ACR Manual on Contrast Media 2025: Guidelines Explained

Key Takeaways

• The 2025 American College of Radiology (ACR) Manual on Contrast Media introduces significant updates to gadolinium-based contrast agent (GBCA) classifications, with refined safety parameters for patients with compromised renal function. 
• Revised contrast-associated acute kidney injury (CA-AKI) risk assessment guidelines now recommend targeted screening based on specific risk factors rather than universal eGFR testing. 
• Enhanced documentation requirements emphasize comprehensive adverse event reporting and standardized patient screening protocols. 
• ContrastConnect ensures medical facilities meet the 2025 ACR updated guidelines by offering virtual supervision services from radiologists with experience supervising 55,000+ exams per month.

What Every Radiologist Needs to Know About the 2025 ACR Contrast Manual

The ACR has released its 2025 Manual on Contrast Media, representing the most comprehensive update in recent years. This evidence-based manual serves as the gold standard for contrast administration protocols across all imaging modalities. 

The 2025 manual integrates recent research findings with practical clinical guidance, emphasizing patient safety while maintaining diagnostic efficacy. Key revisions address ongoing concerns about gadolinium deposition, contrast-associated kidney injury risk assessment, and specialized protocols for vulnerable populations. 

Unlike previous iterations, this version incorporates real-world implementation strategies and quality assurance metrics to facilitate departmental protocol updates.

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Gadolinium-Based Contrast Agents: NSF Classification Changes

‍New Group Classifications Explained

The 2025 ACR Manual brings significant revisions to the classification of gadolinium-based contrast agents (GBCAs). The GBCA classification system has been refined based on accumulated clinical data regarding nephrogenic systemic fibrosis (NSF) risk. Group I agents are associated with the greatest number of NSF cases and include gadodiamide (Omniscan), gadopentetate dimeglumine (Magnevist), and gadoversetamide (OptiMARK). These agents carry FDA contraindications for use in high-risk patients.

Group II agents are associated with few, if any, unconfounded cases of NSF. This group includes gadobenate dimeglumine (MultiHance), gadobutrol (Gadavist), gadoteric acid (Dotarem, Clariscan), gadoteridol (ProHance), gadopiclenol (Elucirem, Vueway), and gadoxetate disodium (Eovist/Primovist). For Group II agents, the ACR Committee considers the risk of NSF sufficiently low or possibly nonexistent at standard or lower doses such that assessment of renal function with questionnaire or laboratory testing is optional before intravenous administration.

Gadopiclenol receives a Group II designation with provisional status (Group III), reflecting favorable biochemical profiles and laboratory data demonstrating kinetic stability comparable to other macrocyclic agents. However, the provisional designation acknowledges relatively limited in-use clinical performance data in higher-risk populations. Local practices may treat gadopiclenol as either Group II or Group III, based on institutional preferences, until more extensive real-world data accumulate.

Risk Stratification for Patient Selection

Patient selection criteria have been refined to reflect evolving understanding of GBCA safety profiles. For Group I agents, patients at risk of developing NSF include those on any form of dialysis, those with severe or end-stage chronic kidney disease (CKD stage 4 or 5, eGFR <30 mL/min/1.73 m²) without dialysis, and those with acute kidney injury (AKI). The manual introduces consideration of "GBCA burden", the cumulative dose received over a patient's lifetime, particularly for patients requiring multiple contrast-enhanced MRI studies.

For patients with eGFR between 30 and 44 mL/min/1.73m², the risk appears significantly lower than previously thought, with some studies suggesting borderline but not statistically significant risk. The guidelines acknowledge that NSF developing after GBCA administration to patients with stable eGFR 30–59 mL/min/1.73m² is exceedingly rare, and no special precautions are necessary for patients with CKD stage 3.

Monitoring Requirements Post-Administration

Post-administration monitoring protocols have been clarified based on current best practices. While immediate hypersensitivity reactions remain uncommon with GBCAs, the manual establishes guidelines for observation periods based on agent type and patient risk factors. 

Facilities should be equipped to evaluate and treat adverse reactions, with personnel trained to recognize and manage them. Most severe reactions occur within 30 minutes of administration. The manual emphasizes that nearly all life-threatening contrast reactions occur within the first 20 minutes after contrast medium injection; therefore, facilities must be quick to manage reactions.

Contrast-Associated Acute Kidney Injury: Updated Guidelines

The shift in terminology from Contrast-Induced Nephropathy (CIN) to Contrast-Associated Acute Kidney Injury (CA-AKI) reflects our evolving understanding of the relationship between contrast media and kidney function. 

