Letter to the Editor
Nephrogenic Systemic Fibrosis: Mini-Review
Juliano Sacramento Mundim
, Sabrina de Castro Lorena, Rosilene Motta Elias, João Egídio Romão Júnior
Corresponding author
Nephrology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
Read
1369
Timeswas read the article
294
Total PDF
1075
Total HTML
Share statistics
array:24 [ "pii" => "S1807593222026400" "issn" => "18075932" "doi" => "10.1590/S1807-59322009000500017" "estado" => "S300" "fechaPublicacion" => "2009-05-01" "aid" => "2640" "copyright" => "CLINICS" "copyrightAnyo" => "2009" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:482-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S1807593222026412" "issn" => "18075932" "doi" => "10.1590/S1807-59322009000500018" "estado" => "S300" "fechaPublicacion" => "2009-05-01" "aid" => "2641" "copyright" => "CLINICS" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:485-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Testicular Tumor Presenting as Scrotal Gangrene" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "485" "paginaFinal" => "486" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3 -" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1107 "Ancho" => 830 "Tamanyo" => 256878 ] ] "descripcion" => array:1 [ "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Complete healing 26 months after excision</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ernesto Reggio, Odival Timm, Roberto Gomes Junqueira, Marcelo José Sette, Jose Bessa" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Ernesto" "apellidos" => "Reggio" ] 1 => array:3 [ "nombre" => "Odival" "apellidos" => "Timm" "sufijo" => "Jr" ] 2 => array:2 [ "nombre" => "Roberto Gomes" "apellidos" => "Junqueira" ] 3 => array:2 [ "nombre" => "Marcelo José" "apellidos" => "Sette" ] 4 => array:3 [ "nombre" => "Jose" "apellidos" => "Bessa" "sufijo" => "Jr" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222026412?idApp=UINPBA00004N" "url" => "/18075932/0000006400000005/v1_202212060738/S1807593222026412/v1_202212060738/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1807593222026394" "issn" => "18075932" "doi" => "10.1590/S1807-59322009000500016" "estado" => "S300" "fechaPublicacion" => "2009-05-01" "aid" => "2639" "copyright" => "CLINICS" "documento" => "simple-article" "crossmark" => 0 "licencia" => "https://creativecommons.org/licenses/by-nc/3.0/" "subdocumento" => "cor" "cita" => "Clinics. 2009;64:479-81" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Systemic Inflammatory Response Syndrome and Multiple Organ Dysfunction in Patients with Acute Tumor Lysis Syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "479" "paginaFinal" => "481" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Márcio Soares, Guilherme A. Feres, Jorge I.F. Salluh" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Márcio" "apellidos" => "Soares" ] 1 => array:2 [ "nombre" => "Guilherme A." "apellidos" => "Feres" ] 2 => array:2 [ "nombre" => "Jorge I.F." "apellidos" => "Salluh" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222026394?idApp=UINPBA00004N" "url" => "/18075932/0000006400000005/v1_202212060738/S1807593222026394/v1_202212060738/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Nephrogenic Systemic Fibrosis: Mini-Review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "482" "paginaFinal" => "484" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juliano Sacramento Mundim, Sabrina de Castro Lorena, Rosilene Motta Elias, João Egídio Romão Júnior" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Juliano Sacramento" "apellidos" => "Mundim" "email" => array:1 [ 0 => "julianomundim@ig.com.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "c1" ] ] ] 1 => array:2 [ "nombre" => "Sabrina" "apellidos" => "de Castro Lorena" ] 2 => array:2 [ "nombre" => "Rosilene Motta" "apellidos" => "Elias" ] 3 => array:2 [ "nombre" => "João Egídio Romão" "apellidos" => "Júnior" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Nephrology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil" "identificador" => "af1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "c1" "etiqueta" => "*" "correspondencia" => "Tel.: 55 11 3069.6570" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2 -" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 740 "Ancho" => 993 "Tamanyo" => 67409 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Band lesion in the left lower limb</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">CASE REPORT</span><p id="para10" class="elsevierStylePara elsevierViewall">The patient was a 43-year-old male who had been diagnosed with Alport syndrome and dialytic chronic kidney disease in 1998. In November 2006, he was admitted to the hospital due to septic shock secondary to a hemodialysis catheter infection that developed into a femoral prosthesis infection.