Gadolinium-based contrast agents: Stimulators of myeloid-induced renal fibrosis and major metabolic disruptors

Precipitation of gadolinium from magnetic resonance imaging contrast agents may be the Brass tacks of toxicity

The formation of gadolinium-rich nanoparticles in multiple tissues from intravenous magnetic resonance imaging contrast agents may be the initial step in rare earth metallosis. The mechanism of gadolinium-induced diseases is poorly understood, as is how these characteristic nanoparticles are formed. Gadolinium deposition has been observed with all magnetic resonance imaging contrast agent brands. Aside from endogenous metals and acidic conditions, little attention has been paid to the role of the biological milieu in the degradation of magnetic resonance imaging contrast agents into nanoparticles. Herein, we describe the decomposition of the commercial magnetic resonance imaging contrast agents Omniscan and Dotarem in the presence of oxalic acid, a well-known endogenous compound. Omniscan dechelated rapidly and preluded measurement by the means available, while Dotarem underwent a two-step decomposition process. The decomposition of both magnetic resonance imaging contrast agents by oxalic acid formed gadolinium oxalate (Gd2[C2O4]3, Gd2Ox3). Furthermore, both observed steps of the Dotarem reaction involved the associative addition of oxalic acid. Adding protein (bovine serum albumin) increased the rate of dechelation. Displacement reactions could occur at lysosomal pH. Through these studies, we have demonstrated that magnetic resonance imaging contrast agents can be dissociated by endogenous molecules, thus illustrating a metric by which gadolinium-based contrast agents (GBCAs) might be destabilized in vivo.

Early endolysosomal dysfunction is a contributing factor to gadolinium-based contrast agent mouse renal proximal tubule epithelial cell injury

The prevalence of contrast-enhanced magnetic resonance imaging (MRI) examinations and the absence of safer alternatives to gadolinium-based contrast agents (GBCAs) make the associated adverse effects of GBCAs much more concerning. Safety concerns arise from the toxic behavior of heavy metal gadolinium (Gd3+) and the potential release of the metal from the chelating ligand. Renal insufficiency and other patient factors increase the susceptibility to the toxic effects of GBCAs. It is, therefore, imperative that the molecular and cellular mechanisms underlying GBCA toxicity be defined. This study aims to determine GBCA-induced endolysosomal dysfunction in mouse renal proximal tubule epithelial cells. Loss of cell viability was agent- and time-dependent, and proximal tubule injury was detectable following 24 h linear GBCA exposure. Both classes of GBCAs displayed lysosomotropic behaviors, characterized by early lysosomal enlargement and lysosomal injury. Hijacking of the endolysosomal system by these agents inhibited cathepsin processing by blocking the transport and maturation of cathepsin B (CTSB) and cathepsin D (CTSD). Lysosomal enlargement coincided with the translocation of CTSB and CTSD from the lysosomal lumen to the cytosol, suggesting lysosomal membrane destabilization. Even though both agents displayed a similar response, linear exposures appeared to exhibit a greater effect. Disturbance of mitochondrial activity and loss of cell viability occurs downstream of early lysosome damage. This effect was partially restored by lysosomal protease inhibitor co-treatment. This data suggests that GBCA exposures induce a lysosomal stress response, and partial LMP occurs upstream of mitochondrial dysfunction and resultant cellular injury.

Gadoteric Acid and Gadolinium: Exploring Short- and Long-Term Effects on Healthy Animals

Regarding the safety of gadolinium (Gd (III))-based contrast agents, we aimed to evaluate the short- and long-term effects following a single exposure to gadoteric acid (DOTA) or to free Gd (III) using animal models. Biomarkers of kidney injury, inflammation, iron metabolism, dyslipidemia, hepatic and hematologic disturbances and kidney histopathological and differential gene expression (DGE) analyses were evaluated. In the short-term study, compared to the controls, exposure to Gd (III) was associated with higher inflammation; changes in lipid, iron and hepatic metabolisms; hematological alterations; and kidney damage. Exposure to DOTA revealed changes in hematological, lipid and hepatic biomarkers. In the long-term study, compared to the controls, exposure to Gd (III) or to DOTA showed much fewer changes than the short-term exposure. Comparing the kidney gene expression of Gd (III) or DOTA exposure versus the control, we found clearly different DGE patterns and a lower number of differently expressed genes in the long-term study, for both compounds. Our data show that a single-dose exposure to these compounds induces several short-term changes which over time return to normal or are sustained, although with less severity, especially in the case of DOTA.

