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Current recommendations and guidelines for administration of radiologic contrast media are reviewed, as well as management of adverse reactions.

Iodinated and gadolinium-based contrast media are used on a daily basis in most radiology practices. These agents often are essential to providing accurate diagnoses, and are nearly always safe and effective when administered correctly. However, reactions to contrast media do occur and can be life threatening. Therefore, it is critical for faculty and staff to know how reactions to contrast agents manifest and how to treat them promptly. The decline in renal function seen occasionally after intravenous administration of iodinated contrast agents is poorly understood and likely multifactorial, and its association with the contrast medium may be overemphasized. However, it is important that radiologists be aware of current understanding and strategies to decrease the incidence of renal dysfunction. Nephrogenic systemic fibrosis, a skin disease, is an adverse reaction related to use of some gadolinium-based contrast agents in patients with chronic renal failure. The types of gadolinium most often associated with this condition and the indications for withholding gadolinium are important and are discussed in this article. The use of enteric contrast agents and contrast agents during pregnancy and nursing are reviewed briefly. Current knowledge for safe use of contrast media and key concepts that all radiologists should know are summarized in this review.

©RSNA, 2015


  • 1. Brenner DJ, Hricak H. Radiation exposure from medical imaging: time to regulate? JAMA 2010;304(2):208–209.
  • 2. OECD Health Statistics. Health care utilisation. OECD.Stat Web site. Published 2014. Accessed February 17, 2015.
  • 3. Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology 2010;256(1):32–61.
  • 4. Katayama H, Yamaguchi K, Kozuka T, Takashima T, Seez P, Matsuura K. Adverse reactions to ionic and nonionic contrast media: a report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990;175(3):621–628.
  • 5. Runge VM. Safety of approved MR contrast media for intravenous injection. J Magn Reson Imaging 2000;12(2):205–213.
  • 6. ACR Committee on Drugs and Contrast Media. ACR manual on contrast media: version 9. American College of Radiology Web site. Published 2013. Accessed February 17, 2015.
  • 7. Thomsen HS. Contrast media safety: an update. Eur J Radiol 2011;80(1):77–82.
  • 8. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol 2001;176(6):1385–1388.
  • 9. Mortelé KJ, Oliva MR, Ondategui S, Ros PR, Silverman SG. Universal use of nonionic iodinated contrast medium for CT: evaluation of safety in a large urban teaching hospital. AJR Am J Roentgenol 2005;184(1):31–34.
  • 10. Wang CL, Cohan RH, Ellis JH, Caoili EM, Wang G, Francis IR. Frequency, outcome, and appropriateness of treatment of nonionic iodinated contrast media reactions. AJR Am J Roentgenol 2008;191(2):409–415.
  • 11. Thomsen HS. European Society of Urogenital Radiology (ESUR) guidelines on the safe use of iodinated contrast media. Eur J Radiol 2006;60(3):307–313.
  • 12. Prince MR, Zhang H, Zou Z, Staron RB, Brill PW. Incidence of immediate gadolinium contrast media reactions. AJR Am J Roentgenol 2011;196(2):W138–W143.
  • 13. Murphy KJ, Brunberg JA, Cohan RH. Adverse reactions to gadolinium contrast media: a review of 36 cases. AJR Am J Roentgenol 1996;167(4):847–849.
  • 14. Dillman JR, Ellis JH, Cohan RH, Strouse PJ, Jan SC. Frequency and severity of acute allergic-like reactions to gadolinium-containing IV contrast media in children and adults. AJR Am J Roentgenol 2007;189(6):1533–1538.
  • 15. Li A, Wong CS, Wong MK, Lee CM, Au Yeung MC. Acute adverse reactions to magnetic resonance contrast media: gadolinium chelates. Br J Radiol 2006;79(941):368–371.
  • 16. Berlin L. Informed consent for contrast media and gadolinium injections. AJR Am J Roentgenol 2011;197(2):W359.
  • 17. Bettmann MA. Frequently asked questions: iodinated contrast agents. RadioGraphics 2004;24(suppl 1):S3–S10.
  • 18. Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions to intravenous iodinated contrast media: a primer for radiologists. Emerg Radiol 2006;12(5):210–215.
  • 19. McCarthy CS, Becker JA. Multiple myeloma and contrast media. Radiology 1992;183(2):519–521.
  • 20. Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology 2000;216(2): 481–484.
  • 21. Duncan L, Heathcote J, Djurdjev O, Levin A. Screening for renal disease using serum creatinine: who are we missing? Nephrol Dial Transplant 2001;16(5):1042–1046.