CA-AKI is a general term describing sudden deterioration in renal function within 48 hours following intravascular iodinated contrast administration, regardless of whether the contrast was the cause. CI-AKI is the specific term for injury caused by contrast media. The 2025 guidelines establish clearer risk-stratification criteria, eliminating universal eGFR screening for patients without specific risk factors.

eGFR Thresholds for Risk Assessment

The updated approach to renal function assessment represents one of the most significant changes in the 2025 ACR guidelines. Rather than universal screening, the manual recommends targeted assessment based on specific risk factors. 

Patients requiring renal function assessment before Group I or Group III GBCA administration, or before iodinated contrast administration, include those with a history of renal disease (known CKD, remote history of AKI, dialysis, kidney transplant, single kidney, kidney surgery, renal cancer, or history of albuminuria). 

For intravenous iodinated contrast media, current evidence indicates that patients with eGFR ≥30 mL/min/1.73 m² are not at increased risk of CI-AKI. For patients with eGFR 30–44 mL/min/1.73m², the risk appears significantly lower than previously thought. Patients with eGFR <30 mL/min/1.73m² or acute kidney injury represent the highest-risk group where careful consideration is required. 

Hydration Protocols: What's Changed

Intravenous volume expansion remains the cornerstone of CI-AKI prevention in at-risk patients, but the 2025 guidelines provide more nuanced protocols. Prophylaxis is indicated for patients with AKI or severe chronic kidney disease with eGFR <30 mL/min/1.73m², though the risks of volume expansion should be considered. 

Prophylaxis is not indicated for the general population with stable eGFR ≥30 mL/min/1.73m² or for patients on chronic dialysis. For patients with eGFR 30–44 mL/min/1.73m², prophylaxis may be considered on an individual basis at the discretion of the ordering provider.

The recommended approach for high-risk patients involves isotonic fluids such as 0.9% normal saline. Typical prophylaxis regimens begin 1 hour before the exam and continue 3–12 hours after, with longer regimens (approximately 12 hours) shown to lower CA-AKI risk. Typical doses may be fixed volume (500 mL before and after) or weight-based (1–3 mL/kg per hour).

Documentation and Follow-up Recommendations

The 2025 ACR Manual emphasizes comprehensive documentation for contrast media administration, including pre-procedure assessment of risk factors, contrast type and volume administered, and any adverse reactions observed. Follow-up recommendations have been refined based on risk stratification. 

Routine post-procedure creatinine measurement is not recommended for patients with normal baseline kidney function who receive intravenous contrast. For patients with eGFR <30 mL/min/1.73m² or AKI who receive contrast, follow-up assessment may be appropriate.

Contrast Administration in Special Populations

Pregnancy and Breastfeeding: 2024–2025 Updates

For pregnancy, iodinated contrast media cross the placenta and enter fetal circulation when given in usual clinical doses. However, in vivo animal studies show no evidence of mutagenic or teratogenic effects with low-osmolality contrast media. 

The manual explicitly states radiologists should not routinely screen for pregnancy in women of child-bearing age receiving radiation to the pelvis and should not withhold iodinated contrast agents in pregnant or potentially pregnant patients when needed for diagnostic purposes.

For gadolinium-based contrast agents, the approach remains more cautious. GBCAs should only be administered when there is a potentially significant benefit to the patient or fetus that outweighs the possible but unknown risk of fetal exposure to free gadolinium ions. Each case requires careful documentation and informed consent.

Pediatric Dosing Refinements

The 2025 ACR update provides comprehensive guidance for pediatric contrast administration. 

Iodinated contrast dosing typically follows 1.5–2 mL/kg for most studies, management of adverse reactions in children includes age-appropriate medication dosing, and special attention is given to neonates and infants, noting that in the immediate newborn period (approximately first 3 weeks), blood creatinine represents at least in part maternal creatinine, making infant plasma creatinine unreliable for measuring renal function.

Regarding thyroid function after iodinated contrast exposure in young children, the manual references the ACR Statement, indicating that, based on available evidence, the risk for clinically relevant hypothyroidism related to iodinated contrast media is quite low in children younger than 3 months and minimal to absent in children 3 months and older. 

Geriatric Considerations

The 2025 guidelines recognize that advanced age alone is not an independent risk factor for contrast reactions or CA-AKI. However, older adults frequently have multiple comorbidities that may increase their risk profile. The manual recommends individualizing contrast protocols based on overall clinical status rather than chronological age. 

Special considerations include a higher prevalence of polypharmacy, which may increase the risk of drug-contrast interactions. Particular attention should be paid to adequate hydration status, as older adults may have diminished thirst sensation.

Patients with Multiple Allergies

The 2025 ACR Manual provides clarified guidance on managing patients with allergic predispositions. Prior allergic-like reactions to contrast media remain the most significant risk factor for future responses, with the likelihood of subsequent reactions estimated at approximately a 5-fold increase for the same class of contrast media. 

