Materiały źródłowe

• #1 Nephrogenic Systemic Fibrosis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK567754/

  Nephrogenic systemic fibrosis (NSF) is a rare yet serious fibrosing disorder primarily affecting patients with impaired renal function who have been exposed to gadolinium-based contrast agents during magnetic resonance imaging. […] Early recognition of NSF and preventive measures, particularly avoiding certain gadolinium agents in at-risk patients, is critical for reducing its incidence and associated morbidity. […] The incidence rate of NSF has been drastically reduced since regulatory authorities like the FDA, American College of Radiology, and the European Society of Urogenital Radiology implemented precautionary guidelines advising radiologists to avoid high-risk GBCAs if the patient has severe renal insufficiency. […] There is no prophylactic agent that prevents the development of NSF aside from choosing a class 2/3 Gd agent. […] High-risk GBCAs (group I) are contraindicated for patients with acute kidney injury or severe chronic kidney disease. […] Early hemodialysis following the GBCA is recommended in patients with chronic hemodialysis, but it does not remove all the contrast medium.

• #2 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3409035/

  Nephrogenic Systemic Fibrosis is a rare condition appearing only in patients with severe renal impairment or failure and presents with dermal lesions and involvement of internal organs. […] To date, there is no known effective treatment thus stressing the necessity of ample prevention measures. An association with the use of Gadolinium based contrast agents (GBCA) makes Nephrogenic Systemic Fibrosis a potential side effect of contrast enhanced magnetic resonance imaging and offers the opportunity for prevention by limiting use of gadolinium based contrast agents in renal failure patients. […] Major medical societies both in Europe and in North America have developed guidelines for the usage of GBCA. Since the establishment of these guidelines and the increased general awareness of this condition, the occurrence of NSF has been nearly eliminated.

• #3 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3409035/

  Nephrogenic Systemic Fibrosis is a rare condition appearing only in patients with severe renal impairment or failure and presents with dermal lesions and involvement of internal organs. […] To date, there is no known effective treatment thus stressing the necessity of ample prevention measures. An association with the use of Gadolinium based contrast agents (GBCA) makes Nephrogenic Systemic Fibrosis a potential side effect of contrast enhanced magnetic resonance imaging and offers the opportunity for prevention by limiting use of gadolinium based contrast agents in renal failure patients. […] Major medical societies both in Europe and in North America have developed guidelines for the usage of GBCA. Since the establishment of these guidelines and the increased general awareness of this condition, the occurrence of NSF has been nearly eliminated.

• #4

  https://journals.lww.com/00001751-200710000-00005

  Nephrogenic systemic fibrosis is a new disorder reported almost exclusively in patients who have renal insufficiency and are exposed to contrast media formulated with gadolinium. […] Because there are no uniformly effective interventions to treat nephrogenic systemic fibrosis other than successful renal transplantation, prevention by avoiding gadolinium contrast media in patients with chronic kidney disease is vital. […] On the basis of suspected pathogenesis, it is also reasonable to limit erythropoietin and iron therapy to dosages ensuring recommended targets and adequately control hyperparathyroidism.

• #5 Preventing Nephrogenic Systemic Fibrosis – Renal and Urology News

  https://www.renalandurologynews.com/commentary/expert-reviews/preventing-nephrogenic-systemic-fibrosis/2/

  Based on the information we have about NSFadvanced kidney disease as a risk factor, GBCA as a trigger, and several potential cofactorsone can put forth reasonable clinical practice guidelines to prevent development of this disorder, recognizing that individual evaluation of each case and weighing risk/benefit are critical. […] First and foremost, identifying high-risk individuals is absolutely required. As previously noted, patients with advanced acute and chronic kidney disease are at highest risk. […] Once high-risk individuals have been recognized, an alternate form of imaging should be pursued to provide the information required. […] Obviously, radiocontrast is a risky choice in patients with advanced CKD and AKI. […] In addition to use of macrocyclic GBCAs, administration of the lowest dose required to obtain optimal images is recommended because of the association of higher-dose exposures with increased NSF risk.

• #6 MRI in the era of nephrogenic systemic fibrosis: Review, controversies and suggestions for risk reduction | Applied Radiology

  https://appliedradiology.com/articles/mri-in-the-era-of-nephrogenic-systemic-fibrosis-review-controversies-and-suggestions-for-risk-reduction

  Since there is no consistently effective therapy for the disease, it cannot be emphasized enough that prevention is the best strategy. […] A prevention strategy has two major points: 1) Define and identify the population at risk in your practice. 2) Minimize risk to that susceptible population. […] Currently, U.S. Food and Drug Administration (FDA) guidelines recommend that all GBCAs should be used with caution in patients with CKD stage 4 and 5 who have an estimated glomerular filtration rate (eGFR) of 30 mL/min/1.73 m2, and the literature supports this, as almost all patients reported either have end stage renal disease (ESRD) on dialysis or have a GFR of 30 mL/min/1.73 m2. […] It is important to estimate GFR rather than depend on serum creatinine alone to judge the presence or severity of renal disease.

• #7 Gadolinium-Associated Nephrogenic Systemic Fibrosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2009/1001/p711.html

  Nephrogenic systemic fibrosis is a progressive, potentially fatal multiorgan system fibrosing disease related to exposure of patients with renal failure to the gadolinium-based contrast agents used in magnetic resonance imaging. […] The U.S. Food and Drug Administration currently warns against using gadolinium-based contrast agents in patients with a glomerular filtration rate less than 30 mL per minute per 1.73 m2, or any acute renal insufficiency related to the hepatorenal syndrome or perioperative liver transplantation. […] Prevention with hemodialysis immediately following gadolinium-based contrast agents has been recommended, but no studies have shown this to be effective. […] The U.S. Food and Drug Administration currently recommends against using gadolinium-based contrast agents in patients with a GFR less than 30 mL per minute per 1.73 m2, including patients on peritoneal dialysis or hemodialysis, or with any acute renal insufficiency related to the hepatorenal syndrome or in perioperative liver transplantation, due to the potential for nephrogenic systemic fibrosis.

