# Gadolinium contrast for MRI in kidney impairment: NSF risk by agent group

Source: https://onco.cc/protocols/gadolinium-contrast-kidney-impairment/  
OnCo record `gadolinium-contrast-kidney-impairment` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Many MRI scans for cancer use a dye containing gadolinium. Older types could cause a rare, serious scarring disease (nephrogenic systemic fibrosis) in people with very weak kidneys. The types used for most scans today carry a very low risk, so an important scan should not be refused because of the kidneys. Tell the team if you have kidney disease, are on dialysis, or are pregnant or breastfeeding.

## Summary

NSF occurs almost only in people with acute kidney injury or an eGFR below 30 ml/min/1.73 m², above all below 15 or on dialysis, and was linked mainly to linear agents: gadodiamide caused most cases, with an estimated incidence of 3 to 18% in severe kidney failure (ESUR 2026). The groupings differ by body. ESUR puts the macrocyclic agents (gadobutrol, gadoterate, gadoteridol, gadopiclenol) at lowest risk, the linear liver-specific agents gadobenate and gadoxetate at intermediate risk and approved in Europe for liver imaging only, and gadodiamide, gadopentetate and gadoversetamide at highest risk, now suspended or withdrawn for intravenous use in Europe. ACR/NKF (2021) put gadobenate with the macrocyclic agents in group II (very low risk: no NSF in 4,931 administrations at eGFR below 30; upper 95% bound 0.07%), gadoxetate in group III (limited data, no unconfounded cases) and the old linear agents in group I.

For lowest-risk or group II agents a kidney blood test beforehand is not mandatory (ESUR) or optional (ACR/NKF); ACR/NKF require it for group III. A clinically indicated scan is never denied (ESUR) and group II contrast is not withheld if harm would follow (ACR/NKF). Use the smallest diagnostic dose and record the agent and dose. No drug prophylaxis prevents NSF. Dialysis is not started or changed for group II or III agents (ACR/NKF); ESUR needs no immediate dialysis after macrocyclic agents but does after linear agents in haemodialysis patients, repeated on the next two days. ESUR suggests waiting between elective gadolinium MRIs: 7 days optimally (60 hours minimum) when eGFR is below 30, 48 hours (16 minimum) at 30 to 60. Gadolinium is not a meaningful kidney toxin at approved doses, so metformin needs no change. In pregnancy the smallest dose of a macrocyclic agent may be given when there is a very strong indication; breastfeeding continues normally after macrocyclic agents; ESUR advises no gadolinium in a pregnant or breastfeeding woman with kidney impairment. Gadolinium is retained in brain and body after repeated doses, most after linear agents, with no confirmed neurological symptoms.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: gadolinium and kidneys; MRI contrast and kidney disease; nephrogenic systemic fibrosis; NSF; GBCA; GBCM; gadolinium-based contrast agent; eGFR before MRI; MRI dye kidneys; gadolinium dialysis

## Connected records

- protocols: [Contrast scans after a previous contrast reaction: allergy referral, switching agent and premedication](https://onco.cc/protocols/contrast-reaction-history-and-premedication/), [Iodinated contrast for CT: kidney function checks, kidney protection and metformin](https://onco.cc/protocols/iodinated-contrast-kidney-and-metformin/), [MRI safety screening for implants, devices and medicine patches](https://onco.cc/protocols/mri-safety-screening-implants/)
- technologies: [Gadolinium-based and other MRI contrast agents](https://onco.cc/technologies/gadolinium-based-contrast-agents/), [MRI](https://onco.cc/technologies/mri/)
- drugs: [Gadobenate dimeglumine](https://onco.cc/drugs/gadobenate-dimeglumine/), [Gadobutrol](https://onco.cc/drugs/gadobutrol/), [Gadodiamide](https://onco.cc/drugs/gadodiamide/), [Gadopiclenol](https://onco.cc/drugs/gadopiclenol/), [Gadoterate meglumine](https://onco.cc/drugs/gadoterate-meglumine/), [Gadoteridol](https://onco.cc/drugs/gadoteridol/), [Gadoxetate disodium (liver-specific MRI contrast)](https://onco.cc/drugs/gadoxetate-disodium/)
- ideas: [Eating and drinking normally before a contrast CT scan](https://onco.cc/ideas/idea-pu-no-fasting-before-contrast/)

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