The association of nephrogenic systemic fibrosis (NSF) with the use of gadolinium-based magnetic resonance contrast agents (GBMCAs) has greatly affected the care of patients with kidney disease. Nephrogenic systemic fibrosis has been reported in patients with end-stage renal disease, chronic kidney disease (CKD) and acute kidney injury. The majority of cases have occurred in patients with end-stage renal disease, but cases of NSF have been reported in CKD patients with glomerular filtration rates less than 30 mL/min/1.73 m(2). Odds ratios have ranged between 8.97 and 32.5 among patients exposed to GBMCAs. Given the significant morbidity, disability, and mortality associated with NSF, it is imperative to properly and preemptively identify those patients at risk. Patients with end-stage renal disease seem to be at highest risk, particularly those maintained on peritoneal dialysis (PD). Although there are no data to support a role for hemodialysis in reducing the risk for NSF after the administration of GBMCAs, hemodialysis is recommended within 2 to 3 hours. Patients maintained on PD and those with CKD present a challenge, as they do not typically have vascular access for hemodialysis, yet the clearance of GBMCAs is very low, and it may be prudent to consider hemodialysis especially for PD patients. Gadolinium-based magnetic resonance contrast agents are removed by dialysis, with estimates that about 99% of a dose is removed after 3 to 4 sessions of hemodialysis. The elimination half-life averaged 9 hours in patients with stage 4 CKD (glomerular filtration rate <30 mL/min/1.73 m(2)) compared with 1.5 hours in those with normal glomerular filtration rates. This prolonged elimination and longer exposure may be important factors in predisposing to NSF.