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

Resources & Tools: 

• ​Clinician Education Pamphlet – Vein Preservation 
• Save the Vein: A Handout and Guide for Nurses
• Save Your Vein Campaign
• Algorithm for Managing CVAD in Patients with Chronic Kidney Disease
• Renal Network Toolkit
• Example Inpatient PICC Order set Criteria​

References: ​

• National Recommendations:
  • National Kidney Foundation
  • ESRD National Coordinating Center
  • Fistula First - Vein Preservation and Hemodialysis Fistula Protection
  • Choosing Wisely - American Society of Nephrology
  • American Society of Diagnostic and Interventional Nephrology
  • The Renal Network- Guidelines for PICC Avoidance in Chronic Kidney Disease, End-Stage Kidney Disease and Renal Transplant Patients
• Shingarev R, et al. Peripherally Inserted Central Catheters and Other Intravascular Devices: How Safe Are PICCs for Hemodialysis patients? American Journal of Kidney Disease 2012
  • 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. 
• McLennan G, Vein Preservation: An Algorithmic Approach to Vascular Access Placement in Patients with Compromised Renal Function. Journal of the Association for Vascular Access 2007
  • 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. 
• McGill RL, et al. Inpatient Venous Access Practices: PICC Culture and the kidney patient. The Journal of Vascular Accesss 2015
  • 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
• Hoggard J. Guidelines for Venous Access in Patients with Chronic Kidney Disease. Seminars in Dialysis 2008
  • 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.
• Drew DA, Weiner DE. PICCs in CKD: PICC’ing the best access for CKD patients. American Journal of Kidney Disease 2016
  • 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.
• McLennan LA. Guidelines and recommendations for PICC avoidance in patients with CKD. Journal of the Association for Vascular Access 2007
  • 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.
• Paje D. Use of Peripherally Inserted Central Catheters in Patients with Advanced Chronic Kidney Disease: A Prospective Cohort Study. Annals of Internal Medicine 2019
  • 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
• Kalloo S. Nephrologists Versus Peripherally Inserted Central Catheters: Are the PICCs Winning? Clinical Journal of American Society of Nephrology 2016
  • Nephrologists must accept the responsibility for protecting patients’ venous real estate both before and after hemodialysis initiation 

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