Nephrogenic systemic fibrosis is a systemic disorder characterized by widespread tissue fibrosis. Gadolinium-based contrast (GBC) was recently noted as a possible trigger for this disease. The vast majority of cases occur in patients with ESRD receiving hemodialysis or peritoneal dialysis. However, approximately 10% of cases develop in patients with AKI (many requiring dialysis), advanced CKD stage 4, and CKD stage 5 not receiving renal replacement therapy. Recommendations to guide the use of GBC in patients with underlying kidney disease are presented. These clinical practice guidelines should be individualized and considered in consultation with the ordering physician, radiologist, and nephrologist.