Patients with multiple unrelated allergies (foods, environmental allergens) but no prior contrast reaction have only a modest (2–3 fold) increased risk compared to the general population. The manual explicitly states that patients with shellfish or povidone-iodine allergies are at no greater risk from iodinated contrast medium than patients with other allergies.

Implementing the 2025 Guidelines in Your Practice

Updating Departmental Protocols

Successfully integrating the updated ACR contrast guidelines requires systematic protocol updates. The first step is revising screening forms, order sets, and procedure manuals. 

Pay particular attention to modified screening criteria focusing on specific risk factors, updated hydration protocols with clear indications, revised GBCA selection criteria based on updated classifications, enhanced documentation requirements, and updated information for breastfeeding patients clarifying that cessation is not required.

Risk assessment workflows should be streamlined to incorporate the targeted screening recommendations. Department leadership should establish clear protocols for cases requiring special consideration, including standardized approaches for pregnant patients, those with previous reactions, and patients with borderline kidney function.

Staff Training Requirements

Comprehensive staff education is essential for successful implementation. All team members involved in contrast administration should receive training on key changes, including not only what has changed but also the evidence behind the modifications. 

Training should be role-specific, with radiologists receiving detailed education on scientific evidence supporting guideline changes, technologists and nurses focusing on practical implementation aspects, and ordering providers requiring guidance on appropriate patient screening and contrast selection. 

Quality Assurance Metrics

Implementing effective quality assurance measures is crucial for ensuring adherence to updated guidelines. 

Departments should establish key performance indicators that reflect key aspects of the new recommendations, including appropriate patient screening completion rates, adherence to hydration protocols in patients with eGFR <30 mL/min/1.73 m², documentation compliance, and adverse event tracking. 

Regular audits should assess performance against these metrics, with quality committees reviewing them to identify opportunities for improvement.

Staying Compliant with 2025 ACR Guidelines Through ContrastConnect

The 2025 ACR Manual on Contrast Media introduces critical updates affecting daily imaging practice. Navigating these evolving standards can be challenging, particularly for facilities facing radiologist shortages or managing multiple locations. ContrastConnect simplifies compliance by providing immediate access to radiologists who are thoroughly trained on the latest ACR guidelines. 

Our physicians supervise over 55,000 contrast exams monthly and manage 5–10 reactions daily, ensuring expert adherence to updated protocols for GBCA administration, CA-AKI prevention strategies, and adverse event management. Our comprehensive approach includes technologist training on the 2025 guideline changes, standardized emergency response protocols aligned with ACR recommendations, and audit-ready documentation that satisfies enhanced reporting requirements. 

Through our HIPAA-compliant virtual platform, we deliver consistent, compliant coverage that enables imaging centers to implement these critical updates confidently while extending hours, scaling operations, and improving patient access.

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Frequently Asked Questions

When do facilities need to implement the 2025 ACR guidelines?

Facilities should implement changes promptly as guidelines become available online. While no mandatory deadline exists, ACR suggests phased implementation, prioritizing safety protocols. Implementation requires updating protocols, screening forms, staff training, emergency response cards, and EHR integration. Facilities undergoing accreditation will be evaluated on current compliance with published guidelines.

How do the revised screening recommendations affect patient protocols?

Universal eGFR screening is eliminated. Targeted screening focuses on patients with renal disease history (CKD, dialysis, kidney transplant, surgery, cancer, or albuminuria), with diabetes as an optional consideration. Patients on metformin should be screened for temporary discontinuation needs. Routine intravascular study patients without risk factors don't require baseline eGFR determination.

What changes apply to contrast administration during pregnancy and breastfeeding?

Routine screening before iodinated contrast during pregnancy is unnecessary, and contrast shouldn't be withheld when clinically indicated. GBCAs require more caution and are administered only when the benefits outweigh the risks. For breastfeeding, cessation is no longer recommended for either contrast type—continued breastfeeding is safe as infant systemic exposure is minimal.

How does ContrastConnect help facilities comply with 2025 ACR guidelines?

ContrastConnect simplifies compliance by providing immediate access to radiologists who are thoroughly trained on the latest ACR guidelines. We deliver comprehensive technologist training, standardized emergency protocols, and audit-ready documentation. Our platform ensures consistent compliance across locations, enabling facilities to implement updated standards without recruiting and training onsite radiologists confidently.

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*Note: Information provided is for general guidance only and does not constitute medical, legal, or financial advice. Pricing estimates and regulatory requirements are current at the time of writing and subject to change. For personalized consultation on imaging center operations and virtual contrast supervision, contact ContrastConnect.