Clinical recommendation	Evidence rating	References
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.	C	7
Gadolinium-based contrast agents should never be used as a method of avoiding nephropathy associated with iodinated contrast media.	C	15
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.	C	15
Risks of inducing nephrogenic systemic fibrosis must be weighed against denying MRI enhanced with gadolinium-based contrast agents to patients in need.	C	7, 15
All patients undergoing MRI enhanced with gadolinium-based contrast agents should be screened for chronic kidney disease by history or laboratory evaluation.	C	7
Gadolinium-based contrast agents should be used with caution in any patients with a GFR less than 60 mL per minute per 1.73 m2.	C	15