Gadolinium contrast in chronic kidney disease

What it is

The use of gadolinium contrast has been associated with acute kidney injury, and also with the development of nephrogenic systemic sclerosis in patients with stage 4 or 5 chronic kidney disease.

The threshold

Because of these risks, the FDA recommends avoiding gadolinium contrast in patients with a glomerular filtration rate below 30 mL/min/1.73 m2, as well as in patients with acute renal failure. Nephrogenic systemic sclerosis is the thing to be avoided, and avoiding the contrast is the only way given to avoid it.

So the two lines to hold are a GFR under 30 mL/min/1.73 m2, and acute renal failure at any GFR.

The worked case

A 64-year-old female with hypertension, diabetes mellitus, hyperlipidemia and chronic kidney disease has headaches escalating over the past 6 months, with double vision and ataxia. Her medications include lisinopril and atorvastatin. Her blood pressure is 144/64 mm Hg, and a basic metabolic panel is normal except for a creatinine level of 2.1 mg/dL against a normal of 0.6-1.1, and an estimated glomerular filtration rate of 26 mL/min/1.73 m2.

An MRI of the brain is indicated by the symptoms, and the answer is avoiding the use of gadolinium contrast, not finding a way to give it.