  • 22. Herts BR, Schneider E, Poggio ED, Obuchowski NA, Baker ME. Identifying outpatients with renal insufficiency before contrast-enhanced CT by using estimated glomerular filtration rates versus serum creatinine levels. Radiology 2008;248(1):106–113.
  • 23. Morcos SK. Review article: acute serious and fatal reactions to contrast media—our current understanding. Br J Radiol 2005;78(932):686–693.
  • 24. Morcos SK, Thomsen HS. Adverse reactions to iodinated contrast media. Eur Radiol 2001;11(7):1267–1275.
  • 25. Bettmann MA, Heeren T, Greenfield A, Goudey C. Adverse events with radiographic contrast agents: results of the SCVIR Contrast Agent Registry. Radiology 1997;203(3): 611–620.
  • 26. Siegle RL, Halvorsen RA, Dillon J, Gavant ML, Halpern E. The use of iohexol in patients with previous reactions to ionic contrast material: a multicenter clinical trial. Invest Radiol 1991;26(5):411–416.
  • 27. Schabelman E, Witting M. The relationship of radiocontrast, iodine, and seafood allergies: a medical myth exposed. J Emerg Med 2010;39(5):701–707.
  • 28. Schopp JG, Iyer RS, Wang CL, et al. Allergic reactions to iodinated contrast media: premedication considerations for patients at risk. Emerg Radiol 2013;20(4):299–306.
  • 29. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition, and specific treatment. AJR Am J Roentgenol 1991;157(6):1153–1161.
  • 30. Christiansen C. Hypersensitivity reactions to iodinated contrast media: an update. In: Pichler WJ, ed. Drug hypersensitivity. Basel, Switzerland: Karger, 2007; 233–241.
  • 31. Idée JM, Pinès E, Prigent P, Corot C. Allergy-like reactions to iodinated contrast agents: a critical analysis. Fundam Clin Pharmacol 2005;19(3):263–281.
  • 32. Bush W Jr, Krecke K, King B Jr, Bettmann M. Radiology life support (RAD-LS): a practical approach. New York, NY: Taylor & Francis, 1999; 208.
  • 33. Brockow K, Christiansen C, Kanny G, et al. Management of hypersensitivity reactions to iodinated contrast media. Allergy 2005;60(2):150–158.
  • 34. Bouachour G, Varache N, Szapiro N, L’Hoste P, Harry P, Alquier P. Noncardiogenic pulmonary edema resulting from intravascular administration of contrast material. AJR Am J Roentgenol 1991;157(2):255–256.
  • 35. Thomsen HS, Bush WH Jr. Adverse effects of contrast media: incidence, prevention and management. Drug Saf 1998;19(4):313–324.
  • 36. Almén T. The etiology of contrast medium reactions. Invest Radiol 1994;29(suppl 1):S37–S45.
  • 37. Singh J, Daftary A. Iodinated contrast media and their adverse reactions. J Nucl Med Technol 2008;36(2):69–74; quiz 76–77.
  • 38. Bellin MF, Stacul F, Webb JA, et al. Late adverse reactions to intravascular iodine based contrast media: an update. Eur Radiol 2011;21(11):2305–2310.
  • 39. Lightfoot CB, Abraham RJ, Mammen T, Abdolell M, Kapur S, Abraham RJ. Survey of radiologists’ knowledge regarding the management of severe contrast material-induced allergic reactions. Radiology 2009;251(3):691–696.
  • 40. Bartlett MJ, Bynevelt M. Acute contrast reaction management by radiologists: a local audit study. Australas Radiol 2003;47(4):363–367.
  • 41. Tapping CR, Culverwell AD. Are radiologists able to manage serious anaphylactic reactions and cardiopulmonary arrest? Br J Radiol 2009;82(982):793–799.
  • 42. Tubbs RJ, Murphy B, Mainiero MB, et al. High-fidelity medical simulation as an assessment tool for radiology residents’ acute contrast reaction management skills. J Am Coll Radiol 2009;6(8):582–587.
  • 43. Niell BL, Vartanians VM, Halpern EP. Improving education for the management of contrast reactions: an online didactic model. J Am Coll Radiol 2014;11(2):185–192; quiz 192e1–192e2.
  • 44. Davenport MS, Cohan RH, Ellis JH. Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction. AJR Am J Roentgenol 2015;204(6):1174–1181.
  • 45. Chatham WW. Glucocorticoid effects on the immune system. UpToDate Web site. Updated August 21, 2014. Accessed February 17, 2015.
  • 46. Lasser EC, Berry CC, Mishkin MM, Williamson B, Zheutlin N, Silverman JM. Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast media. AJR Am J Roentgenol 1994;162(3):523–526.
