Revisiting the risks of MRI with Gadolinium based contrast agents—review of literature and guidelines

Abstract

Gadolinium based contrast agents (GBCA) have been linked to the occurrence of nephrogenic systemic fibrosis (NSF) in renal impaired patients. The exact interaction between the various different available formulations and occurrence of NSF is not completely understood, but has been postulated. This association has triggered public health advisory bodies to issue guidelines and best practice recommendations on its use. As a result, the reported incidence of NSF, as well as the published use of GBCA-enhanced magnetic resonance imaging in renal impairment, has seen a decline. Understanding of the events that led to these recommendations can increase clinical awareness and the implications of their usage. We present a review of published literature and a brief overview of practice recommendations, guidelines and manuals on contrast safety to aide everyday imaging practice.Teaching Points• Low risk gadolinium based contrast agents should be the choice in renal insufficiency.• Higher doses have been linked to NSF development. Doses should be as low as possible.• Clear documentation of date,dose and type of formulation used should be noted.• Post-scan dialysis should be arranged as soon as possible and feasible.• Pre-existing inflammatory state is a risk factor;liver insufficiency is not a contraindication.

Brain gadolinium deposition after administration of gadolinium-based contrast agents

“…Approximately 75 % of NSF was associated with gadodiamide (linear non-ionic GBCA), around 23 % with gadopentate dimeglumine (linear ionic GBCA) and only a few cases with other GBCAs. Most cases of NSF were associated with linear chelate GBCAs, with instability of the chelate compound implicated as the factor inducing NSF [25][26][27][28][29][30]. The European Society of Urogenital Radiology (ESUR) [29] and European Medicines Agency (EMA) [24] classified the NSF risk of GBCAs into three groups (high risk, intermediate risk, low risk), and recommended that high risk GBCAs not be administered to patients on hemodialysis, with eGFR (estimated glomerular filtration rate) under 30, or acute renal dysfunction.…”

“…The American College of Radiology (ACR) [30] identified the GBCAs associated with the greatest apparent NSF-associated risk (gadodiamide, gadopentetate dimeglumine and gadoversetamide), and recommended that their administration be avoided in such patients. Until now, no definitive treatment for NSF has been devised and radiologists play an essential role in preventing its occurrence [24][25][26][27][28][29][30]. …”

Comprehensive review on cardio-oncology: Role of multimodality imaging

“…76,77 Manifesting with scleromyxoedema-like cutaneous findings 75 , NSF has no consistently effective therapy, with variable results from treatments, which include oral and topical steroids, as well as plasmapheresis; clinical improvement has been reported after renal transplant. 77 Although newer lower-risk gadolinium-based contrast agents have been developed, multiple consensus guidelines, including those from the European Society for Urological Radiology, the American College of Radiology, and the UK Royal College of Radiologists, recommend against the use of gadolinium-based contrast enhanced MRI in acute or chronic renal insufficiency with Glomerular Filtration Rate (GFR) \ 30 mL/ (minÁ1.73 m 2 ) and caution in those with stage 3 chronic kidney disease [GFR 30-59 mL/(minÁ1.73 m 2 )]. 76,77 Historically, CMRi has been contraindicated in patients with an implantable cardiac device because of the potential interference with device function.…”

Magnetic Resonance Imaging and the Use in Small Renal Masses

“…Nephrogenic systemic fibrosis (NSF) has been associated with the use of gadolinium-based contrast agents (GBCA) used in patients with renal insufficiency for MR imaging [29]. In patients with end-stage renal failure or acute kidney disease, NSF is a potential complication of IV gadolinium administration [29].…”

“…In patients with end-stage renal failure or acute kidney disease, NSF is a potential complication of IV gadolinium administration [29]. If no alternative mode of imaging is suitable, patients at risk must be carefully counselled about this potential complication associated with morbidity and death [2].…”