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Clinical Pearl: Gadolinium in Emergency Medicine: Follow the Evidence : Emergency Medicine News


gadolinium, contrast agents, nephrogenic systemic fibrosis


Gadolinium-based contrast agents (GBCAs) are divided into three groups based on molecular structure and charge. Group 1 GBCAs are associated with the highest number of reported cases of nephrogenic systemic fibrosis (NSF), a potentially debilitating and life-threatening fibrotic condition that most commonly affects the skin but can involve multiple organs.

Group 2 GBCAs have an extremely low, if any, risk of inducing NSF and should be used whenever possible. Group 3 GBCAs are associated with few or no cases of NSF, but limited data are available. Group 3 GBCAs are primarily used for hepatobiliary imaging.

GBCAs are not usually associated with postcontrast acute kidney injury, especially in patients with normal renal function. The American College of Radiology and the National Kidney Foundation state that routine assessment of kidney function is not required for group 2 GBCAs, but it is for group 3 GBCAs. (Tex Heart Inst J. 2022;49[3]:e217680;; Radiology. 2021;298[1]:28;

Patients on hemodialysis can undergo MRI with GBCA, and the next hemodialysis session should be performed as soon as possible after the MRI, preferably within hours. (Tex Heart Inst J. 2022;49[3]:e217680;; Radiology. 2021;298[1]:28;

Despite theoretical concerns about the safety of GBCA administration during pregnancy, no harm has yet been attributed in any trimester, but studies are lacking. The most recent recommendations state that Group 2 GBCAs should only be used during pregnancy if the potential benefits justify the unknown risk to the fetus. (Tex Heart Inst J. 2022;49[3]:e217680;

The expected systemic dose absorbed by breastfed infants is less than 0.0004% of the intravascular dose administered to the mother. The likelihood of an adverse effect from such a small amount of GBCA absorbed through breast milk is low and suggests that no interruption of breastfeeding is necessary after administration of GBCA. (Tex Heart Inst J. 2022;49[3]:e217680;; Obstet Gynecol. 2017;130[4]:e210.)

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