Gadolinium in Patients with Impaired Renal Function

Nephrogenic systemic fibrosis (NSF), a serious, debilitating, and sometimes fatal scleroderma-like disorder, is associated with the administration of intravenous gadolinium. The primary risk factor is renal failure (patient on dialysis or with a GFR < 30).   The guidelines for administration of gadolinium are as follows:

• Gadolinium should be avoided or minimized in patients with known renal failure (eGFR<30ml/min) or renal insufficiency (eGFR<90ml/min). If enhanced MR is deemed necessary by the radiologist, the exam will be performed after informed consent, with single-dose Multihance or other alternative to Omniscan (gadodiamide). Omniscan (gadodiamide) should be avoided in patients with any amount of renal insufficiency.
• Single-dose Multihance or other gadolinium contrast agent will be used in place of Omniscan (gadodiamide) for enhanced MR studies in patients with any known renal insufficiency (eGFR<90 ml/min).
• Patients with an eGFR>90ml/min reported within 30 days, and who have not had intervening chemotherapy or other treatment or condition that might deteriorate renal function, may receive any gadolinium agent.
• Patients with known renal insufficiency should not receive additional doses of gadolinium contrast within a 48 hour period. If additional gadolinium contrast is required for a patient with known renal insufficiency within 48 hours of the initial dose, Radiologist approval is required.
• Informed consent, obtained by a physician, will be required for gadolinium injection in dialysis patient and all patients with known renal insufficiency with an eGFR<30 ml/min, and for all dialysis patients. A written order for the gadolinium contrast is required from the radiologist. This order must arise explicitly from the radiologist and NOT from either a referring physician or an MR imaging protocol standing order. The name of the patient, the name and specific brand of gadolinium contrast, dose, route, and rate of administration should all be explicitly specified on the order, along with the date and signature of the requesting radiologist.
• Verbal and written instructions will be given to renal insufficiency patients after receiving intravenous gadolinium. Patients with renal insufficiency who receive gadolinium-containing contrast agents should be aware of the following possible signs and symptoms of NSF/NFD, as directed by the FDA warning, and advised to seek medical attention if these occur: swelling and tightening of the skin; difficulty extending the joints of arms, hands, legs, and feet; weakness, reddened or darkened areas on the skin; burning or itching of the skin; and deep bone pain in the hips and ribs.
• Hemodialysis patients who receive intravenous gadolinium contrast will receive dialysis treatments immediately after the procedure (initiated within 2 hours) and the day following the enhanced MR exam.
• For administration to patients on chronic ambulatory peritoneal dialysis (CAPD) or continuous cycler-assisted peritoneal dialysis (CCPD) (also known as automated peritoneal dialysis, or APD), there appears to be strong reason to hesitate to administer these agents. As noted above, this process of dialysis seems to be relatively ineffective at clearing the gadolinium from the body. Thus, special caution should be exercised when deciding whether a peritoneal dialysis patient should receive gadolinium-based MR contrast agents. If it is decided that they should be administered such agents, administration of the lowest reasonable dose is strongly recommended. In the past, it had been recommended that the patient avoid periods of a dry abdomen (i.e., no dialysate in the peritoneal cavity) and that the patient be advised to begin additional dialysis self-treatments or CCPD treatments immediately upon the termination of the MR examination in which the GBMCA was administered. These suggestions seemed prudent, although the efficacy of these recommendations had not been established. However, in light of the near-total apparent ineffectiveness of peritoneal dialysis at clearing the gadolinium from the body, it may well be worth considering immediate initiation of hemodialysis in peritoneal dialysis patients who receive even a low dose of a GBMCA (gadolinium based MR contrast agent), or not administering the agent if clinically feasible.
• Withholding clinically indicated gadolinium contrast can also be associated with its own risks, which should be considered in the decision-making process for all patients with kidney disease.