New recommendations target NSF risk

Nephrogenic systemic fibrosis has received widespread attention, but official protocols on how to avoid the life-threatening skin condition are quite sparse: Only one section in the American College of Radiology's 2007 white paper on safe MR practices is devoted to the condition.

The ACR is already rectifying that situation, however, with detailed recommendations on managing gadolinium-enhanced MR scans in patients with susceptibility to NSF. Currently a work-in-progress, the recommendations will expand on the MR safety white paper and its suggestions for performing gadolinium-enhanced MR studies in patients with renal failure.

The recommendations also will cover pediatric patients and patients with liver disease, said Dr. Jeffrey Weinreb, chair of the ACR's commission on quality and safety.

The recommendations are slated for completion at the end of April, after which the paper will be submitted for publication in a peer-reviewed journal, Weinreb told Diagnostic Imaging.

The section on NSF in last year's MR safe practices guidelines was based on the best available information at that juncture, he said.

"I think most people found it to be very valuable because it was the first guideline of its type from a credible organization," he said. "But at the time that guideline was written, we didn't have the full compliment of expertise on the (MR safety) committee."

The upcoming recommendations are a joint venture of the ACR and the National Kidney Foundation, said Weinreb, who is a professor of diagnostic radiology at Yale University School of Medicine. Weinreb's coauthors on the recommendations are Dr. Ali Abu-Alfa, an associate professor in the department of internal medicine, section of nephrology at Yale, and Dr. Joseph Vassalotti, chief medical officer for the National Kidney Foundation.

Radiologists Dr. Emanuel Kanal, chair of the ACR blue ribbon panel on MR safety, and Dr. Arthur Segal, chair of the ACR committee on drugs and contrast media, also helped craft the recommendations.

"NSF has dramatically impacted our practice processes for MRI. I felt that it was very important that everyone had input, so that we could get a complete picture that isn't just for radiologists," Weinreb said.

In the interest of timeliness, the update information will be billed as recommendations versus guidelines, Weinreb said. Creating and posting guidelines, which have to be officially sanctioned by various levels of ACR leadership, can take as long as a year.

"We felt that (NSF) was rather urgent and opted not to (do a guideline)," he said. "We felt that we could have a similar impact by having this joint group make a recommendation."

In the meantime, radiologists should continue to follow the advice laid out in the guidance document on MR safety, particularly in light of the multiple lawsuits brought against the manufacturers of gadolinium-based contrast agents by NSF patients. Thus far, only vendors have been named in these lawsuits, although radiologists and other physicians may find themselves as defendants in the future. Weinreb stressed, however, that patient safety was paramount.

"The goal of the recommendations is to specifically limit or eliminate the risk of NSF," Weinrab said. "The document is not necessarily geared toward protecting radiologists. It's geared toward preventing the disease."

For more information from the Diagnostic Imaging archives:

Panel orders centralized pretrial proceedings in NSF cases

Report from ECR: NSF's underlying causes remain elusive

Study concludes that NSF is widespread in high-risk patients, but diagnostic method raises questions