Is MRA with contrast contraindicated in a patient with severe renal impairment (eGFR of 12)?

MRA with Contrast is Contraindicated in Patients with eGFR of 12 ml/min/1.73m²

Gadolinium-based contrast agents are contraindicated in patients with severe renal impairment (eGFR <30 ml/min/1.73m²), including those with an eGFR of 12 ml/min/1.73m².

Risk of Nephrogenic Systemic Fibrosis (NSF)

• Gadolinium-based contrast agents used in MRA are associated with the development of nephrogenic systemic fibrosis (NSF) in patients with severe renal dysfunction 1
• NSF is a progressive, potentially fatal multiorgan fibrosing disease that causes cutaneous sclerosis, subcutaneous edema, disabling joint contractures, and injury to internal organs 1
• The FDA advisory specifically states that exposure to gadolinium-based contrast agents increases the risk for NSF in patients with acute or chronic severe renal insufficiency (glomerular filtration rate less than 30 ml/min/1.73m²) 1
• An eGFR of 12 ml/min/1.73m² falls well below this threshold, placing the patient at significant risk 2, 3

Alternative Imaging Approaches

• For patients with severe renal impairment, alternative imaging modalities should be utilized whenever possible 4

• Non-contrast MRA techniques have been developed for patients with severe renal insufficiency, including:

  • Flow-sensitive dephasing 1
  • Quiescent-interval single shot 1
  • Electrocardiogram-gated fresh-blood partial Fourier fast spin echo 1
  • Balanced steady-state free precession 1
  • Arterial spin labeling 1

• These non-contrast techniques may have limitations including:

  • Lower signal-to-noise ratio 1
  • Limited spatial resolution 1
  • Motion artifacts 1
  • Long acquisition times 1
  • Unreliable visualization of lesions with high flow and turbulence 1

Specific Recommendations for Heart Failure Patients with Severe Renal Impairment

• In patients with heart failure with mildly reduced ejection fraction (HFMEF) and severe renal impairment (eGFR 12 ml/min/1.73m²), gadolinium-based contrast should be avoided 4, 5
• The risk of NSF is particularly concerning in this population as they may have additional risk factors such as:
  • Pro-inflammatory state often present in heart failure 5
  • Potential for acute kidney injury due to hemodynamic instability 2
  • Possible need for multiple imaging studies over time, increasing cumulative gadolinium exposure 6

Important Considerations

• If imaging is absolutely necessary, non-contrast MRA should be considered as the first alternative 1

• If gadolinium administration is deemed clinically necessary despite the risks (which would be rare), the following precautions should be taken:

  • Obtain informed consent discussing the significant risk of NSF 4
  • Use macrocyclic gadolinium agents which have lower reported association with NSF 4
  • Use standard dosing (not higher) and avoid repeat injections 4
  • Consider hemodialysis after the procedure for dialysis-dependent patients, although evidence for its effectiveness in preventing NSF is limited 4, 2

• Certain gadolinium agents (gadopentetate dimeglumine, gadodiamide, and gadoversetamide) are absolutely contraindicated in this patient population 4