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Background Access to contrast-enhanced cardiovascular magnetic resonance (CMR) in patients with advanced chronic kidney disease (CKD), defined as estimated glomerular filtration rate (eGFR) <30 and/or hemodialysis dependence, varies across the UK, due to the historical risk of nephrogenic systemic fibrosis (NSF). Patients with heart failure (HF) and advanced CKD are thus often denied contrast-enhanced CMR, when it could alter their diagnosis and management. The 2021 ESC heart failure guidelines recommend that CMR is performed to detect treatable causes of heart failure. We undertook a retrospective review of our patient cohort, to identify whether CMR was appropriately utilized and if it altered management.Methods We performed a retrospective review of patients with heart failure and CKD between January- December 2025, who had been discussed in the cardio-renal MDT (figures 1–3).Results 141 patients were identified from our cardio-renal database. 71/141 (50.4%) had advanced CKD of which 26/71 (36.6%) were dialysis dependent. 21/71 (29.6%) underwent contrast-enhanced CMR and 20/21 (95.2%) produced diagnostic findings (figure 1) resulting in re-evaluation of management strategies in 11/21 (52.4%) (figure 2). An increased number of CMR were performed in younger patients (figure 3). Only 8/26 dialysis-dependent patients had contrast enhanced CMR (table 1).Conclusion In this single-centre cohort study of heart failure patients with severe renal impairment, contrast-enhanced CMR had high diagnostic yields and frequently altered management. Despite this, less than one-third of eligible renal patients underwent contrast-enhanced CMR. These findings support standardization in access to contrast CMR in this population and the need for updated national guidance. QuestionWhat is the strongest message from this audit of contrast-enhanced CMR in heart failure patients with eGFR<30 mL/min/1.73m2 and/or hemodialysis?OptionsA. Contrast-enhanced CMR is rarely abnormal in this groupB. Contrast-enhanced CMR has limited effect on management in severe renal impairmentC. Severe renal impairment should be viewed as an absolute barrier to contrast CMRD. Contrast-enhanced CMR appears underused despite high diagnostic yield and meaningful clinical impactE. All renal patients with heart failure should automatically undergo contrast CMRCorrect AnswerAbstract 34 Figure 3Age distribution in renal patients with and without contrast CMRAbstract 34 Table 1Summary tableAbstract 34 Figure 2Management Outcome following contrast-enhanced CMRAbstract 34 Figure 1Diagnostic categories identified on renal contrast CMRD. Contrast-enhanced CMR appears underused despite high diagnostic yield and meaningful clinical impact.