Key points from the ACR Manual on Contrast Media regarding prevention of nephrogenic systemic fibrosis in patients at risk
| Kidney function | Recommendation | Authors’ comments |
|---|---|---|
| Chronic kidney disease stage 1 and 2 | No increased risk of developing NSF. Any gadolinium-based agent can be given safely. | There are no cases reported in this category with any of the gadolinium-based agents. |
| Chronic kidney disease stage 3 | The risk of developing NSF is exceedingly rare. No special precautions are necessary. | There have been no definite cases reported in patients with stage 3 chronic kidney disease. |
| Chronic kidney disease stage 4 and 5 not on chronic dialysis | Group I agents are contraindicated. If a gadolinium-enhanced MRI study is to be done, a group II agent should be used. | Given the risk of CI-AKI in this population, we believe that MRI using a group II agent would be preferable to CT with iodinated contrast. |
| End-stage kidney disease on hemodialysis | The ACR favors CT rather than MRI if the anticipated diagnostic yield is similar. Group I agents are contraindicated. Group II agents are preferred and gadolinium-enhanced MRI should be performed as closely before hemodialysis as is possible. | We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents. Our current practice is to perform a single dialysis session rather than 2 consecutive sessions. |
| End-stage kidney disease on peritoneal dialysis | The ACR favors CT when possible, but if MRI is desired, then the ACR recommends a group II agent. The ACR recognizes that peritoneal dialysis may provide less NSF risk reduction than hemodialysis. | We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents. The committee does not comment on the necessity of subjecting these patients to hemodialysis. We believe it is safer to perform a single session of hemodialysis, particularly for peritoneal dialysis patients with no residual kidney function. |
| Acute kidney injury | Group I agents should be avoided in patients with known or suspected acute kidney injury. Group II agents are preferred. | We favor a stratified approach: Acute kidney injury on dialysis: As in patients with end-stage kidney disease, we recommend a single session of dialysis following gadolinium exposure. Nonoliguric acute kidney injury not on dialysis: Similar to advanced chronic kidney disease, if a gadolinium-enhanced MRI study is needed, a group II agent should be used. Oliguric acute kidney injury not on dialysis: We favor avoiding administration of gadolinium if possible. Otherwise, our practice is to perform a single hemodialysis session. |
ACR = American College of Radiology; CI-AKI = contrast-induced acute kidney injury; CT = computed tomography; MRI = magnetic resonance imaging; NSF = nephrogenic systemic fibrosis
Based on information in reference 41.