiving a group II gadolinium-based contrast agent: A systematic review and meta-analysis. JAMA Intern Med. 2020;180(2):223-30.

Dr. Midha is a hospitalist at Beth Israel Deaconess Medical Center, instructor of medicine, Boston University, and part-time instructor in medicine, Harvard Medical School, all in Boston.

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