Gadolinium-Based Contrast Agents and the Theater of Safety

In ideal situations, contrast agents used in radiological procedures should provide sufficient image enhancement without high doses and without eliciting any adverse effects. Regrettably, this has not been the case, particularly in states of kidney disease. Standard use, and oftentimes contrast overuse, has highlighted the risk of developing nephrogenic systemic fibrosis and gadolinium toxicity from gadolinium-based contrast agents (GBCAs). Conflicting reports lead to confusion regarding the types of agents that cause injury, the overall injury rates, acceptable defining terms, and even which patient population is most at risk. This confusion can lead to withholding contrast-enhanced examinations in patients for fear of kidney injury. However, at the other end of the spectrum, many providers question the risk or reality of complications, citing conflicting reports. In truth, the risk of complications lies somewhere in between. Educated patients are knowledgeable about the risks associated with GBCA administrations, but many of their concerns are often dismissed by healthcare providers. Transparency is key, as there is still much to learn about the overall risk of gadolinium exposures in states of kidney disease and normal kidney function. A learned provider will be foundational for mitigating patient concerns. To provide a foundational understanding of the risks associated with gadolinium exposure, this review focuses on the complications of gadolinium-based contrast agents.