From the Guidelines
Patients with End-Stage Renal Disease (ESRD) can undergo Magnetic Resonance Imaging (MRI) with gadolinium-based contrast agents, but it is recommended to use group II gadolinium-based contrast agents and the lowest diagnostic contrast dose, with careful risk-benefit analysis by the healthcare team. The risk of nephrogenic systemic fibrosis (NSF) or nephrotoxicity following administration of a standard dose of a group II GBCM is extremely low, as stated in the consensus statements from the American College of Radiology and the National Kidney Foundation 1.
Key Considerations
- The decision to use gadolinium-based contrast agents in ESRD patients should involve careful consideration of the potential benefits and risks, including the risk of NSF, which is a rare but serious condition.
- Group II gadolinium-based contrast agents are considered lower risk and may be used with caution in these patients when absolutely necessary for diagnosis.
- The lowest possible dose of gadolinium should be used, and prompt dialysis following the procedure (ideally within 2-3 hours) is recommended for hemodialysis patients to help remove the contrast agent.
- Alternative imaging techniques or non-contrast MRI should be considered first whenever possible.
Supporting Evidence
- The American College of Radiology and the National Kidney Foundation recommend the use of group II GBCM in patients with impaired kidney function, with careful consideration of the potential risks and benefits 1.
- The ACR Appropriateness Criteria for renal failure recommend the use of unenhanced MR angiography (MRA) techniques or group II GBCM with the lowest diagnostic contrast dose for contrast-enhanced MRA in patients with ESRD 1.
- The risk of NSF is extremely low with the use of group II GBCM, and the benefits of using these agents may outweigh the risks in certain clinical situations 1.
From the Research
Risks Associated with Gadolinium-Based Contrast Agents in ESRD Patients
- Patients with End-Stage Renal Disease (ESRD) are at risk of developing nephrogenic systemic fibrosis (NSF) when exposed to gadolinium-based contrast agents 2, 3, 4, 5.
- The risk of NSF depends on the degree of renal dysfunction, dose of contrast agent, gadolinium contrast agent stability, and severity of concomitant illness 3.
- The occurrence of NSF after gadolinium contrast agent exposure may vary from negligible up to 2% to 5% in select high-risk clinical situations 3.
Use of Gadolinium-Based Contrast Agents in ESRD Patients
- Magnetic Resonance Imaging (MRI) using gadolinium-based contrast agents must be performed judiciously in patients with renal dysfunction, carefully weighing the benefits of MRI and the risk of NSF 3.
- The U.S. Food and Drug Administration warns against using gadolinium-based contrast agents in patients with a glomerular filtration rate less than 30 mL per minute per 1.73 m2, or any acute renal insufficiency related to the hepatorenal syndrome or perioperative liver transplantation 4.
- Alternative imaging modalities should be considered for patients who are at risk of NSF 4.
Prophylactic Hemodialysis
- Prophylactic hemodialysis has been recommended to prevent NSF in patients with severe renal insufficiency following exposure to gadolinium-based contrast agents, but no studies have shown this to be effective 4.
- A retrospective observational study found that frequent prophylactic hemodialysis performed urgently within 4 hours of receipt of gadolinium-based contrast agents did not provide any benefit in preventing NSF 6.
- Aggressive hemodialysis following exposure to gadolinium-based contrast agents may be useful in removing gadolinium from the body, but its effectiveness in preventing NSF is unclear 2.