• #8 Safety Topic/Article:

  https://www.mrisafety.com/SafetyInformation_view.php?editid1=269

  The first step should be to identify patients at risk for NSF, that is, those patients that suffer from severe (stages 4 and 5) chronic kidney disease, that is, GFR below 30 mL/min/1.73 m2, independently of their age, race or gender or acute kidney injury. […] A patient at risk of NSF should receive a GBCA only when a risk-benefit assessment for that particular patient indicates that the benefit of doing so clearly outweighs the potential risk(s). The risk-benefit evaluation should be made by the radiologist in conjunction with the referring physician(s) and should be properly a prospectively documented. […] In the United States, the Food and Drug Administration has requested the prescribing information of all GBCAs to be revised by adding a black boxed warning, according to which the use of GBCAs in risk patients should be avoided, unless the diagnostic information is essential and not available with non-contrast enhanced MRI.

• #9 Nephrogenic systemic fibrosis – Wikipedia

  https://en.wikipedia.org/wiki/Nephrogenic_systemic_fibrosis

  The only known measure for prevention of NSF is the non-use or cautious use of GBCAs in patients with renal impairment, including preferential use of safer, macrocyclic GBCAs. […] Performing dialysis immediately after the MRI exam is recommended for patients already in dialysis treatment, but there is no evidence for introducing dialysis in non-dialytic patients for prevention of NSF. […] Screening for impaired kidney function is routinely conducted and has drastically reduced the incidence of NSF.

• #10 Renal function, nephrogenic systemic fibrosis and other adverse reactions associated with gadolinium-based contrast media | Nefrología

  https://www.revistanefrologia.com/en-renal-function-nephrogenic-systemic-fibrosis-articulo-X2013251414054390

  Nephrogenic systemic fibrosis is a fibrosing disorder that affects patients with impaired renal function and is associated with the administration of gadolinium-based contrast media used in MRI. […] There has been an attempt to establish safety parameters to identify patients with risk factors of renal failure. […] The close pharmacovigilance and strict observation of current regulations, with special attention being paid to the value of glomerular filtration, have reduced the published cases involving the use of gadolinium-based contrast media. […] In a meeting between radiologists and nephrologists we reviewed the most relevant aspects currently and recommendations for its prevention. […] Identification of patients with chronic kidney disease. […] The study of risk factors must be part of the routine before using GBCM in any hospital.

• #11 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3409035/

  The FDA was the first agency to release a public health advisory back in 2006 when the association of GBCA and NSF was not as convincing. However the linkage of high dose GBCA with NSF was suspected, accordingly the advisory stated that only if deemed necessary patients with advanced kidney failure (dialysis or eGFR 15ml/min/1.73m) should receive imaging studies using GBCA. […] In 2010 the latest FDA recommendations explicitly contraindicated Gadodiamide, Gadoversetamide and Gadopentetate dimeglumine use in patients with acute kidney disease or chronic severe kidney disease (eGFR30). […] The European Medicines Agency (EMA) has defined three risk classes of Gadolinium- based contrast agents. For each of them, the EMA has defined measures to reduce the risk of NSF. […] The EMEAs recommendations on the use of GBCAs are based on this classification.

• #12 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance | Journal of Cardiovascular Magnetic Resonance | Full Text

  https://jcmr-online.biomedcentral.com/articles/10.1186/1532-429X-14-31

  In general all GBCA should be avoided in patients with suspected or known impaired drug elimination unless the diagnostic GBCA based study is necessary. […] The European Medicines Agency (EMA) has defined three risk classes of Gadolinium- based contrast agents. For each of them, the EMA has defined measures to reduce the risk of NSF. […] The EMEAs recommendations on the use of GBCAs are based on this classification. […] Further preventative measures should be strived for. It is theorized that low iron serum levels, and an optimized Calcium, phosphate and acid base balance before injection of GBCAs may protect against the development of NSF. […] The American College of Radiology (ACR) recommendations of 2010 agree with the other guidelines on the associations of GBCA exposure, dosage relations and kidney function. The need for adequately assessing the renal function has been highlighted.

• #13 Measures to minimise the risk of developing nephrogenic systemic fibrosis with the use of gadolinium-containing contrast agents | Saudi Food and Drug Authority

  http://www.sfda.gov.sa/en/awarenessarticle/1102

  Measures to minimise the risk of developing nephrogenic systemic fibrosis with the use of gadolinium-containing contrast agents […] The following risk-minimisation measures should be used for gadolinium-containing contrast agents: […] Renal function should be tested in all patients receiving high-risk agents such as Omniscan, Optimark and Magnevist. It is generally advisable for patients receiving medium-risk or low-risk agents such as Primovist, Gadovist, and Dotarem. It is particularly important to screen patients aged 65 years or older […] For patients with severe renal impairment (glomerular filtration rate [GFR] 30 mL/min/173m2), use of a high-risk agents (Omniscan, Optimark and Magnevist) is contraindicated. If use of a medium-risk agent such as Primovist cannot be avoided or if it is necessary to use a low-risk agent such as Gadovist and Dotarem, a single lowest dose possible can be used and should not be repeated for at least 7 days

• #14 Measures to minimise the risk of developing nephrogenic systemic fibrosis with the use of gadolinium-containing contrast agents | Saudi Food and Drug Authority

  http://www.sfda.gov.sa/en/awarenessarticle/1102

  Use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. For medium-risk or low-risk agents, use a single lowest possible dose and do not repeat for at least 7 days […] Discontinue for at least 24 hours after use of a high-risk agent. The decision of whether to continue or suspend breastfeeding for 24 hours after use of a medium-risk or low-risk agent should be at your discretion in consultation with the mother […] Use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary.

