Choosing Wisely:

Don’t place central lines or peripherally inserted PICCs in pediatric patients with advanced (Stage 3-5) chronic kidney disease/end-stage renal disease without consultation with pediatric nephrology due to goals to avoid adverse events, preserve long-term vascular access, and avoid unnecessary and costly procedures.

Rationale and Comments: Preservation of vascular access is critical for long-term dialysis patients. Placement of central and PICC lines has been associated with an increased incidence of complications including vascular injury, thrombosis, and central venous stenosis that can limit future use for dialysis access. Placement of central and PICC lines also potentially increases cost due to the treatment of complications from the lines, requirement for radiological tests to identify patent vessels for dialysis, and the necessity for repeat surgical procedures to create vascular access for dialysis. Studies in children are limited, but research about PICC lines demonstrates a 23-57% incidence of thrombosis in adults and increased complications in children who are exposed to multiple PICC line placements. Studies from adult patients have demonstrated the high risk of vascular injury after central line and PICC line placement. National guidelines from the Kidney Disease Outcomes Quality Initiative have recommended avoiding placement of central lines in chronic kidney disease patients, if possible, due to the high risk of complications. The recommendation to avoid central line placement is the basis of vascular access preservation in the “Fistula First Innovation” program for adult dialysis patients. National guidelines from the Kidney Disease Outcomes Quality Initiative state the following: “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 for the placement of intravenous (IV) catheters, subclavian catheters, or peripherally inserted central catheter lines (PICCs). Because of the substantial risk for loss of useable upper-extremity veins and central venous stenosis with PICCs, the Work Group recommends strongly that PICCs not be used in patients with CKD”. Special consideration may be necessary in emergency circumstances in which no other safe access is achievable.
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology
  • Sources:
  • Expert consensus
  • Disciplines:
  • Pediatric
  • Nephrologic
  • References: • Yang RY, Moineddin R, Filipescu D, Parra D, Amaral J, John P, Temple M, Connolly B. Increased complexity and complications associated with multiple peripherally inserted central catheter insertions in children: the tip of the iceberg. J Vasc Interv Radiol. 2012;23:351-357.
    • Costello JM, Clapper TC, Wypij D. Minimizing complications associated with percutaneous central venous catheter placement in children: recent advances. Pediatr Crit Care Med. 2013;14:273-283.
    • KDOQI. Vascular access guidelines 2006. Am J Kidney Dis. 2006;48(suppl 1):S176-S247.
    • McGill R, Ruthazer R, Meyer K, Miskulin D, Weiner D. Peripherally inserted central catheters and hemodialysis outcomes. Clin J Amer Soc Nephrol. 2016;11:1434-1440.
    • Gonzalves CF, et al. Incidence of central venous stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol. 2003;26:123-127.
    • Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol. 2003;14:1163-1168.

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