Peripherally inserted central venous catheters (PICCs) are associated with low rate of procedure-related complications, ease of placement, and favorable cost profile, and peripherally inserted central venous catheters (PICCs).

The risks

Despite the benefits of PICC, there are several complications related to PICC placement, including phlebitis, stenosis, and thrombosis of the involved veins.

Multiple comorbidities and the recurrent need for intravenous therapies, place the patients with acute kidney injury and chronic kidney diseases at risk to undergo PICC placement. In spite of short-term benefits, the long-term outcomes associated with these devices have been observed to be deleterious.

The problem with PICC

PICCs can damage vessels and render them unusable for dialysis and constitute an important aspect of care. It has been shown that PICCs are associated with high rates of upper extremity venous thrombosis and residual central venous stenosis. In a meta-analysis, it was reported that PICCs were strongly associated with deep venous thrombosis but not pulmonary embolism. It has been recommended that all patients with a history of PICC placement requiring dialysis access undergo upper extremity venography before the placement of permanent access.

PICCs scar the vessels that are required for effective arteriovenous fistula and arteriovenous graft functionality. PICCs are placed pre dialysis for a variety of indications, and many are placed without the knowledge of the nephrologist. Hence, it is important to adhere to the recommendations given by guidelines.

What do the guidelines say?

In view of the dangers of PICCs in patients with CKD, guidelines have limited the use of these devices in susceptible population.

American Society of Nephrology recommendations: PICCs should not be placed in patients with CKD stages 3-5 without consulting a nephrologist

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines: In patients with CKD stage 4 or 5, forearm and upper arm veins suitable for placement of vascular access should not be used for venipuncture or the placement of intravenous catheters, sub clavian catheters, or peripherally inserted central catheter lines

The Fistula First Breakthrough Initiative (FFBI): Recommends against PICC use in patients at risk for or with known mid stage 3 CKD, stage 4 or 5 CKD, or ESRD or if the patient is a renal transplant patient.

Use of PICC in clinical settings

In the clinical setting, PICCs are placed in patients on dialysis primarily for antibiotics and nutritional support. The requirement for antibiotics is not accounted for in the baseline patient features that were adjusted for, and the higher mortality among the patients needing a PICC following dialysis initiation for antibiotic administration almost certainly represents confounding by indication.

In the view of the above discussion, nephrologists must accept the responsibility for protecting patient’s venous real estate both before and after hemodialysis initiation. Alternate strategies and established guidelines should be used to support nephrology input and guidance.

References

1. Kalloo S, Wish JB. Nephrologists versus peripherally inserted central catheters: Are the PICCs winning? Clin J Am Soc Nephrol. 2016; 11:1333-1334.