McGill Rita L, Ruthazer Robin, Meyer Klemens B, Miskulin Dana C, Weiner Daniel E
Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and.
Biostatistics, Epidemiology, and Research Design Center, Department of Medicine, Tufts Clinical and Translational Science Institute, Boston, Massachusetts.
Clin J Am Soc Nephrol. 2016 Aug 8;11(8):1434-1440. doi: 10.2215/CJN.01980216. Epub 2016 Jun 23.
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 time-dependent variables.
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).
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.
外周静脉穿刺中心静脉置管（PICC）的使用迅速增加，但对于最终需要血液透析的患者而言，其影响尚不明确。
设计、研究地点、参与者及测量指标：我们基于全国人口的分析纳入了美国肾脏数据系统中33918名成年医疗保险受益人，这些患者在2010年和2011年开始接受血液透析，其唯一的血管通路为中心静脉导管。我们利用医疗保险关联索赔数据来确定PICC暴露情况，并使用带有时间依存变量的Cox模型评估PICC置管与转变为可用的动静脉内瘘或移植物以及患者生存之间的关联。
在33918名以导管作为唯一通路开始血液透析的患者中，12.6%接受过至少一次PICC置管。中位随访时间为404天（四分位间距为103 - 680天）。在置入的6487根PICC中，3435根（53%）在开始血液透析前2年内置入，3052根（47%）在之后置入。30%接受PICC置管的患者置入了多根PICC。PICC接受者更可能为女性且有合并症诊断，接受透析前肾病护理的可能性较小。在对临床和人口统计学因素进行调整后，血液透析开始前或后置入的PICC均与转变为任何可用内瘘或移植物的可能性降低独立相关（血液透析前PICC的风险比为0.85；95%置信区间为0.79至0.91；血液透析后PICC的风险比为0.81；95%置信区间为0.73至0.89）。
PICC置管很常见，且与不良的血管通路结局相关。认识到PICC潜在的长期不良后果对于照顾慢性肾脏病患者的临床医生至关重要。
