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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.
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in Europe for liver imaging only, and gadodiamide, gadopentetate and gadoversetamide at highest risk, now suspended or withdrawn for intravenous use in Europe.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.
Why: With today's agents the risk to the kidneys and skin is very low, and a missed diagnosis can be the bigger harm.
“Never deny a patient a clinically well-indicated enhanced MR-examination.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: The NSF cases came almost all from older linear agents; the newer, more stable agents have very few or none.
“The risk of NSF is very low for a standard dose (0.1 mmol/kg) of group II GBCM, even in patients with eGFR <30 mL/min per 1.73 m 2 or AKI.”
American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 · Consensus statement (ungraded)
Why: A routine blood test adds delay without changing what happens when the agent is very low risk.
“Kidney function screening is optional for group II GBCM but is necessary for group III GBCM.”
American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 · Consensus statement (ungraded)
Why: Risk rises with dose, and a record lets later teams know exactly what was given.
“Always record the name and dose of the contrast agent used in the patient records.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: They are the people in whom the risk is real, even if small, and the choice is shared.
“Although written documentation of informed consent is not required before administration of group II or group III GBCM, patients with known AKI or known stage 4 or 5 CKD should be informed of the potential risk of NSF associated with GBCM administration, the reason GBCM administration is indicated, and whether there are viable alternative diagnostic strategies.”
American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 · Consensus statement (ungraded)
Why: No preventive treatment has been shown to work, and starting dialysis has its own risks.
“Dialysis should not be initiated or altered based on group II or group III GBCM administration.”
American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 · Consensus statement (ungraded)
Why: Linear agents release gadolinium more easily, and dialysis is the only way to clear them when the kidneys do not.
“An immediate dialysis session is not needed after macrocyclic gadolinium-based contrast agents but is indicated after linear agents (e.g., liver-specific agents) and needs to be repeated on the following two days.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: Weak kidneys take days to clear the dye, and a second dose before the first has gone adds to the body's load.
“In emergency or life-threatening situations, employ less waiting time between contrast- enhanced MRI with successive gadolinium-based contrast agent administrations.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: Gadolinium at approved doses does not injure the kidneys in a way that makes metformin dangerous.
“No special precautions are necessary when diabetic patients on metformin are given gadolinium-based contrast agents as the risk of CA-AKI is extremely low and lactic acidosis has never been reported in this scenario.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: The dye crosses to the baby, so it is kept for scans that are truly needed; with weak kidneys the mother clears it slowly.
“When there is a very strong indication for enhanced MRI, the smallest possible dose of a macrocyclic gadolinium contrast agent may be given to the pregnant female.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Why: Only a tiny amount reaches breast milk and less still is absorbed by the baby.
“Breast feeding may be continued normally when macrocyclic gadolinium-based contrast agents are given to the mother.”
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Use a lowest-risk agent (ESUR: macrocyclic; ACR/NKF: group II) at the smallest diagnostic dose, never deny or delay an indicated contrast MRI on kidney grounds, do not require an eGFR beforehand for these agents (ESUR 2026: not mandatory; ACR/NKF 2021: optional), and do not give prophylaxis or alter dialysis. The two bodies disagree on two points. Gadobenate (MultiHance) is a lowest-risk group II agent for ACR/NKF but an intermediate-risk linear agent in ESUR, approved in Europe for liver imaging only. In haemodialysis patients ESUR still arranges dialysis after linear agents, on three consecutive days, while ACR/NKF say dialysis should not be started or changed for group II or III agents. Neither body grades its statements.
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026 · American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021
Where it differs: Some departments still require an eGFR before any gadolinium.
Evidence: ESUR 2026 states testing is not mandatory for lowest-risk agents; ACR/NKF make it optional for group II and necessary for group III. Earlier guidance (ACR 2018, KDIGO 2013) is compared in ACR/NKF table 3.
European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026 · American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021
Where it differs: KDIGO (2013), as summarised by ACR/NKF, performs dialysis immediately after gadolinium and possibly again at 24 hours; the 2018 ACR manual gave gadolinium as soon as possible before a scheduled dialysis session. ACR/NKF 2021 say not to start or alter dialysis for group II or III agents; ESUR keeps dialysis after linear agents only.
Evidence: ACR/NKF: no evidence that dialysis prevents NSF; ESUR agrees that haemodialysis has not been shown to protect against NSF.
American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 · European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026
Where it differs: Avoid gadolinium if eGFR is below 15 unless there is no alternative, and treat macrocyclic versus linear structure as the dividing line rather than ACR groups.
Evidence: Stated in ACR/NKF table 3 as the historical KDIGO position; KDIGO was not read directly.
Being told not to eat for hours before a CT scan with contrast dye dates from older dyes that made people sick. Randomised trials, including one of more than 3,000 outpatients at a cancer centre, found no more sickness when people ate, and European radiologists recommend against fasting. Some hospitals still ask for it.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Group II contrast is not withheld or delayed if harm would result “Group II GBCM should not be withheld or delayed if harm would result from not proceeding with an indicated contrast-enhanced MRI.” | Consensus statement (ungraded) | American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 |
| No prophylaxis for NSF “Prophylaxis is not indicated for the prevention of NSF.” | Consensus statement (ungraded) | American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 |
| Recommendations unchanged for chemotherapy, nephrotoxic drugs or same-day contrast CT “The above recommendations should not be altered in patients receiving nephrotoxic medications, chemotherapy, or contrast-enhanced CT.” | Consensus statement (ungraded) | American College of Radiology and National Kidney Foundation (Weinreb et al., Kidney Medicine; also published in Radiology, 10.1148/radiol.2020202903) 2021 |
| Kidney test not mandatory for lowest-risk agents “Laboratory testing of renal function (eGFR) prior to contrast agent use is not mandatory.” | ungraded (handbook) | European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026 |
| No gadolinium in a pregnant or breastfeeding woman with kidney impairment “Do not administer gadolinium-based contrast agents.” | ungraded (handbook) | European Society of Urogenital Radiology (ESUR) Contrast Media Safety Committee 2026 |
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