• #15 FDA Drug Safety Communication: New warnings for using gadolinium-based contrast agents in patients with kidney dysfunction | FDA

  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-new-warnings-using-gadolinium-based-contrast-agents-patients-kidney

  The U.S. Food and Drug Administration (FDA) is requiring changes in the drug label for gadolinium-based contrast agents (GBCAs) to minimize the risk of nephrogenic systemic fibrosis (NSF), a rare, but serious, condition associated with the use of GBCAs in certain patients with kidney dysfunction. […] These label changes are intended to help ensure these drugs are used appropriately, and that patients at risk for NSF who receive GBCAs are actively monitored for the development of NSF. […] Patients at greatest risk for developing NSF after receiving GBCAs are those with impaired elimination of the drug, including patients with acute kidney injury (AKI) or chronic, severe kidney disease (with a glomerular filtration rate or GFR 30). […] The revised labeling will enhance the safe use of GBCAs, by recommending that healthcare professionals: Not use three of the GBCA drugs–Magnevist, Omniscan, and Optimark– in patients with AKI or with chronic, severe kidney disease.

• #16 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  Gadolinium-containing contrast agents are associated with a varying degree of risk of nephrogenic systemic fibrosis. See advice below to minimise risk in the following vulnerable groups: patients with renal impairment; patients in the perioperative liver transplantation period; infants, neonates, and the elderly; and women who are pregnant or breastfeeding. […] High-risk gadolinium-containing contrast agents are contraindicated in patients with severe renal impairment, patients in the perioperative liver-transplantation period, and in neonates. […] The following risk-minimisation measures should be used for gadolinium-containing contrast agents for: renal-function monitoring – this should be tested in all patients receiving high-risk agents, and is generally advisable for patients receiving medium-risk or low-risk agents. It is particularly important to screen patients aged 65 years or older.

• #17 Nephrogenic systemic fibrosis – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/nephrogenic-systemic-fibrosis/symptoms-causes/syc-20352299

  Avoidance of older gadolinium-based contrast agents (group 1) is key to preventing nephrogenic systemic fibrosis, as newer gadolinium-based contrast agents (group 2) are safer and are not associated with increased risk.

• #18 Nephrogenic Systemic Fibrosis (NSF): Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/17783-nephrogenic-systemic-fibrosis-nsf

  Avoiding older GBCAs in people with kidney disease is the best way to prevent NSF. Using newer GBCAs is safer and less toxic to people with kidney conditions. […] The FDA recommends against using gadolinium-based contrast agents in people with certain kidney conditions unless there are no other options. […] With preventive measures in place, you’re unlikely to get a diagnosis of NSF. But if you have kidney disease and require an MRI, talk to your healthcare provider about NSF and your risk. While newer GBCAs aren’t toxic and appear safe, sharing your health history with your provider and discussing your risk is always a good practice.

• #19 SciELO Brazil – Nephrogenic systemic fibrosis: concepts and perspectives Nephrogenic systemic fibrosis: concepts and perspectives

  https://www.scielo.br/j/abd/a/YRrkNwbg8vdYmP5SR85wmcG/?lang=en

  Patients with stages 4 and 5 CRI and severe acute renal failure should not be exposed to GBCA. […] The FDA and the American College of Radiology recommend considering hemodialysis immediately after or less than 2 hours after exposure to GBCA for patients with stage 5 CRI and severe acute renal insufficiency (ARI), which is also acceptable for patients already on peritoneal dialysis. […] American and European recommendations for the safe use of GBCA include: avoid use in patients with severe renal impairment (give preference to computed tomography with iodinated contrast agents), in the perioperative period of liver transplantation, in neonates and breastfeeding infants younger than 4 months (due to their immature kidneys); use the lowest recommended dose, avoid multiple exposures to Gd; minimum interval of 1 week between tests; track nephropathy prior to administration of contrast; avoid use of linear chelating agents; consider dialysis after contrast administration in patients on renal replacement therapy.

• #20 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  For patients with severe renal impairment (glomerular filtration rate [GFR] 30 mL/min/173m2), use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] For patients with moderate renal impairment (GFR 30-59 mL/min/173 m2), if it is necessary to use a high-risk agent a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. For medium-risk or low-risk agents, use a single lowest possible dose and do not repeat for at least 7 days.

• #21 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  Use a single lowest dose of agent possible and do not repeat for at least 7 days. […] Discontinue for at least 24 hours after use of a high-risk agent. The decision of whether to continue or suspend breastfeeding for 24 hours after use of a medium-risk or low-risk agent should be at your discretion in consultation with the mother. […] Use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary. […] There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. […] When they become available, peel-off tracking labels found on the vials, syringes, or bottles should be stuck onto the patient record to accurately record the name of the gadolinium contrast agent used. The dose used should also be recorded. […] On a Yellow Card for any suspected adverse reactions, including NSF, to gadolinium-containing contrast agents.

• #22 Nephrogenic Systemic Fibrosis Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/1097889-treatment

  Guidelines have vastly decreased the number of cases of NSF. These guidelines include (1) limiting gadolinium-based contrast agents to a maximum dose of 0.1 mmol/kg, (2) dialyzing renally impaired patients undergoing dialysis rapidly following gadolinium-based contrast agents use, (3) delaying gadolinium-based contrast agents in acute renal failure by waiting until renal function improves or dialysis is started, and (4) not using nonionic linear GBCA in patients with renal failure, in particular when proinflammatory conditions are coincident. […] Nephrogenic systemic fibrosis does not require inpatient care. No inpatient or outpatient treatment has been particularly successful in treating this condition. Plasmapheresis has shown some promise and is still being evaluated for its efficacy in persons who have not undergone transplantation.

• #23 Gadolinium-Associated Nephrogenic Systemic Fibrosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2009/1001/p711.html

  There is no evidence that immediate hemodialysis or initiating hemodialysis for the sole purpose of removing gadolinium-based contrast agents protects against nephrogenic systemic fibrosis. […] Prevention of nephrogenic systemic fibrosis is the best practice. […] The FDA recommends that gadolinium-based contrast agents be avoided unless the diagnostic information is essential and not available with noncontrast-enhanced MRI. […] The ESUR guideline on nephrogenic systemic fibrosis specifically discusses the different types of gadolinium contrast media, recommending against using gadodiamide, gadopentetate dimeglumine (Magnevist), and gadoversetamide (Optimark) in patients with stage 4 or 5 chronic kidney disease and those patients with reduced renal function who are awaiting liver transplantation. […] Screening all patients for renal dysfunction by obtaining a history or ordering laboratory testing for GFR calculation is also recommended.

