Radiographers must be aware that patients with severe renal dysfunction are at higher risk of nephrogenic systemic fibrosis (NSF), and they must check a patient's estimated glomerular filtration rate prior to administration of gadolinium-based contrast agents and ensure that practice and protocols are current and safe, a researcher from Glasgow, U.K., has underlined.
Published guidelines or advice may change as a result of further research -- radiographers must review guidance from bodies such as the Medicines and Healthcare products Regulatory Agency (MHRA) and need to be aware of local policy, according to Sharon Stewart, from the department of psychology and allied health sciences, Glasgow Caledonian University, U.K. Evidence-based practice (EBP) can help to ensure radiographers are practicing safely and effectively.
Nephrogenic systemic fibrosis was first reported in 2000 as a dermopathy of unknown etiology. Image courtesy of Uremic Frost/Kidney International.
"The emergence of NSF provides an excellent example of why radiographers are required to use EBP," she noted at the 2012 U.K. Radiological Congress (UKRC) in Manchester. "EBP can be used as a tool to ensure safe administration of gadolinium contrast agents for patients with chronic kidney disease."
NSF was first reported in 2000 as a "new" dermopathy of unknown etiology, observed only in patients with chronic kidney disease; it is an incapacitating, potentially fatal disease that primarily affects the skin, and is now known to be a systemic disorder affecting other structures such as muscle and internal organs, according to Stewart. A link between NSF sufferers and gadolinium-based contrast agents used in MRI was suggested in 2006, and the U.S. Food and Drug Administration (FDA) published warnings for health professionals, but the guidelines for administering gadolinium remained confusing and complex, and changed almost daily, she added.
EBP involves integrating the best available evidence with clinical expertise to deliver safe and effective diagnosis, care, and treatment. It is a key part of clinical effectiveness, defined as the right person doing the right thing in the right way at the right time in the right place with the right result, she explained. EBP means reviewing your own practice and questioning if it is safe, effective, and based on evidence.
In the U.K., radiographers administer gadolinium-based contrast agents under Patient Group Direction legislation that identifies radiographers as appropriate professionals for this task, but requires them to keep aware of any changes to recommendations by continuing professional development. Radiographers must keep up to date with current practice, and therefore literature searches are a core skill in modern radiography curricula.
"In NSF, the sheer number (of articles) makes it impossible to review the data, and whilst it includes relevant research papers and reports, it also comprises news items, nonpeer-reviewed items and adverts for law firms. Using appropriate keywords and databases and use of Boolean terms can narrow the search to a more manageable and relevant dataset," she pointed out.
Among the questions that still need to be considered are: Which contrast agents are safe? What is the causal link between NSF and gadolinium contrast agents? Is the chelate structure significant? Is dose relevant? What are the patient risk factors, and at what level of renal dysfunction is it safe to administer agents? Is glomerular filtration rate (GFR) more accurate than serum creatinine to evaluate dysfunction? Are patients with normal kidney function at risk? Does dialysis help postadministration?
Stewart noted recent guidelines are clear on certain points; for instance, the European Society of Urogenital Radiology (European Radiology, 4 August 2012), MHRA, and FDA agree that patients with severe renal impairment (GFR < 30 mL/min) should not be given Omniscan or Magnevist, and they advise caution in patients with moderate renal impairment (GFR 30-59 mL/min). No cases of NSF have been reported in patients with GFR of greater than 60 mL/min, and no new cases of NSF have been reported since these guidelines have been implemented.
"The answers to some other questions have changed and evolved in the last five years and remain in flux. For example, initially dialysis patients were required to have prompt dialysis postcontrast. This is now optional and remains a matter of debate," she concluded.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
