ESR Essentials: gadolinium-wise MRI-practice recommendations by the European Society for Magnetic Resonance in Medicine and Biology.

The Gadolinium Research and Education Committee (GREC) is a working group of the European Society for Magnetic Resonance in Medicine and Biology (ESMRMB), established in 2016. The aim of the committee is to monitor scientific evidence for a continuous quality and safety improvement of enhanced MRI using gadolinium-based contrast agents (GBCAs), and also assess potential alternatives. The scope of the present article is to describe the level of evidence concerning safety beyond the single patient (access to community and environmental impact), justification and optimization of the use of GBCAs beyond dosage (appropriateness and influence on clinical decision making), dose reduction with the use of AI (benefits and pitfalls), the advent of next-generation GBCAs (based on currently available data). CLINICAL RELEVANCE: GBCAs are extensively used in MRI and influence clinical decision-making. Their use to enhance the contrast-to-noise ratio is guided by recommendations from subspecialty societies. These guidelines advocate for GBCA use as an additional tool when necessary, ensuring they are administered at the lowest reasonable dose. KEY POINTS: The choice of GBCAs used in radiology should be based on MRI cost-effectiveness, MRI access to the patient community, and impact on the environment, (evidence level: low). GBCA optimization includes reducing GBCA volume burden and increasing appropriateness by including post-contrast enhancement in MRI protocols, depending on clinical indications, (evidence level: moderate). Next-generation GBCAs show higher kinetic stability and higher T1 relaxivity when compared with standard macrocyclic GBCAs allowing comparable diagnostic accuracy at lower doses, (evidence level: moderate).