Peripherally Inserted Central Catheters and Hemodialysis Outcomes

Abstract

Background and objectives Use of peripherally inserted central catheters has expanded rapidly, but the consequences for patients who eventually require hemodialysis are undefined.Design, setting, participants, & measurements Our national, population-based analysis included 33,918 adult Medicare beneficiaries from the US Renal Data System who initiated hemodialysis with central venous catheters as their sole vascular access in 2010 and 2011. We used linked Medicare claims to identify peripherally inserted central catheter exposures and evaluate the associations of peripherally inserted central catheter placement with transition to working arteriovenous fistulas or grafts and patient survival using a Cox model with timedependent variables.Results Among 33,918 individuals initiating hemodialysis with a catheter as sole access, 12.6% had received at least one peripherally inserted central catheter. Median follow-up was 404 days (interquartile range, 103-680 days). Among 6487 peripherally inserted central catheters placed, 3435 (53%) were placed within the 2 years before hemodialysis initiation, and 3052 (47%) were placed afterward. Multiple peripherally inserted central catheters were placed in 30% of patients exposed to peripherally inserted central catheters. Recipients of peripherally inserted central catheters were more likely to be women and have comorbid diagnoses and less likely to have received predialysis nephrology care. After adjustment for clinical and demographic factors, peripherally inserted central catheters placed before or after hemodialysis initiation were independently associated with lower likelihoods of transition to any working fistula or graft (hazard ratio for prehemodialysis peripherally inserted central catheter, 0.85; 95% confidence interval, 0.79 to 0.91; hazard ratio for posthemodialysis peripherally inserted central catheter, 0.81; 95% confidence interval, 0.73 to 0.89).Conclusions Peripherally inserted central catheter placement was common and associated with adverse vascular access outcomes. Recognition of potential long-term adverse consequences of peripherally inserted central catheters is essential for clinicians caring for patients with CKD.

Nephrologists Versus Peripherally Inserted Central Catheters: Are the PICCs Winning?

“…There may be significant confounding by indication, because PICCs are placed in patients with the poorest vessels who also have the poorest outcomes for successful permanent hemodialysis vascular access. McGill et al (11) did not show an increased adjusted hazard ratio for death among all patients who had PICC(s) placed predialysis, but the reported mortality rates among patients who achieved a working arteriovenous fistula or arteriovenous graft were alarmingly high (56.4% with PICC exposure and 44.8% without PICC exposure). This may be caused by the mean age of the population studied (71.2 years old with PICC exposure and 72.8 years old without), because all were Medicare eligible.…”

“…In the article by McGill et al (11) in this issue of the Clinical Journal of the American Society of Nephrology, the authors present a well designed study to systematically explore the hypothesis that PICCs adversely affect outcomes in patients on dialysis with respect to vascular access and patient survival. Because it is impossible to perform a randomized trial comparing patients who have received PICCs with those who have not, McGill et al (11) have chosen to perform a retrospective study of all Medicare beneficiaries who began dialysis with a hemodialysis catheter between April of 2010 and December of 2011.…”

“…Because it is impossible to perform a randomized trial comparing patients who have received PICCs with those who have not, McGill et al (11) have chosen to perform a retrospective study of all Medicare beneficiaries who began dialysis with a hemodialysis catheter between April of 2010 and December of 2011. McGill et al (11) attempt to correct for confounding by using adjusted hazard ratios to show differences in outcomes between patients who had PICC(s) placed and those who had not.…”

“…Because it is impossible to perform a randomized trial comparing patients who have received PICCs with those who have not, McGill et al (11) have chosen to perform a retrospective study of all Medicare beneficiaries who began dialysis with a hemodialysis catheter between April of 2010 and December of 2011. McGill et al (11) attempt to correct for confounding by using adjusted hazard ratios to show differences in outcomes between patients who had PICC(s) placed and those who had not. As McGill et al (11) point out in their limitations, this method is always subject to confounding by indication, namely that there were variables not examined that may have precipitated PICCs placement and also led to adverse outcomes.…”

“…McGill et al (11) attempt to correct for confounding by using adjusted hazard ratios to show differences in outcomes between patients who had PICC(s) placed and those who had not. As McGill et al (11) point out in their limitations, this method is always subject to confounding by indication, namely that there were variables not examined that may have precipitated PICCs placement and also led to adverse outcomes. McGill et al (11) attempt to include all comorbidities from predialysis Medicare claims 2 years before dialysis initiation rather than those just on the 2728 form, the former being a significantly more reliable method of capturing comorbidities.…”