</p><p id="para20" class="elsevierStylePara elsevierViewall">One month later, the patient underwent two MRI scans as preparation for the surgical prosthesis substitution. A gadolinium-based contrast agent was used with a gadodiamide dose of 0.15 mmol/kg in each exam, with a one-week interval between exams.</p><p id="para30" class="elsevierStylePara elsevierViewall">Two months after the MRI, the patient had thickening and hardening of the skin of the right forearm (Figure <a class="elsevierStyleCrossRef" href="#fig1">1</a>) that extended to the remaining limbs, as well as to a band lesion in the left lower limb (Figure <a class="elsevierStyleCrossRef" href="#fig2">2</a>). The remaining physical examination was normal.</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para40" class="elsevierStylePara elsevierViewall">The laboratory findings included an increase in C-reactive protein to 52 mg/L, with a slight increase in serum ferritin to 320 ng/mL. Other tests were normal, such as the hemosedimentation velocity and serum albumin concentration.</p><p id="para50" class="elsevierStylePara elsevierViewall">The pulmonary function test and the echocardiogram were both normal. A computed tomography (CT) scan of the affected areas showed diffuse thickening of the muscle, skin and subcutaneous tissue. The patient then underwent muscle and skin biopsies.</p><p id="para60" class="elsevierStylePara elsevierViewall">Nephrogenic systemic fibrosis (NSF) was confirmed in the skin and muscle biopsies. Immunohistochemical analysis showed the presence of CD34+, CD68+ and factor XIIIa+ mono- and multinucleated cells, and electron microscopy showed gadolinium deposition in the muscle and skin.</p><p id="para70" class="elsevierStylePara elsevierViewall">Treatment with thalidomide and sodium thiosulphate was started, but no significant improvement has been observed.</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">DISCUSSION</span><p id="para80" class="elsevierStylePara elsevierViewall">NSF is a devastating and irreversible disease that affects the skin and other tissues in patients with impaired kidney function (especially in patients with creatinine clearance < 30 ml/min).<a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRef" href="#bib2">2</a> This report describes the first case of NSF in Brazil to the best of our knowledge.</p><p id="para90" class="elsevierStylePara elsevierViewall">In NSF, the mean time between exposure to gadolinium and the onset of the lesions is 25 days, ranging from 2 to 75 days.<a class="elsevierStyleCrossRef" href="#bib1">1</a></p><p id="para100" class="elsevierStylePara elsevierViewall">The characteristic clinical findings are lesions of the extremities, especially the hands and feet, as well as the absence of head and trunk lesions. The affected areas can initially present local edema and develop hard and erythematous plaques, resulting in dermal and epidermal fibrosis, or even fibrosis of deeper tissues such as muscles and internal organs.<a class="elsevierStyleCrossRef" href="#bib2">2</a></p><p id="para110" class="elsevierStylePara elsevierViewall">There are no specific laboratory findings associated with NSF. To attain a definite diagnosis, it is necessary to perform a biopsy of the affected area, to observe evidence of fibrosis in the form of markers such as CD34 and CD68, and to note gadolinium deposits in the affected area.<a class="elsevierStyleCrossRefs" href="#bib1">1–3</a></p><p id="para120" class="elsevierStylePara elsevierViewall">The differential diagnoses include dermatological pathologies that lead to skin thickening such as scleromyxedema, scleroderma, eosinophilic fasciitis and calciphylaxis.<a class="elsevierStyleCrossRef" href="#bib3">3</a></p><p id="para130" class="elsevierStylePara elsevierViewall">Several treatments for NSF have been tested, including both systemic treatments such as corticoids, sodium thiosulfate, cyclophosphamide and thalidomide, and topical treatments such as phototherapy. However, none of these agents have yet been shown to be definitively effective in reversing or even decreasing the progress of the disease.