Updated 10.22.2008

It has been recognized recently that patients with severe renal insufficiency/renal failure are at increased risk for the development of Nephrogenic Systemic Fibrosis (NSF) when given gadolinium agents for MRI imaging. The reported incidence varies from 1% to 7% in patients with severe chronic kidney disease (CKD), particularly those on chronic dialysis. NSF has been reported with several gadolinium agents, although it is more strongly associated with some, specifically gadodiamide (Omniscan®). The occurrence of NSF increases with larger gadolinium doses (e.g. MRA) and repeat administration, in the higher risk categories. NSF occurs primarily in patients on chronic dialysis (hemo-, peritoneal) for their renal failure; therefore, it is found primarily in patients whose GFR is less than 15 ml/min. It has not been reported when the GFR is above 60 ml/min; and there is a theoretical risk when the GFR is between 60 and 30 ml/min. An increased number of cases have occurred in in patients with a GFR of less than 30 ml/min. Dialysis does clear gadolinium agents but in renal failure patients on chronic dialysis, at least 3 treatments would be necessary to clear all of the gadolinium.

Any agent may be utilized without risk.

Gadodiamide (Omniscan®), gadopentetate dimeglumine (Magnevist®) and gadoversetamide (OptiMARK®) should be avoided; the exam can be done with minimal risk, but risk/benefit must always be considered..

The patient is at significant risk for NSF, but the risk is low with the “less risky” gadolinium agents. Risk-benefit should be discussed with the referring physician and the patient and informed consent of the patient should be obtained. (CT with iodinated contrast is not a good option in this group of patients since there is still residual renal function that may be severely damaged by a large dose of iodinated contrast).

• Gadolinium-enhanced MRI should be avoided. MR without gadolinium should be considered as an initial study.
• If a contrast-enhanced examination is indicated and the patient is on permanent dialysis, an iodinated contrast CT should be the imaging study of choice.
• If MR with gadolinium must still be done, this should be discussed in detail with the clinician and patient and written informed consent obtained.
• Although dialysis can remove only a portion of the gadolinium, arranging for the gd-MR exam to be done immediately before a scheduled dialysis treatment might be beneficial, though this is not proven.