Gadolinium is widely employed as a contrast agent for magnetic resonance imaging (MRI) and has generally been considered to be safe. As with iodinated radiocontrast, concern for contrast-induced nephropathy existed with gadolinium- contrast as it possessed many similar qualities (hyperosmolar, renal excretion via glomerular filtration). Early studies in low risk patients suggested a benign renal profile, however, recent studies raise the possibility of nephrotoxicity. In addition, reports of a previously rare condition entitled nephrogenic systemic fibrosis (NSF) have recently emerged in patients with advanced kidney disease and have been linked to exposure to gadolinium-contrast. Nephrogenic systemic fibrosis is a debilitating disorder in which progressive and severe fibrosis of the skin and other systemic organs that leads to significant disability and is associated with increased mortality. Initially reported most commonly in end stage renal disease (ESRD) patients receiving dialysis, it is also described in patients with severe acute kidney injury (AKI) and advanced chronic kidney disease (stages 4 and 5) not requiring dialysis. In addition to underlying kidney disease, the risk of developing NSF is increased with larger doses of gadolinium (or multiple exposures), exposure to specific gadolinium chelates (non-ionic, linear), underlying pro-inflammatory states (in particular vascular endothelial dysfunction), and perhaps some currently unrecognized cofactors. No clearly effective therapies exist for NSF, although recovery from AKI and establishment of normal kidney function with renal transplantation appear to reverse or stabilize the disease in some cases. Avoidance of gadolinium exposure appears to be the best approach for patients who maintain risk factors. When gadolinium exposure occurs, aggressive hemodialysis following exposure may be useful as gadolinium is efficiently removed by this extracorporeal technique. Peritoneal dialysis clearance of gadolinium is poor, but aggressive peritoneal dialysis prescriptions have not been studied for gadolinium removal.