Into the deep: Exploring the molecular mechanisms of hyperactive behaviour induced by three rare earth elements in early life-stages of the deep-sea scavenging amphipod Tmetonyx cicada (Lysianassidae)

With increasing socio-economic importance of the rare earth elements and yttrium (REY), Norway has laid out plans for REY mining, from land-based to deep-sea mining, thereby enhancing REY mobility in the marine ecosystem. Little is known about associated environmental consequences, especially in the deep ocean. We explored the toxicity and modes of action of a light (Nd), medium (Gd) and heavy (Yb) REY-Cl3 at four concentrations (3, 30, 300, and 3000 μg L-1) in the Arcto-boreal deep-sea amphipod Tmetonyx cicada. At the highest concentration, REY solubility was limited and increased with atomic weight (Nd < Gd < Yb). Lethal effects were practically restricted to this treatment, with the lighter elements being more acutely toxic than Yb (from ∼50 % mortality in the Gd-group at dissolved 689-504 μg L-1 to <20 % in the Yb-group at ca. 2000 μg L-1), which could be a function of bioavailability. All three REY induced hyperactivity at the low-medium concentrations. Delving into the transcriptome of T. cicada allowed us to determine a whole array of potential (neurotoxic) mechanisms underlying this behaviour. Gd induced the vastest response, affecting serotonin-synthesis; sphingolipid-synthesis; the renin-angiotensin system; mitochondrial and endoplasmic reticulum functioning (Gd, Nd); and lysosome integrity (Gd, Yb); as well as the expression of hemocyanin, potentially governing REY-uptake (Gd, Yb). While Nd and Yb shared only few pathways, suggesting a link between mode of action and atomic weight/radius, almost all discussed mechanisms imply the disruption of organismal Ca-homeostasis. Despite only fragmental genomic information available for crustaceans to date, our results provide novel insight into the toxicophysiology of REY in marine biota. The neurotoxic/behavioural effects in T. cicada at concentrations with potential environmental relevance warn about the possibility of bottom-up ecological consequences in mining exposed fjords and deep-sea ecosystems, calling for follow-up studies and regulatory measures prior to the onset of REY mining in Norway.

The safety of magnetic resonance imaging contrast agents

Gadolinium-based contrast agents are increasingly used in clinical practice. While these pharmaceuticals are verified causal agents in nephrogenic systemic fibrosis, there is a growing body of literature supporting their role as causal agents in symptoms associated with gadolinium exposure after intravenous use and encephalopathy following intrathecal administration. Gadolinium-based contrast agents are multidentate organic ligands that strongly bind the metal ion to reduce the toxicity of the metal. The notion that cationic gadolinium dissociates from these chelates and causes the disease is prevalent among patients and providers. We hypothesize that non-ligand-bound (soluble) gadolinium will be exceedingly low in patients. Soluble, ionic gadolinium is not likely to be the initial step in mediating any disease. The Kidney Institute of New Mexico was the first to identify gadolinium-rich nanoparticles in skin and kidney tissues from magnetic resonance imaging contrast agents in rodents. In 2023, they found similar nanoparticles in the kidney cells of humans with normal renal function, likely from contrast agents. We suspect these nanoparticles are the mediators of chronic toxicity from magnetic resonance imaging contrast agents. This article explores associations between gadolinium contrast and adverse health outcomes supported by clinical reports and rodent models.

Gadolinium Retention and Nephrotoxicity in a Mouse Model of Acute Ischemic Stroke: Linear Versus Macrocyclic Agents

BACKGROUND

Gadolinium (Gd)-based contrast agents (GBCAs) have been widely used for acute ischemic stroke (AIS) patients. GBCAs or AIS alone may cause the adverse effects on kidney tissue, respectively. However, whether GBCAs and AIS would generate a synergistic negative effect remains undefined.

PURPOSE

To evaluate synergistic negative effects of AIS and GBCAs on renal tissues in a mouse model of AIS, and to compare the differences of these negative effects between linear and macrocyclic GBCAs.

STUDY TYPE

Animal study.

ANIMAL MODEL

Seventy-two healthy mice underwent transient middle cerebral artery occlusion (tMCAO) and sham operation to establish AIS and sham model (N = 36/model). 5.0 mmol/kg GBCAs (gadopentetate or gadobutrol) or 250 μL saline were performed at 4.5 hours and 1 day after model establishing (N = 12/group).

ASSESSMENT

Inductively coupled plasma mass spectrometry (ICP-MS) was performed to detect Gd concentrations. Serum biochemical analyzer was performed to measure the serum creatinine (Scr), uric acid (UA), and blood urea nitrogen (BUN). Pathological staining was performed to observe tubular injury, cell apoptosis, mesangial hyperplasia, and interstitial fibrosis.