• #24 Gadolinium-Associated Nephrogenic Systemic Fibrosis | AAFP

  https://www.aafp.org/pubs/afp/issues/2009/1001/p711.html

  There is no evidence that immediate hemodialysis or initiating hemodialysis for the sole purpose of removing gadolinium-based contrast agents protects against nephrogenic systemic fibrosis. […] Prevention of nephrogenic systemic fibrosis is the best practice. […] The FDA recommends that gadolinium-based contrast agents be avoided unless the diagnostic information is essential and not available with noncontrast-enhanced MRI. […] The ESUR guideline on nephrogenic systemic fibrosis specifically discusses the different types of gadolinium contrast media, recommending against using gadodiamide, gadopentetate dimeglumine (Magnevist), and gadoversetamide (Optimark) in patients with stage 4 or 5 chronic kidney disease and those patients with reduced renal function who are awaiting liver transplantation. […] Screening all patients for renal dysfunction by obtaining a history or ordering laboratory testing for GFR calculation is also recommended.

• #25 Can dialysis prevent nephrogenic systemic fibrosis? – Renal Fellow Network

  https://www.renalfellow.org/2009/01/26/can-dialysis-prevent-nephrogenic/

  There has been a lot of literature over the past few years regarding the identification of gadolinium-based contrast dye as the driving force behind the dermatologic fibrosing condition nephrogenic systemic fibrosis (NSF). […] At our institution, the official policy is to NOT give gadolinium to any patient with ESRD or advanced (Stage 4 or greater) CKD. […] The question arises in these instances: should dialysis be performed to dialyze off the gadolinium and therefore minimize the risk of NSF? […] However, most of the available evidence would say that dialysis is *not* effective in preventing gado-induced contrast injury. […] Several ESRD patients with NSF have been identified in which daily dialysis was initiated within 9-21 hours of being given gadolinium, proving that this strategy is not likely to be uniformly effective for prevention.

• #26 Nephrogenic Systemic Fibrosis in Patients with Chronic Kidney Disease after the Use of Gadolinium-Based Contrast Agents: A Review for the Cardiovascular Imager

  https://www.mdpi.com/2075-4418/12/8/1816

  There is not a specific prophylaxis regimen to prevent the onset of NSF. The current approach is based on minimizing the impact of predisposing risk factors and performing hemodialysis sessions right after GBCA exposure in patients with a history of ESRD on RRT. Hemodialysis or peritoneal dialysis should take place the same day and within 2 or 3 h after contrast administration. Hemodialysis could be more efficient than peritoneal dialysis for gadolinium clearance; however, there is insufficient evidence supporting a clinical superiority of either technique for the prevention of NSF and limited evidence in the use of peritoneal dialysis to effectively remove GBCAs. […] Even though the newer macrocyclic agents have proven to be much safer in patients with chronic kidney disease and end-stage renal failure, clinicians must fully understand the clinical characteristics and risk factors of this devastating pathology and maintain a high degree of suspicion to prevent and recognize it.

• #27 Safety Topic/Article:

  https://www.mrisafety.com/SafetyInformation_view.php?editid1=269

  If the use of a GBCA is still deemed necessary, use the lowest dose needed to reliably provide the diagnostic information being clinically sought. […] The usefulness of hemodialysis in the prevention of NSF is unknown. However, to enhance and speed up the GBCA elimination, many experts recommend that consideration be given to the performance of several dialysis sessions following GBCA administration in patients with end-stage renal disease on chronic dialysis, with use of prolonged dialysis times and increased flow rates and volumes to assist in the process of GBCA clearance. […] Patients at risk of NSF should be followed up at least for one year after a contrast-enhanced MR exam, to promptly identify any symptom or sign suggestive of NSF and confirm or rule out a diagnosis of NSF.

• #28

  https://www.ccjm.org/highwire/markup/10569/expansion?width=1000&height=500&iframe=true&postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed%2Chighwire_table_reference_format

  Key points from the ACR Manual on Contrast Media regarding prevention of nephrogenic systemic fibrosis in patients at risk […] Chronic kidney disease stage 1 and 2: No increased risk of developing NSF. Any gadolinium-based agent can be given safely. There are no cases reported in this category with any of the gadolinium-based agents. […] Chronic kidney disease stage 3: The risk of developing NSF is exceedingly rare. No special precautions are necessary. There have been no definite cases reported in patients with stage 3 chronic kidney disease. […] Chronic kidney disease stage 4 and 5 not on chronic dialysis: Group I agents are contraindicated. If a gadolinium-enhanced MRI study is to be done, a group II agent should be used. Given the risk of CI-AKI in this population, we believe that MRI using a group II agent would be preferable to CT with iodinated contrast. […] End-stage kidney disease on hemodialysis: The ACR favors CT rather than MRI if the anticipated diagnostic yield is similar. Group I agents are contraindicated. Group II agents are preferred and gadolinium-enhanced MRI should be performed as closely before hemodialysis as is possible. We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents. Our current practice is to perform a single dialysis session rather than 2 consecutive sessions. […] End-stage kidney disease on peritoneal dialysis: The ACR favors CT when possible, but if MRI is desired, then the ACR recommends a group II agent. The ACR recognizes that peritoneal dialysis may provide less NSF risk reduction than hemodialysis. We urge caution in dialysis patients with residual kidney function, which is associated with a survival benefit. We lean toward MRI with group II agents. The committee does not comment on the necessity of subjecting these patients to hemodialysis. We believe it is safer to perform a single session of hemodialysis, particularly for peritoneal dialysis patients with no residual kidney function. […] Acute kidney injury: Group I agents should be avoided in patients with known or suspected acute kidney injury. Group II agents are preferred. We favor a stratified approach: Acute kidney injury on dialysis: As in patients with end-stage kidney disease, we recommend a single session of dialysis following gadolinium exposure. Nonoliguric acute kidney injury not on dialysis: Similar to advanced chronic kidney disease, if a gadolinium-enhanced MRI study is needed, a group II agent should be used. Oliguric acute kidney injury not on dialysis: We favor avoiding administration of gadolinium if possible. Otherwise, our practice is to perform a single hemodialysis session.

• #29

  https://www.cdc.gov/Mmwr/preview/mmwrhtml/mm5607a1.htm

  When possible, use of gadolinium-containing contrast agents should be avoided in patients with advanced renal failure, particularly in patients who are undergoing peritoneal dialysis. […] If gadolinium-containing contrast is medically necessary, prompt hemodialysis after contrast administration to facilitate clearance of the contrast might be reasonable for patients who have established hemodialysis access; however, the effectiveness of this strategy in reducing the risk for NFD development or progression is unknown. […] CDC and FDA are collaborating to assess potential differences among gadolinium-containing contrast agents, including the associated risk for NFD and possible related factors. […] Additional studies are needed to assess the ability of peritoneal dialysis and hemodialysis to clear gadolinium-containing contrast agents and to clarify the mechanism by which use of gadolinium or chelating agents might result in NFD. […] Clinicians who treat patients with renal disease should be aware of the risk for NFD and consider the diagnosis in patients with characteristic skin lesions.

• #30 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  For patients with severe renal impairment (glomerular filtration rate [GFR] 30 mL/min/173m2), use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] For patients with moderate renal impairment (GFR 30-59 mL/min/173 m2), if it is necessary to use a high-risk agent a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. For medium-risk or low-risk agents, use a single lowest possible dose and do not repeat for at least 7 days.

• #31 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  Use a single lowest dose of agent possible and do not repeat for at least 7 days. […] Discontinue for at least 24 hours after use of a high-risk agent. The decision of whether to continue or suspend breastfeeding for 24 hours after use of a medium-risk or low-risk agent should be at your discretion in consultation with the mother. […] Use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary. […] There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. […] When they become available, peel-off tracking labels found on the vials, syringes, or bottles should be stuck onto the patient record to accurately record the name of the gadolinium contrast agent used. The dose used should also be recorded. […] On a Yellow Card for any suspected adverse reactions, including NSF, to gadolinium-containing contrast agents.

• #32 Measures to minimise the risk of developing nephrogenic systemic fibrosis with the use of gadolinium-containing contrast agents | Saudi Food and Drug Authority

  http://www.sfda.gov.sa/en/awarenessarticle/1102

  Use of a high-risk agent is contraindicated. If use of a medium-risk agent cannot be avoided or if it is necessary to use a low-risk agent, a single lowest dose possible can be used and should not be repeated for at least 7 days. […] Use of a high-risk agent is contraindicated. For medium-risk or low-risk agents, use a single lowest possible dose and do not repeat for at least 7 days […] Discontinue for at least 24 hours after use of a high-risk agent. The decision of whether to continue or suspend breastfeeding for 24 hours after use of a medium-risk or low-risk agent should be at your discretion in consultation with the mother […] Use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary.

• #33 Nephrogenic systemic fibrosis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/nephrogenic-systemic-fibrosis?lang=us

  Group II GBCAs may be administered to high-risk patients without kidney function screening and without contact with the referring provider, depending on individual practice patterns. […] Joint consensus statements by the American College of Radiology (ACR) and the National Kidney Foundation were issued in November 2020 that stated: „Since the risk of nephrogenic systemic fibrosis is so low with group II gadolinium-based contrast [agents] (GBCAs), the potential harms of delaying or withholding group II GBCAs for a clinically indicated MRI in a patient with acute kidney injury or estimated glomerular filtration rate less than 30 mL/min/1.73 m2 may outweigh the risk of NSF in most clinical situations, regardless of dialysis status.” […] The above recommendations are not altered for infants, children, and patients receiving nephrotoxic medications (which do not need to be withheld prior to administration of group II or group III GBCAs at on-label doses).

• #34 Preventing Nephrogenic Systemic Fibrosis – Renal and Urology News

  https://www.renalandurologynews.com/commentary/expert-reviews/preventing-nephrogenic-systemic-fibrosis/

  NSF is relatively rare. This suggests that other factors must be present to allow NSF to develop, as GBCA exposure and advanced kidney disease are necessary but not sufficient. […] Along with GBCA exposure, both underlying vascular injury and a pro-inflammatory state are important risk factors for NSF. […] Additionally, the GBCAs most commonly described in association with NSF, i.e., gadodiamide and gadopentetate, have also been shown to induce inflammation, perhaps contributing further to patient risk beyond just gadolinium exposure.

• #35 MRI in the era of nephrogenic systemic fibrosis: Review, controversies and suggestions for risk reduction | Applied Radiology

  https://appliedradiology.com/articles/mri-in-the-era-of-nephrogenic-systemic-fibrosis-review-controversies-and-suggestions-for-risk-reduction

  Finally, eGFR should not be estimated in patients with acute kidney injury (AKI) who are typically seen in the inpatient setting. […] Studies support that the risk of developing NSF is increased by both higher doses and frequent administration of GBCA. […] Importantly, while in the minority, cases of NSF after administration of a single dose of GBCA have been reported. […] Limited data suggest that coincident infection or inflammation at the time of GBCA administration increases the risk for NSF. […] No GBCA can be considered absolutely free from the risk of triggering NSF. […] Therefore, until more definitive data become available, a conservative approach would be to utilize similar preventive measures regardless of the GBCA given. […] Administering a lower dose of GBCA may increase the risk of a non-diagnostic scan and may result in a higher total administered dose when a subsequent full dose is given to reach the diagnosis. […] Prompt hemodialysis may hypothetically decrease the risk of NSF and is therefore recommended. […] Consider the full-range of alternatives to enhanced MRI which may mean a less efficient work-up.

