American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology

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July 16, 2018

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

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 percent 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 (KDOQI) have recommended avoiding placement of central lines in CKD 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 (KDOQI) 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.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Academy of Pediatric Section on Nephrology Executive Committee (AAP SONp) and the American Society of Pediatric Nephrology Clinical Affairs Committee (ASPN CAC) utilized a four-stage process to develop its list. First, the two groups independently developed lists based on various common assessments, evaluations, and treatments in the practice of pediatric nephrology. During the second stage, the committee chairs consolidated the lists and then re-convened the individual committees to narrow the topics on the list. During the third stage, a final list of five practices was developed and consensus achieved by both committees that were found to be supported by evidence. The final stage occurred when the list was reviewed and approved by the AAP’s Executive Committee and the ASPN CAC.


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 23:351-357, 2012.

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 Volume 48, Supplement 1, Pages S176–S247.

McGill R, Ruthazer R, Meyer K, Miskulin D, Weiner D: Peripherally Inserted Central Catheters and Hemodialysis Outcomes. Clin J Amer Soc Nephrol 11:1434-1440, 2016.

Gonzalves CF, et al: Incidence of central venous stenosis and occlusion following upper extremity PICC and port placement. Cardiovasc Intervent Radiol 26:123-127, 2003.

Forauer AR, Theoharis C: Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 14:1163-1168, 2003.

Fistula first: