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The Royal Australian and New Zealand College of Radiologists®

Gadolinium Contrast Medium (MRI Contrast agents)

Dr Maurice Molan
Prof Stacy Goergen
Date last modified: May 01, 2009

11. What are the prerequisites for having a gadolinium contrast medium injection?

The RANZCR has issued guidelines on the use of gadolinium-containing MRI contrast agents, endorsed in January 2008.

Questions about renal disease should be included in safety screening.

The following minimum set of 5 questions is suggested:

  1. Is the patient’s age >60?

  2. Is the patient hypertensive?

  3. Does the patient have diabetes mellitus?

  4. Does the patient have a history of renal disease (including renal transplant, solitary kidney)?

  5. Is the patient in the immediate (within 1 month or less) pre- or post-operative period of a liver transplant?

If the answer to any of these questions is yes, an eGFR that has been performed no more than 6 weeks prior to the examination should be available when the patient presents for the MRI.

Unstable or acutely deteriorating renal function is a relative contraindication to GBCA administration.

Female patients of childbearing age should be asked whether they may be pregnant.

12. What are the absolute contraindications for a gadolinium contrast medium injection?

Previous or pre-existing nephrogenic systemic fibrosis.

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13. What are the relative contraindications for a gadolinium contrast medium injection?

  • Previous anaphylactic/anaphylactoid reaction to gadolinium containing contrast agent.
  • Pregnancy: the administration of contrast to a pregnant patient will be at the discretion of the supervising radiologist after consultation with the referring specialist, based on a risk-benefit analysis.
  • Patients with eGFR below 30mL/min/1.73m2.
  • Unstable renal impairment
  • Hepatorenal syndrome
  • Patients with chronic liver function impairment may have reduced muscle mass.  This may make estimation of eGFR less accurate. Therefore eGFR below 40mL/min/1.73m2 rather than 30mL/min/1.73m2 is suggested for safe administration of gadolinium. However, the validity of this cut-off value for the prevention of NSF in this patient subgroup has not been fully established.
  • Breast Feeding: breast feeding may be continued normally after administration of gadolinium to the mother.
  • There is no requirement to express breast milk or withhold breast feeding.

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14. What are the adverse effects of a gadolinium contrast medium injection?

  • Headache, nausea and dizziness in 1-5% of patients. These symptoms are transient and require no specific treatment.
  • Injection site symptoms: coldness/warmth require no specific treatment.
  • Contrast extravasation
  • Anaphylactic reaction (1 in 10,000 risk)
  • Nephrogenic systemic fibrosis: this adverse effect should be avoidable now that the susceptible population can be identified (see Gadolinium versus Iodine in patients with kidney problems)

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15. Are there alternative imaging tests, or interventions to a gadolinium contrast medium injection?

The total number of patients in whom there is a relative or absolute contraindication to the use of gadolinium contrast agents is small. In neuroradiology gadolinium contrast agents may increase confidence in a particular diagnosis but are rarely essential in making a diagnosis. In patients with severe renal impairment the nephrotoxic effects of iodinated contrast agents can be ameliorated by hydration, administration of sodium bicarbonate and N-acetyl cysteine and should be considered as an alternative to MRI with GBCAs in many cases.

In cardiac MRI GBCAs may be essential to the performance of the examination, however in ischaemic heart disease numerous other modalities are available such as conventional ECG stress testing, stress echo, and Thallium Perfusion scanning as well as transoesophageal echo.  In diagnosis of myocardial disease such as specific types of cardiomyopathy contrast enhanced MRI may add to confidence in a particular diagnosis but is rarely if ever essential for management.

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16. Further information about gadolinium contrast medium injections:

In high risk groups (eGFR<30mL/min/1.73m2) assess the risk-benefit of contrast enhanced MRI. History of previous exposure to GBCAs or of other factors thought to contribute to the risk of NSF such as metabolic acidosis, vascular surgery and recent thrombotic events should be taken into account. (see Contrast Medium: Gadolinium versus Iodine in patients with kidney problems)

Informed and written consent should be obtained from the high risk group (or parents/guardians).

Do not exceed the standard dose of 0.1mmol/kg and if the nature of the exam permits use 0.05mmol/kg.

Use an agent which has high thermodynamic and conditional stability with no unconfounded reports of NSF such as Gadoteric acid.

Schedule GBCA administration immediately before haemodialysis and consider an extra dialysis session.

Note: peritoneal dialysis does not remove GBCAs effectively.

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17. Useful websites for referrers about gadolinium contrast medium injections:

  1. The International Centre for Nephrogenic Fibrosing Dermopathy Research (ICNFDR)

  2. American College of Radiology
    (Updated ACR Screening Recommendations on Gadolinium-Based MR Contrast Agents, Renal Disease Patients, and Nephrogenic Systemic Fibrosis (NSF)

  3. The Royal Australian & New Zealand College of Radiologists Procedures and Guidelines