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Published on: June 11, 2019
Gadolinium in pediatric cardiovascular magnetic resonance: what we know and how we practice
Howard Meng1, Lars Grosse-Wortmann
1The Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
Insights
Pediatric cardiac imagers use gadolinium-based contrast agents (GBCAs) in neonates despite concerns about renal function. Guidelines are needed to standardize GBCA use in children, especially the very young, to prevent nephrogenic systemic fibrosis (NSF).
Area of Science:
- Cardiovascular Imaging
- Pediatric Radiology
- Nephrology
Background:
- Awareness of gadolinium-based contrast agent (GBCA) risks, including nephrogenic systemic fibrosis (NSF), necessitates careful monitoring of renal function.
- Established guidelines for GBCA use in adults contrast with less defined best practices for pediatric patients, particularly neonates.
- Cardiovascular magnetic resonance (CMR) in children requires specific considerations for GBCA administration due to immature renal physiology.
Purpose of the Study:
- To investigate current practices regarding GBCA use in pediatric cardiovascular magnetic resonance.
- To identify trends in GBCA selection, renal function monitoring, and administration in neonates and children.
- To highlight the need for evidence-based guidelines for pediatric GBCA use.
Main Methods:
- A global survey was distributed to pediatric cardiac imagers.
- The questionnaire included 21 questions on GBCA usage, renal function assessment, and practices in neonates.
- Data from 70 respondents were analyzed to understand current GBCA administration protocols.
Main Results:
- Gadopentetate dimeglumine was the most frequently used GBCA (49%).
- GBCA choice was primarily driven by availability (37%) and regulatory approval (23%), rather than image quality or side effect profile.
- Despite concerns, 95% of imagers who scanned neonates used GBCAs, with 89% withholding gadolinium in patients with a glomerular filtration rate below 30 ml/min/1.73 m(2).
Conclusions:
- Pediatric cardiac imagers acknowledge the renal risks associated with GBCAs in children.
- Current GBCA practices in pediatric cardiovascular imaging rely heavily on individual clinical judgment.
- There is a critical need for epidemiological data to support pediatric cardiovascular licensure of GBCAs and establish formal practice guidelines.
Background:
The association of gadolinium-based contrast agents (GBCAs) with nephrogenic systemic fibrosis (NSF) has led to a heightened awareness towards patients' renal function. Whereas detailed guidelines exist for the use of GBCAs in adult patients, best practice is less well defined in children, especially in the very young. We aimed at identifying current practice with regards to the use of GBCAs in children who undergo cardiovascular magnetic resonance.
Methods:
We conducted a worldwide survey among cardiac imagers with pediatric expertise. The questionnaire contained 21 questions covering the imagers' work environments, GBCAs used, monitoring of renal function, and a special emphasis was placed on the practice in neonates.
Results:
The survey yielded 70 replies. The single most commonly used GBCA was gadopentetate dimeglumine 34/70 (49%). Among the respondents, the choice of GBCA was more importantly based on availability 26/70 (37%) and approval by a pharmaceutical licensing body that most closely reflects the indication 16/70 (23%) than image quality 7/70 (10%) and side effect profile 8/70 (11%). 55/70 (79%) of respondents performed scans in neonates <1 week of age and 52/55 (95%) of them used GBCA in neonates. 65/70 (93%) respondents at least assess some of their patients' renal functions. Formula-based estimate of glomerular filtration rate is the most popular assessment method 35/65 (54%). In patients with a glomerular filtration rate < 30 ml/min/1.73 m(2) 62/70 (89%) of respondents do not administer gadolinium at all. The single most common side effect of gadolinium was noted to be nausea/emesis 34/57 (60%) followed by discomfort at injection site 17/57 (30%).
Conclusions:
Cardiac imagers are aware of the immature renal function and physiological differences of their pediatric patients that place them at risk for NSF. Epidemiological data is needed for pediatric cardiovascular licensure of gadolinium compounds and for the creation of practice guidelines which will replace current-day practice based on individual clinical judgment.
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