  • 47. Greenberger PA, Patterson R. The prevention of immediate generalized reactions to radiocontrast media in high-risk patients. J Allergy Clin Immunol 1991;87(4):867–872.
  • 48. Tramèr MR, von Elm E, Loubeyre P, Hauser C. Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review. BMJ 2006;333(7570):675.
  • 49. Davenport MS, Cohan RH, Caoili EM, Ellis JH. Repeat contrast medium reactions in premedicated patients: frequency and severity. Radiology 2009;253(2):372–379.
  • 50. American College of Radiology. ACR-SPR practice guideline for the use of intravascular contrast media. American College of Radiology Web site.∼/media/536212D711524DA5A4532407082C89BA.pdf. Updated 2014. Accessed February 17, 2015.
  • 51. Hardie AD, Kereshi B. Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department. Emerg Radiol 2014;21(3):235–238.
  • 52. Herts BR, Cohen MA, McInroy B, Davros WJ, Zepp RC, Einstein DM. Power injection of intravenous contrast material through central venous catheters for CT: in vitro evaluation. Radiology 1996;200(3):731–735.
  • 53. Coyle D, Bloomgarden D, Beres R, Patel S, Sane S, Hurst E. Power injection of contrast media via peripherally inserted central catheters for CT. J Vasc Interv Radiol 2004;15(8): 809–814.
  • 54. Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology 2007;243(1):80–87.
  • 55. Cohan RH, Ellis JH, Garner WL. Extravasation of radiographic contrast material: recognition, prevention, and treatment. Radiology 1996;200(3):593–604.
  • 56. Sum W, Ridley LJ. Recognition and management of contrast media extravasation. Australas Radiol 2006;50(6): 549–552.
  • 57. Sbitany H, Koltz PF, Mays C, Girotto JA, Langstein HN. CT contrast extravasation in the upper extremity: strategies for management. Int J Surg 2010;8(5):384–386.
  • 58. Tonolini M, Campari A, Bianco R. Extravasation of radiographic contrast media: prevention, diagnosis, and treatment. Curr Probl Diagn Radiol 2012;41(2):52–55.
  • 59. Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002;39(5):930–936.
  • 60. Kayibanda JF, Hiremath S, Knoll GA, et al. Does intravenous contrast-enhanced computed tomography cause acute kidney injury? Protocol of a systematic review of the evidence. Syst Rev 2014;3:94.
  • 61. Katzberg RW, Newhouse JH. Intravenous contrast medium-induced nephrotoxicity: is the medical risk really as great as we have come to believe? Radiology 2010;256(1):21–28.
  • 62. Newhouse JH, RoyChoudhury A. Quantitating contrast medium-induced nephropathy: controlling the controls. Radiology 2013;267(1):4–8.
  • 63. Newhouse JH, Kho D, Rao QA, Starren J. Frequency of serum creatinine changes in the absence of iodinated contrast material: implications for studies of contrast nephrotoxicity. AJR Am J Roentgenol 2008;191(2):376–382.
  • 64. McDonald RJ, McDonald JS, Bida JP, et al. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon? Radiology 2013;267(1):106–118.
  • 65. McDonald JS, McDonald RJ, Carter RE, Katzberg RW, Kallmes DF, Williamson EE. Risk of intravenous contrast material-mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate. Radiology 2014;271(1):65–73.
  • 66. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11(2):R31.
  • 67. Bruce RJ, Djamali A, Shinki K, Michel SJ, Fine JP, Pozniak MA. Background fluctuation of kidney function versus contrast-induced nephrotoxicity. AJR Am J Roentgenol 2009;192(3):711–718.
  • 68. Pickering JW, Endre ZH. The definition and detection of acute kidney injury. J Renal Inj Prev 2014;3(1):21–25.
  • 69. Younathan CM, Kaude JV, Cook MD, Shaw GS, Peterson JC. Dialysis is not indicated immediately after administration of nonionic contrast agents in patients with end-stage renal disease treated by maintenance dialysis. AJR Am J Roentgenol 1994;163(4):969–971.
  • 70. Kribben A, Witzke O, Hillen U, Barkhausen J, Daul AE, Erbel R. Nephrogenic systemic fibrosis: pathogenesis, diagnosis, and therapy. J Am Coll Cardiol 2009;53(18):1621–1628.
  • 71. Bernstein EJ, Schmidt-Lauber C, Kay J. Nephrogenic systemic fibrosis: a systemic fibrosing disease resulting from gadolinium exposure. Best Pract Res Clin Rheumatol 2012;26(4):489–503.