• #36 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance | Journal of Cardiovascular Magnetic Resonance | Full Text

  https://jcmr-online.biomedcentral.com/articles/10.1186/1532-429X-14-31

  In general all GBCA should be avoided in patients with suspected or known impaired drug elimination unless the diagnostic GBCA based study is necessary. […] The European Medicines Agency (EMA) has defined three risk classes of Gadolinium- based contrast agents. For each of them, the EMA has defined measures to reduce the risk of NSF. […] The EMEAs recommendations on the use of GBCAs are based on this classification. […] Further preventative measures should be strived for. It is theorized that low iron serum levels, and an optimized Calcium, phosphate and acid base balance before injection of GBCAs may protect against the development of NSF. […] The American College of Radiology (ACR) recommendations of 2010 agree with the other guidelines on the associations of GBCA exposure, dosage relations and kidney function. The need for adequately assessing the renal function has been highlighted.

• #37

  https://journals.lww.com/00001751-200710000-00005

  Nephrogenic systemic fibrosis is a new disorder reported almost exclusively in patients who have renal insufficiency and are exposed to contrast media formulated with gadolinium. […] Because there are no uniformly effective interventions to treat nephrogenic systemic fibrosis other than successful renal transplantation, prevention by avoiding gadolinium contrast media in patients with chronic kidney disease is vital. […] On the basis of suspected pathogenesis, it is also reasonable to limit erythropoietin and iron therapy to dosages ensuring recommended targets and adequately control hyperparathyroidism.

• #38 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3409035/

  Further preventative measures should be strived for. It is theorized that low iron serum levels, and an optimized Calcium, phosphate and acid base balance before injection of GBCAs may protect against the development of NSF. […] The American College of Radiology (ACR) recommendations of 2010 agree with the other guidelines on the associations of GBCA exposure, dosage relations and kidney function. The need for adequately assessing the renal function has been highlighted.

• #39

  https://journals.lww.com/10.4103/0019-5154.77554

  Other precautionary measures include usage of ultra-pure dialysate, increasing dialysate bicarbonate concentration to correct acidosis and longer and slower dialysis therapies to avoid hypotension during dialysis. […] The efficacy of hemodialysis as a preventive strategy will become significant only when it is initiated early and removes the gadolinium before it gets deposited in the tissues. […] Precautionary measures need to be taken in unavoidable circumstances to ameliorate the condition of patients suffering from this devastating disorder.

• #40 Safety Topic/Article:

  https://www.mrisafety.com/SafetyInformation_view.php?editid1=269

  If the use of a GBCA is still deemed necessary, use the lowest dose needed to reliably provide the diagnostic information being clinically sought. […] The usefulness of hemodialysis in the prevention of NSF is unknown. However, to enhance and speed up the GBCA elimination, many experts recommend that consideration be given to the performance of several dialysis sessions following GBCA administration in patients with end-stage renal disease on chronic dialysis, with use of prolonged dialysis times and increased flow rates and volumes to assist in the process of GBCA clearance. […] Patients at risk of NSF should be followed up at least for one year after a contrast-enhanced MR exam, to promptly identify any symptom or sign suggestive of NSF and confirm or rule out a diagnosis of NSF.

• #41 Nephrogenic Systemic Fibrosis (NSF) Best Nephrologist In Delhi | Dr Rajesh Goel | Kidney Care Centre

  https://www.kidneycarecentre.in/nephrogenic-systemic-fibrosis-nsf/

  Informed Consent: Make sure that individuals receiving GBCAs, particularly those with impaired kidney function, are aware of the dangers involved. […] Post-procedure Monitoring: In high-risk patients, close observation of renal function and symptoms after GBCA administration. […] Early Detection and Monitoring: Patients who are at risk should be regularly observed for early indications of NSF, particularly if they have renal impairment. […] Choosing alternate imaging modalities wherever feasible and limiting the use of gadolinium-based contrast agents in high-risk patients. […] Optimized Dialysis: Making sure patients receiving dialysis receive it effectively in order to lower their gadolinium levels. […] Physical treatment: Early implementation of physical and occupational treatment is recommended to preserve muscular strength and joint flexibility. […] Prompt Treatment: To enhance outcomes and decrease the progression of the disease, skin and joint symptoms should be treated aggressively and early.

• #42 Gadolinium-containing contrast agents: new advice to minimise the risk of nephrogenic systemic fibrosis – GOV.UK

  https://www.gov.uk/drug-safety-update/gadolinium-containing-contrast-agents-new-advice-to-minimise-the-risk-of-nephrogenic-systemic-fibrosis

  Use a single lowest dose of agent possible and do not repeat for at least 7 days. […] Discontinue for at least 24 hours after use of a high-risk agent. The decision of whether to continue or suspend breastfeeding for 24 hours after use of a medium-risk or low-risk agent should be at your discretion in consultation with the mother. […] Use of any gadolinium-containing contrast agent is not recommended unless absolutely necessary. […] There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. […] When they become available, peel-off tracking labels found on the vials, syringes, or bottles should be stuck onto the patient record to accurately record the name of the gadolinium contrast agent used. The dose used should also be recorded. […] On a Yellow Card for any suspected adverse reactions, including NSF, to gadolinium-containing contrast agents.

• #43 Nephrogenic Systemic Fibrosis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK567754/

  Nephrogenic systemic fibrosis (NSF) is a rare yet serious fibrosing disorder primarily affecting patients with impaired renal function who have been exposed to gadolinium-based contrast agents during magnetic resonance imaging. […] Early recognition of NSF and preventive measures, particularly avoiding certain gadolinium agents in at-risk patients, is critical for reducing its incidence and associated morbidity. […] The incidence rate of NSF has been drastically reduced since regulatory authorities like the FDA, American College of Radiology, and the European Society of Urogenital Radiology implemented precautionary guidelines advising radiologists to avoid high-risk GBCAs if the patient has severe renal insufficiency. […] There is no prophylactic agent that prevents the development of NSF aside from choosing a class 2/3 Gd agent. […] High-risk GBCAs (group I) are contraindicated for patients with acute kidney injury or severe chronic kidney disease. […] Early hemodialysis following the GBCA is recommended in patients with chronic hemodialysis, but it does not remove all the contrast medium.

