Gadolinium-based contrast (GBC) agents have recently been the subject of intense interest for physicians across numerous specialties. These agents are widely used as contrast for magnetic resonance imaging and have been generally considered safe. Early on, phase III trials and small studies in low-risk patients suggested a benign renal profile; however, more recent studies raised the possibility of nephrotoxicity, although it is not clear whether it approaches the incidence of nephropathy associated with iodinated radiocontrast. In 2006, reports of a rare systemic fibrosing condition called nephrogenic systemic fibrosis (NSF) were recently linked to exposure of patients with advanced kidney disease to GBC agents. Analysis of the data suggests that certain GBC agents are more likely to be associated with NSF. Also, not all patients with kidney disease are at risk for developing NSF, only those with advanced acute or chronic kidney disease. Avoidance of GBC exposure is the best approach for high-risk patients. When GBC is required to obtain optimal images, use of low dosages of more stable macrocyclic agents is safer and preferred. This article reviews the current status of GBC agents as nephrotoxins and causes of NSF and provides opinions on how to use these agents in patients with underlying kidney disease.