STATISTICAL TESTS

Two-way analysis of variances with post hoc Sidak's tests and independent-samples t-tests were performed. A P-value <0.05 was considered statistically significant.

RESULTS

AIS groups showed higher Gd concentration than sham group on day 1 p.i. regardless of gadopentetate or gadobutrol used. Increased total Gd concentration was also found in AIS + gadopentetate group compared with the sham group on day 28 p.i. Significantly higher rates for renal dysfunction, higher tubular injury scores, and higher numbers of apoptotic cells on days 1 or 28 p.i. were found for AIS mice injected with GBCA. AIS + gadopentetate group displayed more severe renal damage than the AIS + gadobutrol group.

DATA CONCLUSION

AIS and GBCAs may cause increased total Gd accumulation and nephrotoxicity in a mouse, especially linear GBCAs were used.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 4.

Toxicity Mechanisms of Gadolinium and Gadolinium-Based Contrast Agents-A Review

Gadolinium-based contrast agents (GBCAs) have been used for more than 30 years to improve magnetic resonance imaging, a crucial tool for medical diagnosis and treatment monitoring across multiple clinical settings. Studies have shown that exposure to GBCAs is associated with gadolinium release and tissue deposition that may cause short- and long-term toxicity in several organs, including the kidney, the main excretion organ of most GBCAs. Considering the increasing prevalence of chronic kidney disease worldwide and that most of the complications following GBCA exposure are associated with renal dysfunction, the mechanisms underlying GBCA toxicity, especially renal toxicity, are particularly important. A better understanding of the gadolinium mechanisms of toxicity may contribute to clarify the safety and/or potential risks associated with the use of GBCAs. In this work, a review of the recent literature concerning gadolinium and GBCA mechanisms of toxicity was performed.

The onset of rare earth metallosis begins with renal gadolinium-rich nanoparticles from magnetic resonance imaging contrast agent exposure

The leitmotifs of magnetic resonance imaging (MRI) contrast agent-induced complications range from acute kidney injury, symptoms associated with gadolinium exposure (SAGE)/gadolinium deposition disease, potentially fatal gadolinium encephalopathy, and irreversible systemic fibrosis. Gadolinium is the active ingredient of these contrast agents, a non-physiologic lanthanide metal. The mechanisms of MRI contrast agent-induced diseases are unknown. Mice were treated with a MRI contrast agent. Human kidney tissues from contrast-naïve and MRI contrast agent-treated patients were obtained and analyzed. Kidneys (human and mouse) were assessed with transmission electron microscopy and scanning transmission electron microscopy with X-ray energy-dispersive spectroscopy. MRI contrast agent treatment resulted in unilamellar vesicles and mitochondriopathy in renal epithelium. Electron-dense intracellular precipitates and the outer rim of lipid droplets were rich in gadolinium and phosphorus. We conclude that MRI contrast agents are not physiologically inert. The long-term safety of these synthetic metal-ligand complexes, especially with repeated use, should be studied further.

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 commercialization of Gd use in imaging studies is outpacing the science addressing the long-term consequences of harboring this alien, toxic, nonphysiologic rare earth metal.

Cellular and molecular pathways underlying the nephrotoxicity of gadolinium

Mounting evidence on the short- and long-term adverse effects associated with gadolinium [Gd (III)]-based contrast agents used in magnetic resonance imaging have emerged in the past three decades. Safety issues arise from the release of Gd (III) from chelates and its deposition in tissues, which is exacerbated in patients with renal disease, since the kidney is the major excretion organ of most of these agents. This study aimed at unveiling the cellular and molecular mechanisms of nephrotoxicity of Gd (III), using an in vitro model of human proximal tubular cells (HK-2 cell line). Cell viability declined in a concentration- and time-dependent manner after exposure to GdCl3·6H2O. The estimated inhibitory concentrations (ICs) eliciting 1 to 50% of cell death, after 24 h of exposure, ranged from 3.4 to 340.5 µM. At toxic concentrations, exposure to Gd (III) led to disruption of the oxidative status, mitochondrial dysfunction, cell death by apoptosis, switching to necrosis at higher levels, and autophagic activation. Disturbance of the lipid metabolism was already observed at low-toxicity ICs, with accumulation of lipid droplets, and upregulation of genes related to both lipogenesis and lipolysis. Gd (III)-exposure, even at the subtoxic IC01, increased the expression of modulators of various signaling pathways involved in the development and progression of renal disease, including inflammation, hypoxia and fibrosis. Our results give new insights into the mechanisms underlying the nephrotoxic potential of Gd (III) and highlight the need to further clarify the risks versus benefits of the Gd (III)-based contrast agents currently in use.

