Can an intravenous (IV) contrast-enhanced Magnetic Resonance Imaging (MRI) of the sella cause nephrotoxicity, specifically Impaired Renal Function, in a 90-year-old man with incidental findings?

From the Guidelines

IV contrast-enhanced MR sella poses a very low risk of kidney injury in a 90-year-old man, and the benefits of the diagnostic procedure likely outweigh the risks, as supported by the American College of Radiology and the National Kidney Foundation consensus statements 1. The gadolinium-based contrast agents used in MRI have a significantly better safety profile than iodinated contrast used in CT scans, particularly regarding kidney function. Given the patient's advanced age, I would recommend assessing his baseline kidney function with serum creatinine and estimated glomerular filtration rate (eGFR) before proceeding. Some key points to consider:

• If his kidney function is severely impaired (eGFR <30 mL/min/1.73m²), a risk-benefit discussion should occur, though even in this case, the risk remains relatively low, as stated in the consensus statements 1.
• The risk of nephrogenic systemic fibrosis (NSF) following administration of a standard dose of a group II gadolinium-based contrast media (GBCM) is extremely low, as demonstrated in a review of 2581 individuals 1.
• More importantly, consider whether this additional imaging would actually change clinical management at his age. If the incidental finding is unlikely to require intervention due to age or comorbidities, it may be reasonable to forego the contrast-enhanced study.
• The decision should balance the diagnostic benefit against the patient's overall health status, life expectancy, and treatment goals.
• Macrocyclic gadolinium agents (like gadobutrol, gadoteridol, or gadoterate meglumine) are preferred if contrast is deemed necessary, as they have the lowest risk of gadolinium retention, although the specific choice of agent may not be directly addressed in the provided evidence 1.

From the Research

Nephrotoxicity and Impaired Renal Function

• The use of intravenous gadolinium-based contrast media in magnetic resonance imaging (MRI) has been associated with a risk of nephrotoxicity, particularly in patients with underlying chronic renal insufficiency 2.
• Gadolinium-based contrast media have been reported to induce a usually reversible decrease of glomerular filtration rate in a high-risk population group, especially in patients with altered baseline renal function 2.
• A study found that 16.5% of patients with baseline renal impairment developed acute kidney injury (AKI) after exposure to gadolinium-based contrast media 3.

Risk Factors for Nephrotoxicity

• Sepsis has been identified as an independent risk factor for gadolinium-induced AKI in patients with renal impairment 3.
• Comorbid conditions such as coronary artery disease, liver cirrhosis, diabetes mellitus, and hypertension were not significantly associated with the development of gadolinium-induced AKI 3.
• The type and dose of gadolinium-based contrast agent used, as well as the cumulative lifetime dose, are important considerations in minimizing the risk of nephrotoxicity 4.

Minimizing the Risk of Nephrotoxicity

• A multidisciplinary approach, involving urologists, nephrologists, and radiologists, can help guide patient therapy and minimize the risk of nephrotoxicity 5.
• The use of high-stability gadolinium-based contrast agents and careful monitoring of renal function after administration can help reduce the risk of nephrotoxicity 4, 5.
• Alternative imaging modalities, such as MRI with manganese-based contrast agents, may be considered in patients with renal impairment to minimize the risk of nephrotoxicity 6.