Use of Gadolinium-Based Contrast Agents in Patients with Severe Renal Impairment. Absence of Risk Versus Caution: A Nephrologist's Perspective.

Abstract

Nephrogenic systemic fibrosis (NSF) was initially reported in 2000 and was causally linked to gadolinium-based contrast agents (GBCAs) in 2006 (1,2). NSF with rare exceptions is limited to patients with severe CKD, with the vast majority on dialysis. The causal role of GBCAs has been confirmed in subsequent clinical and experimental studies, which led to restrictive policies about GBCA use in patients with severe CKD. As a result of these policies, reports of NSF have virtually disappeared. More recent clinical studies investigating the risk of NSF in severe CKD after exposure to GBCAs that bind gadolinium (Gd+3) more tightly to the chelate have not demonstrated a risk of NSF (3). These observations have resulted in recommendations by some organizations such as the American College of Radiology (ACR) that state that GBCAs with high Gd+3 -binding properties (termed group 2 GBCAs, Table 1) can be safely used without risk of NSF in patients with severe CKD (4). The ACR states that because the risk of NSF with group 2 GBCAs is very low or nonexistent, these GBCAs can be safely given to patients with severe CKD without informed consent, and assessment of renal function by laboratory testing or questionnaire pre-GBCA is optional. The ACR qualifies this recommendation by stating that GBCAs should be administered only when deemed necessary using the lowest dose needed for diagnosis, that the risk of administering a group 2 GBCA in a high-risk patient must be balanced against the risk of not performing a needed contrast-enhanced study, and in patients with no residual renal function it is reasonable to use a contrast-enhanced computed tomography study if the anticipated diagnostic yield is similar. The recommendations of the ACR and other professional societies with similar recommendations are opposite to the restrictive policies of GBCA use, …