Gadolinium Deposition Disease: A Case Report and the Prevalence of Enhanced MRI Procedures Within the Veterans Health Administration
Background: Gadolinium (Gd) usage in the Veterans Health Administration is increasing and patients with renal disease are frequently exposed. Gd is not entirely eliminated within 24 hours after administration, which may pose long-term adverse effects.
Case Presentation: A Vietnam-era veteran aged > 70 years presented for evaluation of Gd-based contrast agent–induced chronic multisymptom illness. In the course of his routine clinical care, he was exposed to repeated Gd-enhanced magnetic resonance imaging studies. After his second Gd-based contrast agent exposure, he noted rash, pain, headaches, and hoarseness. Years after the exposure to the contrast agents, he continued to have detectable Gd in urine and serum.
Conclusions: Practitioners should be aware of long-term intracellular Gd retention (including the brain) as patients increasingly turn to consultants with concerns about Gd deposition disease. Data from patient advocates demonstrate that Gd is eliminated in intermediate and long phases, which may represent a multicompartment model. The commercial ization of Gd use in imaging studies is outpacing the science addressing the long-term consequences of harboring this alien, toxic, nonphysiologic rare earth metal .
Prolonged elimination of Gd after MRI contrast administration (months to years) may be universal.10 Gd compartmentalizes into leukocytes and erythrocytes and into the cerebrospinal fluid within minutes.37,43 Patients with multisymptomatic illnesses attributed to Gd (Gd deposition disease) have perturbations in cytokine levels, many inflammatory.44,45 The results are concerning: Gd is retained intracellularly in vital organs, including brain neurons. It is inarguable that Gd is an alien, nonphysiologic element. With mounting evidence that Gd retention has clinical consequences, patients should be provided proper informed consent. Complications of renal insufficiency (ie, hyperkalemia, hyperphosphatemia, renal osteodystrophy, hyponatremia, anemia, immunosuppression, etc) follow a smooth, curvilinear slope as the true (not estimated) glomerular filtration declines; the worst iatrogenic complication from Gd—systemic fibrosis—is likely no different.
Patient Perspective
“Seems like it’s one thing after another. My family doctor said that once I had the gadolinium exposures, I have had problems ever since that I don’t recover from.” This includes chronic numbness from the rectum to the bilateral lower extremities and an indolent worsening kidney function; “I have already developed stage 3B chronic kidney disease.” Similar to many suffering with gadolinium retention, the patient was concerned about the long-term consequences. Gadolinium “is a toxic metal that is going through my body for 4 years. That has to be a problem. How come we don’t have that answer?” Clinician ignorance of Gd-induced complications and long-term retention is frustrating. “Not one of my doctors has taken gadolinium retention seriously. Where else are patients supposed to go?”
Conclusions
Health care professionals should be considering subclinical manifestations of nephrogenic systemic fibrosis or open to considering that intracellular neuronal retention of Gd may correlate with symptoms arising after MRI contrast exposures. The science concerning the mechanisms of how Gd exerts its pathologic effects is lagging behind the commercialization of enhancing Gd elimination (ie, chelation therapies) and other untested remedies. Practitioners need to acknowledge the unknown potential consequences of Gd and listen to patients who suspect chronic adverse effects.
