From the Guidelines
Magnetic Resonance Imaging (MRI) contrast agents containing gadolinium do not cause significant nephrotoxicity in most patients, particularly when using newer, more stable macrocyclic agents like gadoterate meglumine (Dotarem), gadobutrol (Gadavist), and gadoteridol (ProHance) at standard doses. The risk of nephrogenic systemic fibrosis (NSF), a rare but serious condition, is extremely low with group II gadolinium-based contrast media (GBCM) 1. Patients with severe kidney impairment (GFR < 30 mL/min/1.73m²) are at highest risk for developing NSF, but the potential harms of delaying or withholding group II GBCM for an MRI in these patients may outweigh the risk of NSF 1.
Key Considerations
- The risk of NSF is very low for a standard dose (0.1 mmol/kg) of group II GBCM, even in patients with eGFR < 30 mL/min per 1.73m² or acute kidney injury (AKI) 1.
- Kidney function screening prior to group II GBCM administration is optional, but it is necessary for group III GBCM 1.
- The lowest diagnostic dose of GBCM should be used, regardless of whether it is on-label or off-label 1.
- Hydration before and after contrast administration can help reduce kidney stress.
Recommendations
- Group II GBCM should not be withheld or delayed if harm would result from not proceeding with an indicated contrast-enhanced MRI 1.
- Patients with normal kidney function can safely receive modern gadolinium contrast agents without significant concern for kidney damage.
- Healthcare providers should screen patients for kidney problems before administering contrast and may adjust or avoid contrast use in high-risk individuals 1.
From the FDA Drug Label
5.2 Nephrogenic Systemic Fibrosis (NSF) Gadolinium-based contrast agents (GBCAs) increase the risk for nephrogenic systemic fibrosis (NSF) among patients with impaired elimination of the drugs. 5.5 Acute Kidney Injury In patients with chronically reduced renal function, acute kidney injury requiring dialysis has occurred with the use of GBCAs.
Nephrotoxicity associated with Magnetic Resonance Imaging (MRI) contrast agents, specifically Gadolinium-based contrast agents (GBCAs), is a recognized risk. The risk of nephrogenic systemic fibrosis (NSF) and acute kidney injury is increased in patients with impaired renal function. Therefore, it can be concluded that MRI contrast agents may cause nephrotoxicity, particularly in patients with pre-existing kidney disease 2 3.
From the Research
Nephrotoxicity of MRI Contrast Agents
- The use of gadolinium-based contrast agents (GBCAs) in magnetic resonance imaging (MRI) has been associated with nephrotoxicity, particularly in patients with pre-existing kidney disease 4, 5, 6.
- Studies have shown that GBCAs can cause nephrogenic systemic fibrosis (NSF), a debilitating disorder characterized by progressive fibrosis of the skin and other systemic organs 4, 5, 6, 7.
- The risk of NSF is increased in patients with advanced kidney disease, particularly those with end-stage renal disease (ESRD) or severe acute kidney injury (AKI) 4, 5, 6.
- The use of certain GBCAs, such as non-ionic linear agents, has been linked to a higher risk of NSF 4, 5.
- Avoidance of GBCA exposure is recommended for high-risk patients, and alternative imaging modalities should be considered 5, 7.
Safe Use of GBCAs in Patients with Kidney Disease
- Some studies suggest that the use of GBCAs with high binding affinity for free gadolinium may be safer in patients with severe chronic kidney disease (CKD) 7.
- A retrospective analysis of 2053 patients with CKD who underwent Gd-MRI found no cases of NSF, even after multiple Gd doses in some patients 8.
- However, caution is still warranted when using GBCAs in patients with CKD, particularly those with stage 5 CKD or acute kidney injury 8.
- Physicians should carefully weigh the benefits and risks of GBCA use in patients with kidney disease and consider alternative imaging modalities when possible 7.