  • 72. Girardi M, Kay J, Elston DM, Leboit PE, Abu-Alfa A, Cowper SE. Nephrogenic systemic fibrosis: clinicopathological definition and workup recommendations. J Am Acad Dermatol 2011;65(6):1095–1106.e7.
  • 73. Grobner T. Gadolinium: a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? Nephrol Dial Transplant 2006;21(4):1104–1108.
  • 74. High WA, Ayers RA, Chandler J, Zito G, Cowper SE. Gadolinium is detectable within the tissue of patients with nephrogenic systemic fibrosis. J Am Acad Dermatol 2007;56(1):21–26.
  • 75. Cowper SE, Bucala R. Nephrogenic fibrosing dermopathy: suspect identified, motive unclear. Am J Dermatopathol 2003;25(4):358.
  • 76. Daftari Besheli L, Aran S, Shaqdan K, Kay J, Abujudeh H. Current status of nephrogenic systemic fibrosis. Clin Radiol 2014;69(7):661–668.
  • 77. Perez-Rodriguez J, Lai S, Ehst BD, Fine DM, Bluemke DA. Nephrogenic systemic fibrosis: incidence, associations, and effect of risk factor assessment—report of 33 cases. Radiology 2009;250(2):371–377.
  • 78. Thomsen HS, Morcos SK, Almén T, et al. Nephrogenic systemic fibrosis and gadolinium-based contrast media: updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 2013;23(2):307–318.
  • 79. Chow DS, Bahrami S, Raman SS, et al. Risk of nephrogenic systemic fibrosis in liver transplantation patients. AJR Am J Roentgenol 2011;197(3):658–662.
  • 80. Heverhagen JT, Krombach GA, Gizewski E. Application of extracellular gadolinium-based MRI contrast agents and the risk of nephrogenic systemic fibrosis. Rofo 2014;186(7): 661–669.
  • 81. Thomsen HS. How to avoid nephrogenic systemic fibrosis: current guidelines in Europe and the United States. Radiol Clin North Am 2009;47(5):871–875, vii.
  • 82. Frenzel T, Lengsfeld P, Schirmer H, Hütter J, Weinmann HJ. Stability of gadolinium-based magnetic resonance imaging contrast agents in human serum at 37 degrees C. Invest Radiol 2008;43(12):817–828.
  • 83. Thomsen HS, Marckmann P. Extracellular Gd-CA: differences in prevalence of NSF. Eur J Radiol 2008;66(2): 180–183.
  • 84. Gelfand DW, Sowers JC, DePonte KA, Sumner TE, Ott DJ. Anaphylactic and allergic reactions during double-contrast studies: is glucagon or barium suspension the allergen? AJR Am J Roentgenol 1985;144(2):405–406.
  • 85. Morcos SK. Review article: effects of radiographic contrast media on the lung. Br J Radiol 2003;76(905):290–295.
  • 86. Eisenberg RL, Hedgcock MW, Shanser JD, Brenner RJ, Gedgaudas RK, Marks WM. Iodine absorption from the gastrointestinal tract during hypaque-enema examination. Radiology 1979;133(3 Pt 1):597–599.
  • 87. Miller SH. Anaphylactoid reaction after oral administration of diatrizoate meglumine and diatrizoate sodium solution. AJR Am J Roentgenol 1997;168(4):959–961.
  • 88. Wang PI, Chong ST, Kielar AZ, et al. Imaging of pregnant and lactating patients. I. Evidence-based review and recommendations. AJR Am J Roentgenol 2012;198(4): 778–784.
  • 89. Moon AJ, Katzberg RW, Sherman MP. Transplacental passage of iohexol. J Pediatr 2000;136(4):548–549.
  • 90. De Santis M, Straface G, Cavaliere AF, Carducci B, Caruso A. Gadolinium periconceptional exposure: pregnancy and neonatal outcome. Acta Obstet Gynecol Scand 2007;86(1):99–101.
  • 91. Dillman JR, Strouse PJ, Ellis JH, Cohan RH, Jan SC. Incidence and severity of acute allergic-like reactions to IV nonionic iodinated contrast material in children. AJR Am J Roentgenol 2007;188(6):1643–1647.
  • 92. Penfield JG. Nephrogenic systemic fibrosis and the use of gadolinium-based contrast agents. Pediatr Nephrol 2008;23(12):2121–2129.
  • 93. Bailey CJ, Turner RC. Metformin. N Engl J Med 1996;334(9):574–579.

Article History

Received: Feb 24 2015
Revision requested: Apr 22 2015
Revision received: June 18 2015
Accepted: June 23 2015
Published online: Oct 14 2015
Published in print: Oct 2015