• #44 Minimizing Risk of Nephrogenic systemic fibrosis in Cardiovascular Magnetic Resonance

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3409035/

  Nephrogenic Systemic Fibrosis is a rare condition appearing only in patients with severe renal impairment or failure and presents with dermal lesions and involvement of internal organs. […] To date, there is no known effective treatment thus stressing the necessity of ample prevention measures. An association with the use of Gadolinium based contrast agents (GBCA) makes Nephrogenic Systemic Fibrosis a potential side effect of contrast enhanced magnetic resonance imaging and offers the opportunity for prevention by limiting use of gadolinium based contrast agents in renal failure patients. […] Major medical societies both in Europe and in North America have developed guidelines for the usage of GBCA. Since the establishment of these guidelines and the increased general awareness of this condition, the occurrence of NSF has been nearly eliminated.

• #45 Nephrogenic systemic fibrosis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/nephrogenic-systemic-fibrosis?lang=us

  Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy, occurs almost exclusively in patients with renal impairment and is associated with the administration of gadolinium-based contrast agents (GBCAs) used in MRI. […] The application of preventive guidelines in the usage of gadolinium-based contrast agents in patients with reduced renal function has been shown to be extremely effective in protecting patients from NSF. […] Recommendations pertaining to the administration of gadolinium-based contrast agents (GBCAs) in patients with kidney disease were updated in 2021, specifically with regard to the three different groups of GBCAs. […] The 2021 ACR Committee on Drugs and Contrast Media considers the risk of NSF among patients administered standard doses of group II GBCAs „sufficiently low or possibly nonexistent such that assessment of renal function with a questionnaire or laboratory testing is optional prior to intravenous administration.”

• #46

  https://link.springer.com/article/10.1007/s00467-013-2636-z

  Taking sales figures as a surrogate for quantities of Gd prescribed, there has been a decrease in worldwide sales of gadodiamide (the agent most frequently associated with NSF) since 2007 against a backdrop of increasing sales prior to this period. […] These results are promising and imply that NSF is unlikely to occur if guidelines limiting Gd-based contrast administration are followed. […] Vigilance when planning MRI, the use of nonenhanced MRI for vascular imaging, and the use of reduced-dose Gd in high-risk children are suggested as important preventative measures.

• #47

  https://link.springer.com/article/10.1007/s00467-013-2636-z

  Taking sales figures as a surrogate for quantities of Gd prescribed, there has been a decrease in worldwide sales of gadodiamide (the agent most frequently associated with NSF) since 2007 against a backdrop of increasing sales prior to this period. […] These results are promising and imply that NSF is unlikely to occur if guidelines limiting Gd-based contrast administration are followed. […] Vigilance when planning MRI, the use of nonenhanced MRI for vascular imaging, and the use of reduced-dose Gd in high-risk children are suggested as important preventative measures.

• #48 Renal function, nephrogenic systemic fibrosis and other adverse reactions associated with gadolinium-based contrast media | Nefrología

  https://revistanefrologia.com/en-renal-function-nephrogenic-systemic-fibrosis-articulo-X2013251414054390

  Since 2008, there have been no cases of any CM being reported without these CM being replaced. […] The classification of chronic kidney disease (CKD) followed the initial publication of the National Kidney Foundation through the Kidney Disease Outcomes Quality Initiative (K-DOQI) guidelines. […] The study of risk factors must be part of the routine before using GBCM in any hospital. […] Since gadolinium has been considered an agent the potentially causes NSF, restrictive guidelines have been designed for its administration, with the most important aspects being the possession of recent GFR data and the adjustment of doses used in accordance with the latter. […] The reporting of this delayed and potentially severe adverse reaction marked a turning point, since it made it compulsory to establish consensuses to protect patients by assessing the GFR and risk factors. […] All of this along with dose adjustment have decreased the number of adverse reactions significantly and in the last five years there have hardly been any published cases with the use of gadolinium.

• #49

  https://link.springer.com/article/10.1007/s00467-013-2636-z

  Nephrogenic systemic fibrosis (NSF) is a multisystem disease seen exclusively in patients with renal impairment. […] After implementation of guidelines restricting the use of gadolinium-based contrast agents in at-risk patients, there has been a sharp reduction in new cases and no new reports in children. […] Continued vigilance is recommended: screening for renal impairment, use of more stable gadolinium chelates, consideration of non-contrast-enhanced MRI or alternative imaging modalities where appropriate. […] The conclusion drawn in the European and American guidelines is that patients most at risk of NSF are those with CKD stage 4 or 5, including those needing dialysis and those with reduced renal function who have or are awaiting liver transplantation. […] The FDA advises that in patients already undergoing regular hemodialysis, there may be some benefit in scheduling a session immediately following Gd administration, although there is only scant evidence that this reduces the risk of NSF.

• #50

  https://link.springer.com/article/10.1007/s40134-014-0064-x

  According to the current guidelines, patients in whom contrast-enhanced MRI is indicated should not be excluded due to impaired renal function and can be safely scanned utilizing a low-risk GBCA at the appropriate dose. […] Although there is no definitive treatment for NSF, improving renal function seems to be one key. […] Therapies resulting in the elimination of free gadolinium ions is another potential option, as a decrease of dermal gadolinium deposition has been correlated with an improvement of clinical symptoms. […] Dialysis following administration of gadolinium chelates may prove a useful preventative or therapeutic measure. […] NSF can be effectively prevented by identifying associated risk factors and avoiding certain GBCAs in patients with such risk factors.

