From the Guidelines
Gadolinium-based contrast agents can be safely used in patients with impaired renal function, with a very low risk of nephrogenic systemic fibrosis (NSF) or nephrotoxicity, as long as a group II gadolinium-based contrast media (GBCM) is used at a standard dose of 0.1 mmol/kg. The risk of NSF is extremely low, even in patients with stage 5 or 5D chronic kidney disease, as reported in a study of 2581 individuals 1. When considering the use of GBCM in patients with acute kidney injury or estimated glomerular filtration rate less than 30 mL/min per 1.73 m2, the potential harms of delaying or withholding the contrast agent for a clinically indicated MRI may outweigh the risk of NSF.
Key Considerations
- The safety margin of group II GBCM should be considered with the potential harm of delayed diagnosis or misdiagnosis 1.
- Kidney function screening prior to group II GBCM administration is optional, and it is not necessary to initiate or alter an established dialysis schedule based on group II or group III GBCM administration 1.
- The recommendations apply to patients receiving nephrotoxic medications, chemotherapy, or contrast-enhanced CT, and further study investigating the clinical benefits of GBCM for common indications can improve risk-benefit decision making 1.
Clinical Implications
- For patients with impaired renal function, the use of group II GBCM at a standard dose is recommended, as the risk of NSF is extremely low.
- Alternative imaging techniques that don't require contrast should be considered for high-risk patients.
- Prompt hemodialysis after exposure may be beneficial for patients already on hemodialysis, though it's not recommended solely to remove gadolinium.
Gadolinium-Based Contrast Agents
- Group II GBCM, such as macrocyclic agents, are preferred due to their lower risk of NSF compared to linear agents.
- The use of linear GBCAs, such as gadodiamide and gadopentetate dimeglumine, should be avoided in patients with severe renal impairment.
From the Research
Relationship Between Gadolinium and Impaired Renal Function
The relationship between Gadolinium-based contrast agents (GBCAs) and impaired renal function is complex and has been the subject of numerous studies. Key points to consider include:
- The use of GBCAs in patients with renal impairment is controversial due to concerns regarding nephrogenic systemic fibrosis (NSF) 2, 3, 4, 5.
- Patients with mild-to-moderate chronic kidney disease (CKD) (eGFR ≥30 and <60 mL/min/1.73 m2) can safely receive standard doses of GBCAs without additional precautions 2, 3.
- In patients with acute kidney injury (AKI), severe CKD (eGFR <30 mL/min/1.73 m2), or on dialysis, the administration of GBCAs should be considered individually, and alternative imaging modalities should be utilized whenever possible 2, 3, 4, 5.
- Newer GBCAs may be administered with patient consent in patients with AKI, severe CKD, or on dialysis, citing an exceedingly low risk (much less than 1%) of developing NSF 2, 3.
- Certain GBCAs, such as gadopentetate dimeglumine, gadodiamide, and gadoversetamide, remain absolutely contraindicated in patients with AKI, severe CKD, or on dialysis 2, 3.
Risk of Nephrogenic Systemic Fibrosis
The risk of NSF associated with GBCAs is a significant concern in patients with impaired renal function. Key points to consider include:
- The development of NSF among patients with severe renal insufficiency following exposure to GBCAs is approximately 4%, and mortality can approach 31% 4.
- The mechanism for NSF is unclear, and current treatments are disappointing 4.
- Prevention with hemodialysis immediately following GBCA administration has been recommended, but no studies have shown this to be effective 4.
- Screening for renal disease is important, but less critical when using macrocyclic and newer linear GBCAs 2, 3.
Gadolinium Deposition and Toxicity
Gadolinium deposition and toxicity are also concerns in patients with impaired renal function. Key points to consider include:
- Evidence of in vivo gadolinium deposition in bone tissue in patients with normal renal function is well-established 6.
- Recent literature suggests that gadolinium might also deposit in the brain in patients with intact blood-brain barriers 6.
- Low-stability agents are the ones most often associated with brain deposition 6.