<a class="elsevierStyleCrossRef" href="#bib4">4</a></p><p id="para140" class="elsevierStylePara elsevierViewall">In individuals with normal kidney function, gadolinium rapidly distributes between the plasma and the interstitium. It has a half-life of 2 hours and is eliminated through glomerular filtration without any contribution from tubular secretion, with clearance varying from 1.1 to 1.6 ml/kg/min. More than 95% of the injected dose is eliminated in 24 hours, and less than 3% is eliminated in the stool.<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para150" class="elsevierStylePara elsevierViewall">In patients with advanced kidney failure (stage 5), the pharmacokinetics of the gadolinium complexes are altered. Due to their relatively low molecular weight (500 kDa), small volume of distribution (0.28 l/kg) and low protein binding, they are easily removed by hemodialysis, but not by peritoneal dialysis.<a class="elsevierStyleCrossRef" href="#bib5">5</a></p><p id="para160" class="elsevierStylePara elsevierViewall">A study showed that the half-life of gadolinium in a patient with chronic kidney disease was 34.3 hours. It decreased to 2.6 hours in patients undergoing hemodialysis, whereas in the patients undergoing peritoneal dialysis, it increased to 52.7 hours.<a class="elsevierStyleCrossRef" href="#bib6">6</a></p><p id="para170" class="elsevierStylePara elsevierViewall">The existing data in the literature allow for the following recommendations for preventing and minimizing the risks of acquiring this disease; however, there is no treatment for this pathology at the present date.<a class="elsevierStyleCrossRef" href="#bib4">4</a>,<a class="elsevierStyleCrossRef" href="#bib7">7</a></p><p id="para180" class="elsevierStylePara elsevierViewall">The first and best measure is to suggest that all patients undergoing MRI should be evaluated for the presence of kidney disease, thus identifying those at increased risk of developing NSF, such as: patients with acute kidney disease, mainly associated with liver failure; patients that received kidney or liver transplants and have kidney disease; patients with kidney disease in stages 4 or 5 not undergoing dialytic therapy;<a class="elsevierStyleCrossRef" href="#bib5">5</a>,<a class="elsevierStyleCrossRef" href="#bib10">10</a> and patients undergoing hemodialysis or peritoneal dialysis. Kidney function assessment is recommended for patients with elevated serum creatinine levels to ensure safety when performing the MRI. When a patient at risk of developing NSF is identified, the use of gadolinium should be avoided, unless such an examination is mandatory.<a class="elsevierStyleCrossRef" href="#bib5">5</a>,<a class="elsevierStyleCrossRefs" href="#bib8">8–10</a> If the MRI with gadolinium is truly essential, the lowest possible dose should be used,<a class="elsevierStyleCrossRef" href="#bib1">1</a>,<a class="elsevierStyleCrossRefs" href="#bib8">8–11</a> and multiple exposures to gadolinium should be avoided. The patient must be informed of the risks, benefits and alternatives. All at-risk patients that are exposed to examinations with contrast must undergo a clinical assessment. The use of gadolinium must be avoided in patients with acute kidney failure until the kidney function has recovered.<a class="elsevierStyleCrossRef" href="#bib8">8</a>,<a class="elsevierStyleCrossRef" href="#bib9">9</a></p><p id="para190" class="elsevierStylePara elsevierViewall">Among patients with chronic kidney disease undergoing hemodialysis that are exposed to gadolinium, three hemodialysis sessions should be performed, with the first beginning within three hours after the exposure. It must be emphasized that the efficacy of hemodialysis in preventing NSF is unknown.<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para200" class="elsevierStylePara elsevierViewall">For patients with chronic kidney disease undergoing peritoneal dialysis that are exposed to gadolinium, the number of dialysis bag changes should be increased, or the automatic peritoneal dialysis prescription should be extended to at least 48 hours. Also, hemodialysis should be considered for those that have vascular access and have been exposed to high or multiple doses of gadolinium, or if the nephrologist deems it necessary.