Woolen SA, et al. - This study was undertaken to investigate the pooled risk of nephrogenic systemic fibrosis (NSF) in individuals with stage 4 or 5 chronic kidney disease (CKD) receiving a group II gadolinium-based contrast agent (GBCA). This systematic review and meta-analysis included Sixteen unique studies recruiting a total of 4,931 individuals. Out of 4,931, the pooled incidence of NSF was 0 (0%; upper bound of 95% CI, 0.07%). The results showed that the upper bound varied owing to different sample sizes for gadobenate dimeglumine, gadoterate meglumine, gadobutrol, and gadoteridol. It was noted that, in stage 4 or 5 CKD, the risk of NSF from group II GBCA administration is likely less than 0.07%. In this population, the potential diagnostic harms of withholding group II GBCA for indicated examinations may exceed the risk of NSF.