• #51 SciELO Brazil – Nephrogenic systemic fibrosis: concepts and perspectives Nephrogenic systemic fibrosis: concepts and perspectives

  https://www.scielo.br/j/abd/a/YRrkNwbg8vdYmP5SR85wmcG/?lang=en

  Nephrogenic systemic fibrosis is a chronic, progressive condition that develops in some patients with renal impairment after exposure to gadolinium-based contrast agents used in magnetic resonance imaging. […] Reduction and prevention of nephrogenic systemic fibrosis cases are based on limiting the use of gadolinium-based contrast agents in patients with kidney disorders (especially in patients with advanced renal failure at stages 4 and 5), and restricting their use to situations in which they are essential to diagnosis/follow-up. […] Other than limiting exposure to gadolinium based contrast agents, no effective preventive methods have been reported. […] The occurrence of NSF is closely related to the exposure of patients with GFR 30ml/min/1.73m2 to GBCA. Due to the exclusive occurrence of the disease in patients with renal impairment, non-use or cautious use of GBCA in these individuals seems to be the only preventive measure.

• #52 Nephrogenic Systemic Fibrosis (NSF) Best Nephrologist In Delhi | Dr Rajesh Goel | Kidney Care Centre

  https://www.kidneycarecentre.in/nephrogenic-systemic-fibrosis-nsf/

  Immediate treatment and early detection are essential for reducing the diseases impact. […] Reducing the occurrence of NSF requires taking preventive steps, such as avoiding or using gadolinium-based contrast agents as little as possible in high-risk patients. […] Avoidance Strategies to reduce gadolinium-based contrast agent (GBCA) exposure in people with reduced renal function are the mainstay of NSF prevention: […] Risk assessment: Prior to giving GBCAs to patients, carefully evaluate their renal function. Patients with significant renal impairment (eGFR 30 mL/min/1.73 m2) should not use this medication. […] Alternative Techniques for Imaging: When feasible, use non-contrast-enhanced MRI, ultrasonography, or other imaging methods. […] GBCAs with low risk: Use of the more recent, macrocyclic GBCAs is preferred since they are less likely to dissociate and accumulate in tissues.

• #53 Nephrogenic systemic fibrosis (NSF) and gadolinium-based contrast media | Ngoya | South African Journal of Radiology

  https://sajr.org.za/index.php/sajr/article/view/277/354

  Nephrogenic systemic fibrosis (NSF), unknown before March 1997 and first described in 2000, is a systemic disorder characterised by widespread tissue fibrosis. […] This note comprises guidelines on the prevention of NSF. […] Because there is no consistently effective treatment for NSF, prevention is important. Screening to identify patients at high risk is essential. […] Because 70 – 80% of NSF cases occur in patients undergoing dialysis, screening for dialysis is important. Data on the serum creatinine level should be looked up for all inpatients, and the glomerular filtration rate (GFR) should be calculated to identify patients with a GFR 30 ml/min. […] The most up-to-date assessment and guidelines were reported by Thomsen et al. in 2012. […] Based on the evidence presented in this review, the ESUR CMSCs new guidelines are summarised below, with their strength of evidence and recommendation ratings.

• #54 Nephrogenic systemic fibrosis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/nephrogenic-systemic-fibrosis?lang=us

  Group II GBCAs may be administered to high-risk patients without kidney function screening and without contact with the referring provider, depending on individual practice patterns. […] Joint consensus statements by the American College of Radiology (ACR) and the National Kidney Foundation were issued in November 2020 that stated: „Since the risk of nephrogenic systemic fibrosis is so low with group II gadolinium-based contrast [agents] (GBCAs), the potential harms of delaying or withholding group II GBCAs for a clinically indicated MRI in a patient with acute kidney injury or estimated glomerular filtration rate less than 30 mL/min/1.73 m2 may outweigh the risk of NSF in most clinical situations, regardless of dialysis status.” […] The above recommendations are not altered for infants, children, and patients receiving nephrotoxic medications (which do not need to be withheld prior to administration of group II or group III GBCAs at on-label doses).

• #55 Nephrogenic systemic fibrosis | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/nephrogenic-systemic-fibrosis?lang=us

  Nephrogenic systemic fibrosis (NSF), also known as nephrogenic fibrosing dermopathy, occurs almost exclusively in patients with renal impairment and is associated with the administration of gadolinium-based contrast agents (GBCAs) used in MRI. […] The application of preventive guidelines in the usage of gadolinium-based contrast agents in patients with reduced renal function has been shown to be extremely effective in protecting patients from NSF. […] Recommendations pertaining to the administration of gadolinium-based contrast agents (GBCAs) in patients with kidney disease were updated in 2021, specifically with regard to the three different groups of GBCAs. […] The 2021 ACR Committee on Drugs and Contrast Media considers the risk of NSF among patients administered standard doses of group II GBCAs „sufficiently low or possibly nonexistent such that assessment of renal function with a questionnaire or laboratory testing is optional prior to intravenous administration.”

• #56

  https://link.springer.com/article/10.1007/s40134-014-0064-x

  Nephrogenic systemic fibrosis (NFS) is a potentially fatal disease that is linked to the administration of gadolinium based contrast agents (GBCA). […] However, there is ongoing research to better understand its pathogenesis and studies on the safety of different GBCA in the context of NSF are carried on. […] The radiologist plays an essential role in managing at risk patients and in reminding clinical colleagues of such risks. By assessing the main risk factors for NSF in patients undergoing contrast-enhanced MRI, i.e., impaired renal function, and excluding those patients from administration of high-risk GBCA, NSF can be effectively prevented. […] Additionally, the use of macrocyclic compounds that are considered low-risk GBCA further decreases the risk of NSF, especially when administered in low doses.

• #57 Nephrogenic Systemic Fibrosis in a Patient With Multiple Inflammatory Disorders | MDedge

  https://medauth2.mdedge.com/content/nephrogenic-systemic-fibrosis-patient-multiple-inflammatory-disorders

  Nephrogenic systemic fibrosis is a devastating and rapidly progressive condition, making its prevention in at-risk populations of utmost importance. […] Providers weighing the decision to administer gadolinium contrast to patients with ESRD should discuss the risks and benefits thoroughly, especially in patients with preexisting inflammatory conditions. […] Given the lack of effective treatment options for NSF, prevention is key. A deeper understanding of the pathophysiology of NSF and identification of its risk factors is paramount to the prevention of this devastating disease.

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