Gadolinium NSF Risk Assessment (ACR 2024)

Algorithm Steps

1. ▶

   Start

   Gadolinium Contrast MRI Ordered

   Assess NSF risk before administration

   1. ●

      Action

      NSF Background

      Understanding the risk

      • NEPHROGENIC SYSTEMIC FIBROSIS:
      • - Fibrosing disorder of skin/organs
      • - Associated with GBCA in renal impairment
      • - Can be disabling or fatal
      • - No effective treatment
      • - Onset: Days to months after exposure
      • SYMPTOMS:
      • - Skin thickening/hardening
      • - Joint contractures
      • - Organ fibrosis (rare)
      • PREVENTION IS KEY
      1. ●

         Action

         Check eGFR

         Kidney function assessment

         • WHEN TO CHECK eGFR:
         • - All patients before Group I agents
         • - Patients with known renal disease
         • - Diabetes, hypertension, age >60
         • - History of kidney disease
         • - Single kidney, transplant
         • ACCEPTABLE TIMING:
         • - Within 6 weeks for stable patients
         • - Same day for unstable/inpatient
         1. ◆

            Decision

            eGFR Level

            Risk stratification

            1. ●

               Action

               eGFR ≥30 mL/min/1.73m²

               Standard risk

               • Any GBCA may be used
               • Group I, II, or III agents OK
               • Standard precautions
               • No special restrictions
               1. ●

                  Action

                  ACR GBCA Risk Groups

                  Agent classification

                  • GROUP I (High Risk - NSF associated):
                  • - Gadodiamide (Omniscan)
                  • - Gadopentetate dimeglumine (Magnevist)
                  • - Gadoversetamide (OptiMARK)
                  • GROUP II (Low Risk):
                  • - Gadobenate dimeglumine (MultiHance)
                  • - Gadobutrol (Gadavist)
                  • - Gadoterate meglumine (Dotarem)
                  • - Gadoteridol (ProHance)
                  • GROUP III (Insufficient Data):
                  • - Gadoxetate disodium (Eovist)
                  • - Gadopiclenol (Elucirem)
                  1. ●

                     Action

                     Consider Alternatives

                     When MRI contrast risky

                     • NON-CONTRAST MRI:
                     • - May answer clinical question
                     • - Time-of-flight angiography
                     • - Diffusion-weighted imaging
                     • ALTERNATIVE MODALITIES:
                     • - CT with iodinated contrast
                     • - Ultrasound
                     • - Nuclear medicine
                     • RISK-BENEFIT DISCUSSION:
                     • - Document discussion with patient
                     • - Informed consent if proceeding
                     1. ●

                        Action

                        Acute Kidney Injury

                        Special situation

                        • AKI: Potentially higher risk
                        • eGFR may not reflect true function
                        • If GBCA needed:
                        • - Use Group II agent
                        • - Lowest dose possible
                        • - Document medical necessity
                        • - Consider nephrology input
                        • Avoid if possible until AKI resolved
                        1. ✓

                           Outcome

                           Summary

                           Key points

                           • NSF is rare with Group II agents
                           • Group I agents: Avoid if eGFR <30
                           • Prevention is only treatment
                           • Document risk assessment
                           • Consider non-contrast alternatives
                           • NSF incidence has dropped dramatically with risk screening
            2. ●

               Action

               eGFR <30 mL/min/1.73m² (not on dialysis)

               Increased risk - agent selection critical

               • GROUP I AGENTS: CONTRAINDICATED
               • - Gadodiamide (Omniscan)
               • - Gadopentetate (Magnevist)
               • - Gadoversetamide (OptiMARK)
               • GROUP II AGENTS: USE WITH CAUTION
               • - Gadobenate (MultiHance)
               • - Gadobutrol (Gadavist)
               • - Gadoterate (Dotarem)
               • - Gadoteridol (ProHance)
               • Use lowest effective dose
            3. ●

               Action

               On Dialysis (HD or PD)

               Special considerations

               • GROUP I: CONTRAINDICATED
               • GROUP II: May be used with caution
               • POST-MRI DIALYSIS:
               • - Hemodialysis: Consider within 3h
               • - Does NOT prevent NSF
               • - May reduce risk (unproven)
               • - Extra session after MRI reasonable
               • PD: Multiple rapid exchanges (limited data)