<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para210" class="elsevierStylePara elsevierViewall">Among patients with acute kidney disease or chronic kidney disease in stages 4 or 5 that are not undergoing dialysis and were exposed to gadolinium, it is not currently possible to estimate the risk of developing NSF. The decision to submit patients to dialysis must be assessed on an individual basis, by evaluating the risks and benefits in a joint decision among the nephrologist, the patient and the clinician.<a class="elsevierStyleCrossRef" href="#bib8">8</a></p><p id="para220" class="elsevierStylePara elsevierViewall">In conclusion, NSF is a progressive and potentially fatal disease that has been described in patients with acute or chronic kidney disease with a glomerular filtration rate < 30 mL/min/1.73 m<span class="elsevierStyleSup">2</span> who are not undergoing dialysis therapy and are exposed to gadolinium-based contrast agents. To date, no therapy or combination of therapies has shown any consistent benefit for recovery of kidney function in NSF patients.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "cesec10" "titulo" => "CASE REPORT" ] 1 => array:2 [ "identificador" => "cesec20" "titulo" => "DISCUSSION" ] 2 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1 -" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 726 "Ancho" => 993 "Tamanyo" => 76562 ] ] "descripcion" => array:1 [ "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Thickening and hardening of the skin of the right forearm</p>" ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2 -" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 740 "Ancho" => 993 "Tamanyo" => 67409 ] ] "descripcion" => array:1 [ "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Band lesion in the left lower limb</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Description of 12 cases of nephrogenic fibrosing dermopathy and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ FA Mendoza \n \t\t\t\t\t\t\t\t """ 1 => """ CM Artlett \n \t\t\t\t\t\t\t\t """ 2 => """ N Sandorfi \n \t\t\t\t\t\t\t\t """ 3 => """ K Latinis \n \t\t\t\t\t\t\t\t """ 4 => """ S PieraVelazquez \n \t\t\t\t\t\t\t\t """ 5 => """ SA Jimenez \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semarthrit.2005.08.002" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2006" "volumen" => "35" "paginaInicial" => "238" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16461069" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nephrogenic fibrosing dermopathy with systemic involvement" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ WW Ting \n \t\t\t\t\t\t\t\t """ 1 => """ MS Stone \n \t\t\t\t\t\t\t\t """ 2 => """ KC Madison \n \t\t\t\t\t\t\t\t """ 3 => """ K Kurtz \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.139.7.903" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2003" "volumen" => "139" "paginaInicial" => "903" "paginaFinal" => "906" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12873886" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scleromyxedemalike cutaneous disease in renal-dialysis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => """ SE Cowper \n \t\t\t\t\t\t\t\t """ 1 => """ HS Robin \n \t\t\t\t\t\t\t\t """ 2 => """ SM Steinberg \n \t\t\t\t\t\t\t\t """ 3 => """ LD Su \n \t\t\t\t\t\t\t\t """ 4 => """ S Gupta \n \t\t\t\t\t\t\t\t """ 5 => """ PE LeBoit \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(00)02694-5" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2000" "volumen" => "356" "paginaInicial" => "1000" "paginaFinal" => "1001" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11041404" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of nephrogenic systemic fibrosis: limited options but hope for the future" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ DR Linfert \n \t\t\t\t\t\t\t\t """ 1 => """ JO Schell \n \t\t\t\t\t\t\t\t """ 2 => """ DM Fine \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-139X.2007.00407.x" "Revista" => array:6 [ "tituloSerie" => "Semin Dial" "fecha" => "2008" "volumen" => "21" "paginaInicial" => "155" "paginaFinal" => "159" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18226000" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gadolinium use in patients with kidney disease: A cause for concern" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ MA Perazella \n \t\t\t\t\t\t\t\t """ 1 => """ RA Rodby \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-139X.2007.00269.x" "Revista" => array:6 [ "tituloSerie" => "Semin Dial" "fecha" => "2007" "volumen" => "20" "paginaInicial" => "179" "paginaFinal" => "185" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17555477" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacokinetics of gadodiamide injection in patients with severe renal insufficiency and patients undergoing hemodialysis or continuous ambulatory peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ P Joffe \n \t\t\t\t\t\t\t\t """ 1 => """ HS Thomsen \n \t\t\t\t\t\t\t\t """ 2 => """ M Meusel \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acta Radiol" "fecha" => "1998" "volumen" => "5" "paginaInicial" => "491" "paginaFinal" => "502" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Cyted 2007 july 12]" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Food and Drug Administration" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "Available from: URL:http://www.fda.gov/cder/drug/advisory/gadolinium" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nephrogenic systemic fibrosis: recommendations for gadolinium-based contrast use in patients with kidney disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => """ MA Perazella \n \t\t\t\t\t\t\t\t """ 1 => """ RF Reilly \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1525-139X.2007.00402.x" "Revista" => array:6 [ "tituloSerie" => "Semin Dial" "fecha" => "2008" "volumen" => "21" "paginaInicial" => "171" "paginaFinal" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18226005" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How should nephrologists approach gadolinium-based contrast imaging in patients with kidney disease?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => """ MA Perazella \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2215/CJN.00670208" "Revista" => array:6 [ "tituloSerie" => "Clin J Am Soc Nephrol" "fecha" => "2008" "volumen" => "3" "paginaInicial" => "649" "paginaFinal" => "651" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18385396" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nephrogenic systemic fibrosis: A population study examining the relationship of disease development to gadolinium exposure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ A Deo \n \t\t\t\t\t\t\t\t """ 1 => """ M Fogel \n \t\t\t\t\t\t\t\t """ 2 => """ SE Cowper \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2215/CJN.03921106" "Revista" => array:6 [ "tituloSerie" => "Clin J Am Soc Nephrol" "fecha" => "2007" "volumen" => "2" "paginaInicial" => "264" "paginaFinal" => "267" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17699423" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 35004. A 68 year old man with end stage renal disease and thickening of the skin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ SL Moschella \n \t\t\t\t\t\t\t\t """ 1 => """ J Kay \n \t\t\t\t\t\t\t\t """ 2 => """ BT Mackool \n \t\t\t\t\t\t\t\t """ 3 => """ V Liu \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMcpc049026" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2004" "volumen" => "351" "paginaInicial" => "2219" "paginaFinal" => "2227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15548783" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/0000006400000005/v1_202212060738/S1807593222026400/v1_202212060738/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/0000006400000005/v1_202212060738/S1807593222026400/v1_202212060738/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222026400?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 30 | 28 | 58 |
| 2024 September | 34 | 30 | 64 |
| 2024 August | 29 | 33 | 62 |
| 2024 July | 27 | 36 | 63 |
| 2024 June | 27 | 20 | 47 |
| 2024 May | 20 | 17 | 37 |
| 2024 April | 28 | 14 | 42 |
| 2024 March | 50 | 15 | 65 |
| 2024 February | 50 | 14 | 64 |
| 2024 January | 43 | 10 | 53 |
| 2023 December | 49 | 11 | 60 |
| 2023 November | 49 | 18 | 67 |
| 2023 October | 47 | 18 | 65 |
| 2023 September | 36 | 11 | 47 |
| 2023 August | 46 | 1 | 47 |
| 2023 July | 80 | 8 | 88 |
| 2023 June | 63 | 1 | 64 |
| 2023 May | 81 | 2 | 83 |
| 2023 April | 102 | 1 | 103 |
| 2023 March | 126 | 1 | 127 |
| 2023 February | 38 | 0 | 38 |
| 2023 January | 5 | 3 | 8 |
| 2022 December | 12 | 2 | 14 |
Show all