High-resolution, whole-body vascular imaging with ferumoxytol as an alternative to gadolinium agents in a pediatric chronic kidney disease cohort

Abstract

Background: Exposure to gadolinium-based contrast agents (GBCA) in patients with chronic kidney disease (CKD) has been associated with the development of a potentially fatal disorder, nephrogenic systemic fibrosis (NSF). Although contrast-enhanced computed tomography (CT) is an alternative to magnetic resonance imaging (MRI), it carries the risk of radiation exposure and further reduction of residual renal function. Therefore we sought to assess the feasibility of ferumoxytol as an alternative to GBCA for contrast-enhanced MR angiography (MRA) in a pediatric cohort with CKD. Ferumoxytol is a parenteral iron supplement that contains ultrasmall superparamagnetic iron oxide (USPIO) and is a potent relaxivity agent for MRI.

Methods: We describe the MRI findings in ten pediatric patients who needed detailed vascular mapping. Ferumoxytol (4 mg/kg) was administered intravenously for contrast-enhanced MRA. The patients tolerated the procedure without complications.

Results: Resulting studies were highly diagnostic and were pivotal in guiding patient management. The images were notable for clear delineation of multiple vascular occlusions.

Conclusions: Given the concerns associated with the use of GBCAs in renal failure, ferumoxytol is an excellent alternative contrast agent in pediatric end stage renal disease (ESRD) patients. Future studies are needed in order to further evaluate safety and efficacy of ferumoxytol in this patient population.

Fig. 1

a–e Magnetic resonance (MR) angiogram with ferumoxytol in 3-year-old male post-renal transplant. Arterial phase-dominant (a, b) and venous phase-dominant (c, d) images show widely patent graft artery and vein and multiple thrombosed neck/chest veins (green arrows). For comparison (e) is a non-contrast, time-of-flight MR angiogram performed before the transplant, which highlights the superior clarity of the ferumoxytol studies

Fig. 2

a, b MR venogram with ferumoxytol in a 5-year-old male with CKD, showing multiple upper venous occlusions (red and green arrows). LSV left subclavian vein, RSA right subclavian artery, AA aortic arch, AzV azygos vein vein. c Non-contrast (“time of flight”) MRA done previously in this 5-year-old male patient showing the difference in image quality. Ao aorta

Fig. 3

Magnetic resonance angiogram with ferumoxytol in an 8-year-old male post-second renal transplant. a Enlarged and edematous graft in the left lower quadrant (as denoted by green arrows). b Patent right renal artery to previous graft (green arrow) and a thrombosed left renal artery (red arrow) to the infarcted second graft. c Volume-rendered 3D image of the same patient, highlighting the thrombosed left renal graft artery (green arrow)