Consultations for Approval of Peripherally Inserted Central Catheters Examined

San Diego—Currently, guidelines advise against placement of peripherally inserted central catheters (PICCs) in stage 3 to 5 chronic kidney disease (CKD) without nephrology consultation in an attempt to preserve veins for creation of future arteriovenous fistula access for hemodialysis. Nephrology input is also often required for PICC placement for patients with acute kidney injury (AKI). There are no official guidelines defining patients for whom PICC would be appropriate; the burden on renal fellows consultation can be significant.

Irene Chernova, MD, PhD, and colleagues at Yale New Haven Hospital, New Haven, Connecticut, sought to determine the medical and demographic factors influencing practice patterns for approval of PICC placement. To potentially alleviate the burden of consults, the researchers aimed to develop objective guidelines to identify patients who unanimously are or are not appropriate for PICCs. Results were reported during a poster session at Kidney Week 2018 in a poster titled Factors Influencing Approval Rates of Peripherally Inserted Central Catheters (PICCs) in Patients with Kidney Disease.

The researchers identified more than 100 patients who had a nephrology consult regarding PICC placement over 10 months at three separate hospitals. Accounting for age, sex, serum creatinine at time of consult and baseline, CKD stage, acute kidney injury stage, diabetes, hypertension, and end-stage comorbidities (cirrhosis, heart failure, malignancy, dementia, and hospice), the PICC placement decision for the initial 51 patients was adjudicated by the first year class of clinical fellows and one attending nephrologist in a blinded manner.

Of those 51 patients, 47% (n=24) had universal agreement between both the original consulting fellow and the adjudicating fellows and the attending. The major factors predictive of universal agreement for PICC placement were a diagnosis of end-stage renal disease, hospice status, and advanced age. In younger patients, there was high correlation between stage 4 to 5 CKD and nephrology recommendation against PICC placement.

In conclusion, the researchers said, “These preliminary data suggest that certain patient characteristics (such as an end-stage diagnosis) correlate highly with PICC approval including patients with CKD stage 3-5 who may otherwise be excluded from PICC placement based on strict guidelines. Further analysis is currently underway to facilitate the development of an objective criteria list which can be used to standardize decision-making regarding PICC placement amongst nephrology practitioners and provide guidance to practitioners as to when a nephrology consult is indicated.”

Source: Chernova I, Cavanaugh CJ, Kodali R, Okoba N, Virmani S, Belcher JM. Factors influencing approval rates of peripherally inserted central catheters (PICCs) in patients with kidney disease. Abstract of a poster (TH-PO1141) presented at the American Society of Nephrology Kidney Week 2018, October 25, 2018, San Diego, California.