Prolonged exposure to gadolinium-based contrast (GBC) appears to be the core pathophysiologic factor in the development of nephrogenic systemic fibrosis (NSF). As the GBC is renally excreted, this condition is predominantly seen only following exposure in patients with severe reductions in renal function. Fortunately, GBC is easily hemodialyzed with 95% of an administered dose removed after two hemodialysis sessions. Peritoneal dialysis, on the other hand, is not an efficient means of GBC removal. This has led to recommendations to hemodialyze a high-risk patient immediately following GBC administration and to repeat the treatment the following day. Although this approach seems logical and is more aggressive than the usual thrice-weekly hemodialysis schedule that most patients were receiving when they developed this devastating condition, there are no data to support the supposition that this approach will reduce the risk of NSF. Therefore, although an aggressive hemodialysis strategy postexposure is not unreasonable, it is probably best at this point to try to avoid GBC administration altogether in these high-risk patients.