What are the recommendations for using Gadolinium-based contrast agents in a patient with Chronic Kidney Disease stage 3?

Gadolinium-Based Contrast Agents in CKD Stage 3

Group II gadolinium-based contrast agents (GBCAs) can be safely administered to patients with CKD stage 3 without kidney function screening, as the risk of nephrogenic systemic fibrosis (NSF) is extremely low in this population. 1

Risk Stratification for NSF in CKD Stage 3

• The risk of NSF in patients with CKD stage 3 (eGFR 30-59 mL/min/1.73 m²) is very low, with only rare published reports of questionable validity 1
• There are no published reports of NSF in patients with eGFR greater than or equal to 60 mL/min/1.73 m² 1
• Patients at greatest risk for NSF include those undergoing renal replacement therapy, those with acute kidney injury (AKI), and those with stage 4 or 5 CKD (eGFR <30 mL/min/1.73 m²) 1

GBCA Classification and Safety

GBCAs are categorized into three groups based on their risk association with NSF:

Group I GBCAs (Highest Risk)

• Nearly all unconfounded cases of NSF have been linked to linear group I GBCAs 1
• These agents are no longer advertised in the United States and have been withdrawn from many markets 1

Group II GBCAs (Very Low Risk)

• Few, if any, unconfounded cases of NSF have been associated with group II GBCAs 1
• Include linear ionic GBCA gadobenate dimeglumine (MultiHance) and macrocyclic agents 1
• In a systematic review of 4,931 group II GBCA administrations in patients with stage 4 or 5 CKD, the risk of NSF was 0% 1

Group III GBCAs (Likely Very Low Risk)

• Few, if any, unconfounded cases of NSF have been associated with group III GBCAs 1
• Currently includes only gadoxetate disodium (Eovist/Primovist) 1
• Data remain limited about NSF risk due to fewer published administrations in high-risk patients 1

Recommendations for CKD Stage 3 Patients

• Kidney function screening is optional for group II GBCAs in patients with CKD stage 3 1
• Kidney function screening is necessary for group III GBCAs even in CKD stage 3 1
• Direct communication between radiologist and referring provider regarding NSF risk is not necessary for group II GBCA administration in CKD stage 3 1
• The lowest diagnostic dose of GBCA should be used, regardless of whether it is on-label or off-label 1

Important Safety Considerations

• The risk of NSF increases with larger doses of GBCAs, particularly group I agents 1
• Prophylaxis is not indicated for the prevention of NSF 1
• On-label dosing of group II or group III GBCAs does not have a clinically important risk of nephrotoxicity 1
• Hypersensitivity reactions, including anaphylactic reactions, can occur with any GBCA regardless of kidney function 2

Practical Algorithm for GBCA Use in CKD Stage 3

1. Determine if contrast enhancement is necessary for diagnosis
2. Select a group II GBCA when possible (preferred option for CKD stage 3) 1
3. Use the lowest effective dose of GBCA (standard dose 0.1 mmol/kg) 1
4. No kidney function screening is required before group II GBCA administration 1
5. If using group III GBCA, obtain kidney function screening 1
6. No special post-procedure monitoring or dialysis is required 1

Common Pitfalls and Caveats

• Avoid using group I GBCAs in patients with any degree of kidney impairment 1
• Do not withhold or delay group II GBCAs if harm would result from not proceeding with an indicated contrast-enhanced MRI, even in patients with more advanced CKD 1
• Be aware that gadolinium retention in tissues can occur with all GBCAs, though the clinical significance in patients with normal or mildly impaired renal function remains uncertain 2
• Multiple closely spaced doses should be avoided when possible; if not urgent, delay subsequent doses >24 hours 1