Can a patient with Chronic Kidney Disease (CKD) stage 3 undergo a Magnetic Resonance Angiography (MRA)?

MRA in CKD Stage 3: Safety and Recommendations

Yes, you can safely perform MRA with gadolinium-based contrast in a patient with CKD stage 3 (eGFR 30-59 mL/min/1.73 m²) using Group II (macrocyclic) agents without special precautions or kidney function screening. 1

Risk Stratification by CKD Stage

The risk of nephrogenic systemic fibrosis (NSF) is stratified by kidney function, and CKD stage 3 carries minimal to no risk: 1

• CKD Stage 3 (eGFR 30-59): Rare published reports exist, many of questionable validity, and no confirmed cases with Group II agents 1
• CKD Stage 4-5 (eGFR <30): Highest risk population, particularly with Group I agents 1
• No cases of NSF have been reported in patients with eGFR ≥60 mL/min/1.73 m² 1

Contrast Agent Selection

Use Group II (macrocyclic) gadolinium-based contrast agents exclusively: 1, 2

• Group II agents (gadobutrol, gadoterate meglumine, gadoteridol) have very low NSF risk even in severe CKD 1
• Group I agents (gadopentetate dimeglumine, gadodiamide, gadoversetamide) are absolutely contraindicated in all CKD patients 3
• Group III agents require kidney function screening but are likely very low risk 1

Screening Requirements

Kidney function screening is optional for Group II agents in CKD stage 3: 1

• The 2021 ACR-NKF consensus liberalized screening requirements for Group II agents, departing from the FDA's 2010 black box warning 1
• If you already know the patient has CKD stage 3, no additional screening is needed 1
• Direct communication with the referring provider is not necessary for Group II agent administration 1

Dosing Considerations

Use standard on-label dosing (0.1 mmol/kg) of Group II agents: 1, 3

• The lowest diagnostic dose should be used, but half or quarter dosing is not recommended 3
• The risk of NSF is very low even at standard doses in CKD stage 3 1
• Avoid repeated doses within 24 hours unless urgent 1

Alternative Imaging Options

Non-contrast MRA sequences are emerging as viable alternatives: 1

• Time-resolved and non-contrast MRA techniques provide high spatial resolution without gadolinium exposure 1
• These sequences can visualize infrapopliteal and pedal vessels effectively 1
• Consider non-contrast MRA if there is any concern, though it is not necessary for CKD stage 3 1

Common Pitfalls to Avoid

Do not withhold clinically indicated MRA based solely on CKD stage 3 diagnosis: 2

• The harm from delayed or missed diagnoses exceeds the theoretical NSF risk in CKD stage 3 2
• Exaggerated fear of contrast complications leads to withholding beneficial diagnostic studies 2
• Group II GBCM should not be withheld if harm would result from not proceeding with indicated imaging 1

Do not confuse gadolinium safety with iodinated contrast safety: 2

• These are different agents with different risk profiles 2
• Gadolinium nephrotoxicity is not a concern at on-label dosing 1

No Prophylaxis or Dialysis Needed

No prophylaxis reduces NSF risk, and dialysis should not be initiated based on gadolinium administration: 1

• Hemodialysis removes gadolinium but does not reduce NSF risk 1
• Dialysis should not be initiated or altered for Group II or Group III agent administration 1