Overlapping roles of NADPH oxidase 4 for diabetic and gadolinium-based contrast agent-induced systemic fibrosis

Dozens of millions of people are exposed to gadolinium-based contrast agents annually for enhanced magnetic resonance imaging. Gadolinium-based contrast agents are known nephrotoxins and can trigger the potentially fatal condition of systemic fibrosis. Risk factors are practically entirely undefined. We examined the role of NADPH oxidase 4 (Nox4) in gadolinium-induced systemic disease. Age- and weight-matched mice were randomized to experimental diabetes (streptozotocin) and control groups followed by systemic gadolinium-based contrast agent treatment. Nox4-deficient mice were randomized to experimental diabetes and gadolinium-based contrast agent treatment. Skin fibrosis and cellular infiltration were apparent in both gadolinium-based contrast agent-treated and experimental diabetes groups. Similarly, both groups demonstrated renal pathologies with evidence of reactive oxygen species generation. Deletion of Nox4 abrogated both skin and renal pathology, whether from diabetes or gadolinium-based contrast agent treatment. These discoveries demonstrate the importance of Nox4 in gadolinium-based contrast agent- and diabetes-induced fibrosis.NEW & NOTEWORTHY A mouse model of gadolinium-based contrast agent- and diabetes-induced fibrosis was used to demonstrate the role of NADPH oxidase 4 (Nox4) in gadolinium-induced systemic disease. Using these models, we established the role of Nox4 as a mediator of reactive oxygen species generation and subsequent skin and kidney fibrosis. These novel findings have defined Nox-4-mediated mechanisms by which gadolinium-based contrast agents induce systemic diseases.

Effects of gadolinium-based magnetic resonance imaging contrast media on red blood cells and K562 cancer cells

BACKGROUND

Gadolinium-based contrast media (GBCM) are commonly used in diagnostic magnetic resonance imaging (MRI) in clinical applications. The objective of this study is to evaluate the antioxidant properties and effects on red blood cells (RBCs) and K562 cancer cells of three GBCMs (i.e.; gadoterate meglumine, gadopentetate dimeglumine, and gadobenate dimeglumine) inin vitro levels.

METHODS

For determiningin vitro antioxidant properties, the di (phenyl)-(2,4,6-trinitrophenyl) iminoazanium (DPPH) and ferric reducing ability of plasma (FRAP) assay were used. For determining effect on red blood cells, hemolysis, morphology and reactive oxygen species (ROS) were used. For determining effect on K562 cancer cells, cytotoxicity and ROS were used. The GBCM -exposed cells were compared to corresponding non-exposed control groups at various harvest times.

RESULTS

The results show no changes occurring in the DPPH data. However, there were significant increases based on FRAP data in three GBCMs compared to the corresponding control at all concentrations. The ROS, morphology, and percentage of hemolysis in red blood cells indicated that no change had occurred in three GBCMs-exposed red blood cells compared to the corresponding non-exposed control groups at all harvest times. The percentage of cell viability in K562 cancer cells showed decreases in gadoterate meglumine- and gadobenate dimeglumine- in a concentration dependent manner, but did not show same in gadopentetate dimeglumine-exposed K562 cancer cells. The percentage of ROS in K562 cancer cells indicated that no change in three GBCMs-exposed cells had occurred when compared to the corresponding non-exposed control groups at all harvest times.

CONCLUSION

These findings suggests thatin vitro antioxidant properties exhibited by those three GBCMs depends on their concentration and species of radical in testing assay. There were no toxic effects from those GBCMs when red blood cells were exposed in an in vitro condition. In addition, some of those GBCMs could induce cell death in cancer cells.

Gadolinium-Based Contrast Agent Use, Their Safety, and Practice Evolution

Gadolinium-based contrast agents (GBCAs) have provided much needed image enhancement in magnetic resonance imaging (MRI) important in the advancement of disease diagnosis and treatment. The paramagnetic properties of ionized gadolinium have facilitated these advancements, but ionized gadolinium carries toxicity risk. GBCAs were formulated with organic chelates designed to reduce these toxicity risks from unbound gadolinium ions. They were preferred over iodinated contrast used in computed tomography and considered safe for use. As their use expanded, the development of new diseases associated with their use (including nephrogenic systemic fibrosis) has drawn more attention and ultimately caution with their clinical administration in those with impaired renal function. Use of GBCAs in those with preserved renal function was considered to be safe. However, in this new era with emerging clinical and experimental evidence of brain gadolinium deposition in those with repeated exposure, these safety assumptions are once again brought into question. This review article aims to add new perspectives in thinking about the role of GBCA in current clinical use. The new information begs for further discussion and consideration of the risk-benefit ratio of use of GBCAs.