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High Levels of Gadolinium Deposition in the Skin of a Patient With Normal Renal Function

Roberts, Donna R. MD; Lindhorst, Scott M. MD; Welsh, Cynthia T. MD; Maravilla, Kenneth R. MD; Herring, Mary N. MD; Braun, K. Adam MD; Thiers, Bruce H. MD; Davis, W. Clay PhD

doi: 10.1097/RLI.0000000000000266
Original Articles

Objective The aim of this study was to assess gadolinium deposition in the skin of a patient with normal renal function, based on estimated glomerular filtration rate values greater than 59 mL/min/1.73 m2 after exposure to large cumulative doses of gadolinium-based contrast agents (GBCAs).

Materials and Methods The patient underwent 61 contrasted brain MRI scans over the course of 11 years. Skin biopsies from the forearm and lower extremity were analyzed with inductively coupled plasma mass spectrometry (ICP-MS), laser ablation ICP-MS, and hydrophilic interaction liquid chromatography ICP-MS.

Results The ICP-MS demonstrated high levels of gadolinium deposition (14.5 ± 0.4 μg/g), similar to previously reported gadolinium levels within the skin of patients with nephrogenic systemic fibrosis. The laser ablation ICP-MS demonstrated deposition of gadolinium within the deep layers of skin. Speciation analysis using hydrophilic interaction liquid chromatography ICP-MS demonstrated the presence of intact gadolinium-chelate species, although most of the gadolinium present could not be further characterized. Light microscopy demonstrated increased CD34 immunoreactivity in the connective tissue septations of the subcutaneous adipose tissue. The patient had no history of skin disorders and did not have a history of nephrogenic systemic fibrosis but did have severe joint contractures of unknown etiology.

Conclusions Our results, in contradiction to published literature, suggest that in patients with normal renal function, exposure to GBCAs in extremely high cumulative doses can lead to significant gadolinium deposition in the skin. This finding is in line with more recent reports of gadolinium deposition in the brain of patients with normal renal function. Future studies are required to address possible clinical consequences of gadolinium deposition in the skin, brain, and potentially other organs in patients with normal renal function. We recommend, in addition to following current US Food and Drug Administration and American College of Radiology guidelines based on estimated glomerular filtration rate values, that caution be used when administering large cumulative doses of GBCAs and that total cumulative dose of each agent administered is recorded in the patient's medical record.

From the Departments of *Radiology and Radiological Sciences; †Neurosurgery and Hematology/Oncology, and ‡Pathology, Medical University of South Carolina, Charleston, SC; §Departments of Radiology and Neurological Surgery, University of Washington, Seattle, WA; ∥Department of Physical Medicine & Rehabilitation and ¶Dermatology & Dermatologic Surgery, Medical University of South Carolina; and #National Institute of Standards and Technology, Chemical Sciences Division, Charleston, SC.

Received for publication December 11, 2015; and accepted for publication, after revision, January 20, 2016.

Conflicts of interest and sources of funding: none declared.

Disclaimer: Certain commercial equipment, instruments, software, or materials are identified in this document. Such identification does not imply recommendation or endorsement by the National Institute of Standards and Technology, nor does it imply that the products identified are necessarily the best available for the purpose.

Correspondence to: Donna R. Roberts, MD, 96 Jonathan Lucas Street, MSC 323, CSB Suite 210, Charleston, SC 29425-3230. E-mail:

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