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NSF

Policy Description:

Intravenous use of MRI contrast agents in patients with renal failure

Effective Date:

November 16, 2007

Purpose:

To reduce the risk of patients developing ‘NSF’ who receive intravenous MRI contrast

Definition:

NEPHROGENIC SYSTEMIC FIBROSIS (NSF) is a rare disabling systemic disease occurring in patients with renal insufficiency that has only been described since 1997. Recent literature has suggested that there is an increased incidence of this disease occurring as a complication after intravenous MR contrast administration particularly in patients with renal failure.

Patients at Increased Risk of Developing ‘NSF’

  1. Chronic Renal Failure (Stage IV-V), Acute Kidney Injury, and Dialysis Patients. Stage III patients risk, if any, is unknown at this time
  2. Increased Dose of MR Contrast (Dose Related)
  3. Liver Transplant Patients.
  4. Patients with Hepato-Renal Syndrome.

Policy:

  1. Stage IV-V patients or patients with acute kidney injury must receive risk-benefit assessment by radiologist. Administration of contrast only with approval and signature of radiologist. Dose amount and type of contrast* will be documented within the consent form. Currently, risk of NSF in patients with normal, mild or moderate renal insufficiency is unknown
  2. If gadolinium contrast is administered to a Hemodialysis patient it is strongly recommended they should have same day hemodialysis (preferably within 2 hours of exam) and additional dialysis at 24 hours. Peritoneal dialysis provides no protective effect. Dose Modification should be considered in these patients.
  3. Stage IV-V patients requiring contrast administration and not currently on hemodialysis should be carefully evaluated as to the risk/benefit of administering MR contrast. If administered, the patient should be considered for the lowest possible diagnostic dose. The decision to use gadolinium in these patients may be best made in consultation with the patient’s ordering physician and/or nephrologist. Hemodialysis after gadolinium may also be considered as prophylaxis in this group of at risk patients.
  4. Any patient with any history of kidney disease, diabetes, hypertension or recent liver transplant history will require calculation of eGFR based on a serum/creatnine level. The serum/creatnine level should be obtained within 30-90 days of date of procedure (Radiologist will review patient history to determine acceptable period)**

*ACR recommends that patients with any level of renal disease should not receive Omniscan for their contrast (Source: ACR Whitepaper: Enhanced MR Examination June 2007 Section G14)

**eGFR is not validated for patients <18 or >85 years of age. Any patient greater than 85 years should have a GFR calculation within 6 weeks of procedure. Patients younger than 18 years may have an eGFR but the Pediatric Calculator available on the National Kidney Foundation website should be utilized.