Background: Peripherally inserted central catheters (PICCs) are associated with central vein stenosis and failure to establish a functioning arteriovenous fistula. Thus, guidelines recommend avoiding PICC placement when patients with chronic kidney disease (CKD) are likely to require hemodialysis. We sought to describe the current practice of PICC placement in hospitalized patients with an estimated glomerular filtration rate (eGFR) less than 45 ml/min.
Methods: Trained abstractors collected clinical data on a representative sample of PICC placements at 52 hospitals participating in the Michigan Hospital Medicine Safety (HMS) consortium between November 2013 and September 2016. Patients were followed until the minimum time of PICC removal, death or 70 days. For this analysis, PICC placements in patients with eGFR <45 ml/min were described in terms of patient, provider and device characteristics, and incidence of PICC-related complications. Comparisons with the rest of the cohort utilized chi-square test for categorical variables and Wilcoxon two-sample test for continuous variables.
Results: Of 23,388 PICC placements, 22,757 (97.3%) had available data to determine eGFR, of which 5,221 (22.9%) were patients with eGFR <45, including 731 (14.0%) who were on hemodialysis treatment. The proportion of PICC placements in patients with eGFR <45 varied by institution, with a median of 21.5% (IQR 16.9%-26.7%). The most common indications for PICC placement in patients with eGFR<45 were antibiotic administration (28.9%), difficult access (26.8%) and medications requiring central access (16.7%). When compared to the remaining 17,536 PICC placements in patients with eGFR ≥45, PICC placements in patients with eGFR <45 had higher median Charlson-Deyo score (5 [IQR 3-6] vs. 3 [IQR 1-4]), were more likely placed in the ICU (43.1% vs. 27.2%), were more likely multi-lumen (73.0% vs. 59.5%), had shorter median dwell time (9 days [IQR 5-18] vs. 11 days [IQR 5-23]), and were more likely to be removed after 5 days or fewer (29.7% vs. 25.1%) and prior to discharge (67.3% vs. 54.9%), with p<0.0001 for all comparisons. PICC-related complications occurred in 973 (18.6%) PICC placements in patients with eGFR <45 and in 3,153 (18.0%) of the rest of the cohort, p=0.28 (Table 1).
Conclusions: PICC placement is common among hospitalized CKD patients that require vein preservation for future hemodialysis access. These patients are likely to have more comorbidities and short-term need for vascular access. PICC-related complications are common but similar to those without CKD. Quality interventions to promote alternative access appear necessary.