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1. Avoid gadolinium contrast in patients with CKD stages 4 and 5.

2. Know that gadolinium can cause nephrogenic systemic fibrosis (NSF) in patients with advanced CKD.

3. NSF - presents as a thickening of the skin with erythema, symmetrical plaques, papules, or nodules. Usually it starts distally and moves proximally. Systemic symptoms: organ fibrosis, scleral yellowing, and tissue calcification.

4. Definitive diagnosis is made with deep punch biopsies of involved skin.

5. Course is progressive, sometimes fulminant. If renal recovery occurs, commonly the NSF remits, otherwise - no treatment.


1. Wilkinson, I. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press.
2. Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
3. Image: no reference available.

Ⓒ A. Manickam 2018

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