USE OF GADOLINIUM-BASED CONTRAST AGENT FOR RENAL ANGIOGRAPHY: CASE REPORT AND REVIEW OF THE LITERATURE

Abstract

A 67-year-old woman suffering from chronic renal failure (Creatinine 480 μmol/L) underwent a gadolinium renal angiography, which visualized a stenosis of the right renal artery. There was no deterioration of renal function after the arteriography. A review of the literature is presented which show the efficiency of this technique to visualize the renal arteries, and the absence of nephrotoxicity after the use of gadolinium as a based contrast agent in high risk patients.

• Renal failure
• Gadolinium
• Renal arteries
• Angiography

INTRODUCTION

The prevalence of renal artery stenosis (RAS) is nearly 5% in persons older than 50 years with generalized vascular disease [[1]]. Angiography is the reference standard for the diagnosis RAS [[2]]. However contrast media nephrotoxicity remains a major draw back especially in patients with renal insufficiency. Indeed in patients with moderate renal insufficiency the incidence of RAS induced ARF is 5,5%. Furthermore in patients with diabetes and severe renal insufficiency the incidence of iodinated contrast agent nephropathy is higher than 50%. Gadolinium is normally used in enhanced Magnetic Resonance Imaging (MRI). Although gadolinium is potentially nephrotoxic at very high doses in rats [[3]] these compounds are not nephrotoxic in humans at the dose which are usually administered.

Therefore gadolinium may be useful as an alternative contrast agent for diagnostic and intervention angiographic procedures in patients with a history of renal insufficiency or severe reactions to iodinated contrast material [[4]].

We describe a case of a patient suffering from chronic renal insufficiency. Furthermore we reviewed the literature for the use of gadolinium as the radiographic contrast agent for renal artery angiography.

CASE REPORT

A 67-year-old white woman with history of severe aortic valve stenosis, hypertension and who was treated from pulmonary and gastrointestinal tract tuberculosis was admitted in our department. The patient had a chronic renal failure since 1994 with a creatinine value of 150 μmol/L due to chronic interstitial nephritis secondary to renal calcium carbonate calculus. In 1998 the patient had rapid deterioration of her renal function with a creatinine rise up to 290 μmol/L. Stenosis of the renal arteries was suspected and a spiral CT angiography with iodinated contrast agent was performed which showed a stenosis of the right renal artery. An anaphylactic shock occurred during the spiral CT iodinated angiography, which prevented dilatation of the right renal artery. In December 1999 the patient had further deterioration of her renal function with a serum creatinine at 480 μmol/L. The patient underwent a renal arteries enhanced MRI with gadolinium which visualized the same lesions. A renal arteriography with injection of 30 ml of gadolinium (0.3 mmol/kg) was carried on. The right renal artery was to thin to be dilated (Figure 1) and the patient refused renal revascularization by surgery. Serum creatinine which was monitored during 15 days remained stable (495 μmol/L) after gadolinium injection.

Figure 1. Renal artery angiography with gadolinium showing severe stenosis of the right renal artery (arrow).

DISCUSSION

The natural history of progression of atherosclerotic renovascular disease (at arteriography) between 1968 and 1991 was estimated at 49% in 237 patients by Rimmer and col [[1]]. In the same study 14% of the patients had unilateral total renal artery occlusion [[1]]. In a series of 1304 patients who underwent routine cardiac catheterization who also had a technically adequate single-plane renal angiogram to screen for renovascular disease 195 of them (15%) had stenosis of more than 50% of the renal artery [[5]]. In order to explore and treat this pathology by arteriography with an iodinated contrast medium, patients having a pre-existing renal impairment and diabetes mellitus are exposed to the risk of acute renal failure [[6]].

Gadolinium-have been used extensively in renal arteries enhanced MRI imaging. This contrast agent is distributed in the extracellular space, excreted almost exclusively by glomerular filtration, and has a blood half-life of 1.53 ± 0.13 h [[6]]. In a series of 64 patients with preexisting impaired renal function who underwent enhanced MRI contrast angiography, no change in serum creatinine was observed, even after the administration of 0.4 mmol/kg of gadolinium which is considered as a high dose (0.3 mmol/kg, dose approved for human use [[7]]. Gadolinium can be distributed in arteries throughout the body with the exception of the cerebral vessels and coronaries [[2]]. Gemery and col [[8]] reported a case of acute reversible renal failure in a diabetic patient who underwent lower extremity arteriography with high dose of gadolinium based contrast agent (0.44 mmol/kg). In that case report acute tubular necrosis due to gadolinium was evoked as an etiology of this acute renal failure. However, the authors for this severe arteriopathic diabetic patient did not exclude cholesterol embolization.

Gadolinium has also been used for diagnostic renal angiography, followed by percutaneous transluminal angioplasty and stent placement (Table 1) for 40 patients (including our patient) either for native renal arteries or transplant renal artery (Table 1).

Table 1. Main Characteristics of Patients Who Had a Gadolinium-Enhanced Renal Angiography

Characteristics	Spinosa [[9]]	Bouiller [[10]]	Spinosa [[11]]	Spinosa [[2]]	Present Case
Number of patients	1	1	13	24	1
Sex	M	F	10 M, 3 F	14 M, 10 F	F
Mean age, y	74	72	49	59	67
Native renal arteries arteriography	1	1	0	17	1
Transplant renal artery arteriography	0	0	13	7	0
Diagnostic only	0	0	9	15	0
Diagnostic and interventional	1	1	4	10	1
Dilatation only	0	0	2	19	0
Stent insertion + dilatation	1	0	2	6	0
Number of hypertensive patients	1	1	4	ND^*	1
Number of diabetic patients	1	0	ND^*	ND^*	0
Mean creatinine level before arteriography	300 μmol/L	117 μmol/L	211 μmol	274 μmol/L	480 μmol/L
Mean creatinine level after arteriography	300 μmol/L	117 μmol/L	204 μmol/L	283 μmol/L	495 μmol/L

^*Not determined.

In these patients (Table 1), indication for gadolinium-based contrast angiography was usually due to the presence of a preexisting renal failure (n = 38) or history of allergic reaction to iodinated contrast media (n = 2). For all these patients the clinical tolerance was good and their renal function remained stable (Table 1).

From this review we suggest that gadolinium is not nephrotoxic even if used for patients suffering from renal failure.