ORLANDO – Patients with chronic kidney disease (CKD) received percutaneous inserted central catheters (PICC) in the acute care setting more often than other patients, despite professional guidelines that discourage PICC use in a CKD population, researchers said here.
In an observational study of 375 inpatients at a single institution, 86 PICC lines were placed and 21% of those were in CKD patients (P<0.01), reported Rita McGill, MD, from Allegheny General Hospital in Pittsburgh, and colleagues at the National Kidney Foundation meeting.
In addition, more patients with higher-stage CKD received PICC compared with other patients, the authors stated.
However, guidelines from the American Society of Diagnostic and Interventional Nephrology (ASDIN) state that PICC lines should be avoided in CKD patients and those with end-stage renal disease (ESRD), "but this guideline appears to have relatively little traction outside of the nephrology community," they pointed out.
"PICCs, which seem to be a marker for a higher burden of illness, are [being used in] CKD patients even more commonly than other types of patients," McGill told MedPage Today. "Many of these patients with chronic kidney disease have diabetes – probably at least 30% -- which makes them at higher risk for ESRD, and also gives them fragile blood vessels, so these are exactly the type of patients who should not be getting PICC."
McGill's group spent a single morning at their hospital assessing every patient for PICC. They took note of age, gender, and service line. Monitoring level was used as a surrogate for clinical acuity and burden of illness. CKD was assessed on the day of the survey and compared with data from previous surveys. Finally, the ordering physician was contacted to determine the reason for PICC.
They found that CKD patients who received PICC did not differ from the general inpatient population in terms of age, gender, and service line. For monitoring level and acuity, the authors reported the following:
- Regular floor: 19.7% PICC, 55.3% no PICC
- Telemetry: 16.3% PICC, 33.6% no PICC
- Stepdown: 16.3% PICC, 9.7% no PICC
- Intensive care unit (ICU): 47.7% PICC, 1.4% no PICC
Convenience was reported by ordering physicians as the most common reason for PICC (34.8%) followed by the need for vancomycin intravenous therapy (17.4%), and poor access (14%). Other reasons included chemotherapy and parenteral nutrition.
The authors also found that 10% of patients who received PICC had had stages 5-6 CKD.
"As PICC can reduce future arteriovenous fistula prospects, future hemodialysis patients may be at risk for negative consequences of the burgeoning PICC rate," the group concluded.
One issue may be that nephrologists are not routinely consulted in CKD patients, pointed out Allan Jhagroo, MD, from the University of Wisconsin in Madison.
Other physicians "call us when it is acute kidney disease," said Jhagroo, who was not part of the study. But "it is a nephrologist who is likely to recognize that the access point for dialysis fistulas may be compromised by the use of PICC. You would hope there would be less use of PICCs in patients with more severe illness, but while these numbers in this study are small, there are actually more PICCs in these more severely ill patients."
Amanda Valliant, MD, also from the University of Wisconsin in Madison, said a similar study was done at her institution involving 600 patients. "We saw a PICC usage of around 19%. Down the road when these people need dialysis access, it can become a big mess. It is going to be hard to get clinicians to change."
She explained that at her institution, they have started a program to reduce PICC placement in CKD patients. "For anyone with a glomerular filtration rate of less than 30 mg/L, you cannot just order a PICC. You have to go through an algorithm where you consider other line placements."
McGill, Jhagroo, and Valliant reported on conflicts of interest.
Primary source: National Kidney Foundation
Source reference:
Mejia L, et al "The PICC epidemic and the kidney patient" NKF 2013.
Source reference:
Mejia L, et al "The PICC epidemic and the kidney patient" NKF 2013.
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