Gadolinium and nephrogenic systemic fibrosis: have we overreacted?

Imaging is an increasingly important part of clinical medicine and contrast enhancement adds valuable diagnostic information. Prior to 2006 gadolinium based contrast agents (GBCA) were used in patients with kidney disease in an attempt to avoid the adverse consequences of iodinated contrast agents. The amount administered often exceeded the United States Food and Drug Administration (FDA)-recommended dosing. After the association between GBCA and nephrogenic systemic fibrosis (NSF) was reported, usage of GBCA was markedly reduced in patients with kidney disease. As a result, iodinated contrast was often used in place of GBCA. Recently, several studies showed that the risk of NSF using GBCA with increased thermodynamic and kinetic stability or increased relaxivity along with a restricted use policy has dramatically reduced NSF risk in patients with chronic kidney disease (CKD). We discuss the risks of GBCA and iodinated contrast use in different stages of CKD and suggest that in some situations GBCA use may pose less overall risk to the patient with advanced kidney disease.