Avoid PICC Placement in Patients with eGFR < 45 ml/min (CKD Stage IIIb)
Action Items:
Use of PICCs in patients with advanced kidney disease (per the National Kidney Foundation, those with an estimated GFR (eGFR) < 45 ml/min) is contraindicated as these patients are likely to progress to hemodialysis. PICC placement in such patients is the strongest risk factor for subsequent fistula failure and is contraindicated if renal replacement therapy is likely.
When PICC placement in patients with eGFR < 45 is requested, empower PICC inserters to ask for approval from nephrology and explore alternative devices prior to placing the PICC
Patients with eGFR < 45 are candidates for small bore central catheters (SBCCs) rather than PICC if long-term venous access is necessary. SBCCs do not lead to stenosis of arm veins
Develop strategies to place SBCCs in consultation with interventional radiology or other operators that oversee PICC placement
Consider changes to the electronic health system that flag patients with reduced eGFR to indicate a contra-indication to PICC use
Given the deleterious effects of PICC lines on the veins that are used to create an AVF, it is likely that PICC placement affects the subsequent ability to create successful AVFs in patients with CKD.
The decision to place PICCs in patients with Chronic Kidney Disease requires physician oversight and involvement. An algorithm is presented for access assessment with particular attention to patients with CKD Stages 4 and 5. Development and implementation of such an algorithm is recommended.
PICC placement and invasion of the non-dominant arm are both frequent in patients with abnormal kidney function, in spite of guidelines discouraging their use
Identifying CKD patients at risk and adoption of a vein preservation care path will enhance our ability to achieve a higher percentage of native AVFs.
This commentary highlights the important role nephrologists should play in making decisions regarding PICC use in patients with CKD. The comment emphasizes protocols, use of electronic tools and patient engagement to avoid PICC use when their kidney function declines.
This guideline provides brief recommendations that emphasize the role and ways in which vascular access teams and nephrologists can work together to reduce PICC placement in patients with CKD.
In hospitalized patients who received PICCs, placement in those with CKD was common and not concordant with clinical guidelines. 1 in 4 patients who get a PICC have CKD. Note: Publication is based on data provided by the Michigan Hospital Medicine Safety (HMS) Consortium