General Correspondence Strong association between the use of gadolinium-based contrast agents with nephrogenic fibrosing dermopathy/ nephrogenic systemic fibrosis I read with interest the letter by Drs Cheung and Dorai Raj. 1 I wish to bring to your notice the recent reports of a strong association between nephrogenic fibrosing dermo- pathy (NFD)/nephrogenic systemic fibrosis (NSF) and the use of gadolinium(Gd)-based i.v. contrast agents used in magnetic resonance imaging(MRI)/magnetic resonance angiography (MRA) studies. In the patient reported, it needs to be confirmed whether she underwent such a Gd-based contrast study while being investigated for the numerous vascular and spine problems. Until recently, MRI/MRA studies using Gd-based con- trast agents were considered safe in patients with chronic kidney disease (CKD) because of the absence of nephro- toxicity attributable to Gd. Gd is almost entirely excreted by the kidneys with a half-life of 70–90 min in people with normal renal function. In patients with CKD, Gd has a prolonged half-life 2 and accumulates to cause/predispose to the occurrence of NFD/NSF. Evidence is emerging from skin and soft tissue biopsies of Gd accumulation in patients with NFD/NSF. 3 Prompt dialysis in patients who are dial- ysis dependent has been recommended, based on the ob- servation that the first three haemodialysis sessions resulted in eliminating 78, 96 and 99% of the total dose of Gd given. 4 There seems to be a narrow therapeutic window period for these dialysis sessions in preventing NSF/NFD. A population study has suggested an incidence of 2.4% per each Gd-based contrast exposure for the development of NFD/NSF in the setting of CKD stage 5. 5 A survey by the International NSF registry at Yale University has shown that an overwhelming 95% of 100 patients studied had been exposed to Gd within 2–3 months. Presently it is unclear as to whether only some or all of the six available Gd-based contrast agents are associated with NSF. The Food and Drug Administration believes it is a class effect of Gd and warns physicians to exercise cau- tion when using any Gd-based contrast agent in patients with CKD. 6 Given the enormity of the situation, most of the publi- cations have been fast tracked and are being published online before print. The Royal Australasian College of Physi- cians should endeavour to spread the message across to the various specialists caring for patients with CKD. The follow- ing recommendations are of urgent importance especially to renal physicians, radiologists, vascular surgeons, neurolo- gists and neurosurgeons and their patients. In patients with CKD on dialysis 1 Review the need for MRI/MRA with Gd-based contrast studies. Non-contrast MR studies or alternative methods of imaging should be considered 6 2 For patients on maintenance haemodialysis, dialyse within 3 h of the Gd exposure. A second dialysis treatment within 24 h may be of further benefit 7 3 For patients on peritoneal dialysis, intensify the treat- ment for the next 48 h by repeated manual exchanges or continuous cycler therapy 7 The management strategy for patients with CKD in stages 4 and 5 who have not yet started dialysis is unclear at the present time. The renal physicians and their patients are now caught between the rock and the hard place – the established nephrotoxicity of iodinated radiocontrast agents and the evolving evidence of systemic toxicity of Gd! Received 24 February 2007; accepted 1 March 2007. doi:10.1111/j.1445-5994.2007.01413.x J. Jamboti Dubbo Base Hospital, Renal Medicine University of Sydney, Medicine, Sydney New South Wales, Australia References 1 Cheung PP, Dorai Raj AK. Nephrogenic fibrosing dermopathy: a new clinical entity mimicking scleroderma. Intern Med J 2007; 37: 139–41. 2 Joffe P, Thomsen HS, Meusel M. Pharmacokinetics of gadodiamide injection in patients with severe renal insufficiency and patients undergoing hemodialysis or continuous amulatory peritoneal dialysis. Acad Radiol 1998; 5: 491–502. 3 High WA, Ayers RA, Chandler J, Zito G, Cowper SE. Gadolinium is quantifiable within the tissue of patients with nephrogenic systemic fibrosis. J Am Acad Dermatol 2007; 56: 21–6. 4 Okada S, Katagiri K, Kumazaki T, Yokoyama H et al. Safety of gadolinium contrast agent in hemodialysis patients. Acta Radiologica 2001; 42: 339–41. 508 ª 2007 The Author Journal compilation ª 2007 Royal Australasian College of Physicians Letters to the Editor