Should I always use the most recent Glomerular Filtration Rate (GFR) value to assess a patient's kidney function when administering group II Gadolinium-Based Contrast Media (GBCM)?

GFR Assessment for Group II Gadolinium-Based Contrast Media Administration

For group II Gadolinium-Based Contrast Media (GBCM), kidney function screening is optional and you do not need to always look at the most recent GFR value to make administration decisions. 1, 2

Group II GBCM Administration Guidelines

When GFR Testing Is NOT Required

• Group II GBCM (macrocyclic agents and gadobenate dimeglumine) can be safely administered without prior kidney function screening 1, 2
• The risk of Nephrogenic Systemic Fibrosis (NSF) is extremely low with group II GBCM, even in patients with eGFR <30 mL/min/1.73 m² or acute kidney injury (AKI) 1
• Direct communication between radiologist and referring provider regarding NSF risk is not necessary for group II GBCM administration 1

When GFR Testing IS Required

• GFR testing is necessary if using group I or group III GBCM 1, 2
• GFR testing should be considered if planning multiple or higher than recommended doses of any GBCM 2

Risk Assessment and Clinical Decision Making

Risk Stratification

• Group II GBCM have demonstrated extremely low risk of NSF:
  • In 4,931 group II GBCM administrations in patients with eGFR <30 mL/min/1.73 m², zero cases of NSF were reported 1
  • For patients with stage 5 or 5D CKD, the upper bound of the 95% confidence interval of risk was only 0.1% (one case per 1,000 exposed individuals) 1

Clinical Considerations

• The harms of delaying or withholding a clinically indicated MRI with group II GBCM often outweigh the minimal risk of NSF 1
• For urgent clinical indications, group II GBCM should not be withheld or delayed even in patients with severely impaired kidney function 1

Special Situations

Multiple Doses

• If multiple urgent group II GBCM doses are indicated, subsequent doses should not be delayed for fear of NSF 1
• For non-urgent cases requiring multiple doses, allowing >24 hours between doses or an intercurrent dialysis session may promote GBCM clearance 1

Dialysis Patients

• Dialysis should not be initiated or altered based on group II GBCM administration 1
• Standard dialysis schedules can continue without modification 1

Pediatric Patients

• The above recommendations also apply to pediatric patients 1
• For infants and children, kidney function should be evaluated using the Bedside Schwartz equation or creatinine-cystatin C-based CKiD equation rather than adult eGFR equations 1

Common Pitfalls to Avoid

• Don't confuse group II GBCM with group I or III GBCM, which have different safety profiles and requirements for GFR testing
• Don't unnecessarily delay clinically indicated MRI examinations with group II GBCM due to kidney function concerns
• Don't initiate dialysis solely for the purpose of removing group II GBCM
• Don't withhold group II GBCM from patients with impaired kidney function when the benefits of the diagnostic information outweigh the minimal risks

By following these evidence-based guidelines, you can safely administer group II GBCM without always requiring the most recent GFR value, while maintaining patient safety and obtaining necessary diagnostic information.