Although guidelines such as Choosing Wisely recommend against using peripherally inserted central catheters (PICCs) in patients with moderate to advanced chronic kidney disease (CKD), many CKD patients are still receiving PICCs while in hospital, a new study finds. 

Of 20,545 patients who had PICCs placed within the Michigan Hospital Medicine Safety Consortium, 4743 (23.1%) had an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73 m2 and 699 (3.4%) were receiving hemodialysis (HD), David Paje, MD, MPH, of the University of Michigan in Ann Arbor, and colleagues reported in the Annals of Internal Medicine. In the intensive care unit (ICU), 30.9% of patients with PICCs had an eGFR less than 45 mL/min/1.73 m2. In general medicine units, that proportion was 19.3%.

The creation of an arteriovenous fistula is the preferred choice for HD and more likely to succeed when the native venous segment in CKD patients has not been injured by an indwelling vascular catheter, such as a PICC, the investigators explained.

Advanced CKD patients with PICC placement in the ICU vs medical wards were more likely to experience major complications (5.6% vs. 3.5%) such as venous thromboembolism. Overall complication rates were comparable, however. PICC-related complications occurred in 22.4% vs 23.9% of ICU patients with an eGFR of less than vs more than 45 mL/min/1.73 m2, respectively. In the medical ward, PICC complications occurred in 15.3% vs 15.2%, respectively.

For 25.8% of CKD patients, PICC dwell time was less than 5 days, a duration favoring alternative venous access devices. In addition, multilumen PICCs were placed more often than single-lumen PICCs (32.6% vs 21.5% of patients in ICUs; 22.0% vs 16.1% in wards) for unclear reasons and were associated with more complications (22.7% vs 12.5% of patients in ICUs; 19.3% vs 10.3% in wards).

“In conclusion, despite guidelines that recommend against the use of PICCs in patients with CKD, we found that such practice is common in the hospital setting,” the authors wrote. “Now more than ever, interventions that operationalize and implement guideline recommendations and offer alternative strategies for venous access in patients who need vein preservation for hemodialysis are necessary.”

Dr Paje and colleagues pointed out that the American Society of Nephrology recommends consultation with a nephrologist prior to PICC placement in patients with CKD stage 3 to 5, noting that “this strategy may be leveraged as a means to better guide PICC use.”

Nephrologist approval of PICC placement could not be determined in this study, which is a limitation.

“Attention to vein protection guidelines is an important aspect of advanced planning for dialysis, and its neglect likely contributes to the high rate of catheterization in incident dialysis patients,” Marcia R. Silver, MD, of Case Western Reserve University in Cleveland, commented in an accompanying editorial.

Dr Silver also noted: “As Paje and colleagues’ data remind us, so much of vein protection depends on decision making by nonnephrologists caring for complex patients with CKD,” Dr Silver stated. “Hence, education and engagement of the general medical community are critically important to further progress.”

The study was funded by Blue Cross Blue Shield of Michigan and Blue Care Network.

References

Paje D, Rogers MAM, Conlon A, Flanders SA, Bernstein SJ, and Chopra V. Use of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease: A Prospective Cohort Study. Ann Intern Med. doi:10.7326/M18-2937

Silver MR. Saving Veins, Saving Lives, for Patients With Chronic Kidney Disease. Ann Intern Med. doi:10.7326/M19-1086