Can a patient who requires hemodialysis use a peripherally inserted central catheter (PICC) for dialysis?

PICC Lines Cannot Be Used for Hemodialysis

No, a patient requiring hemodialysis should never dialyze through a PICC line—this is explicitly contraindicated by multiple guidelines, and the appropriate access is a tunneled cuffed double-lumen hemodialysis catheter placed via the internal jugular vein. 1

Why PICC Lines Are Absolutely Contraindicated for Dialysis

Technical Inadequacy

• PICC lines lack the flow rates required for hemodialysis, which demands high-volume bidirectional blood flow that only large-bore (typically 11.5-14 French) double-lumen catheters can provide 1
• Standard PICC lines range from 2F to 7F—far too small for the 300-500 mL/min blood flow rates needed for effective dialysis 1

Vein Preservation Is Critical

• Placing a PICC in any arm vein of a dialysis patient destroys future arteriovenous fistula (AVF) options, which are the gold standard for long-term dialysis access 1
• The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) explicitly rates PICC placement in arm veins as inappropriate for all patients with stage 3b CKD or greater (eGFR <45 mL/min), regardless of indication 1
• A case-control study demonstrated that patients with prior PICC use had 3.2-fold increased odds of AVF failure (95% CI 1.9-5.5, P<0.001), with 44.2% of patients without functioning AVFs having prior PICC use versus only 19.7% of those with functioning AVFs 2

Infection Risk

• PICC lines in hemodialysis patients carry a 2.46-fold increased risk of catheter-related infections (95% CI 1.71-3.53, p<0.001) compared to appropriate dialysis catheters 3
• Catheter-related bloodstream infections are the leading cause of bacteremia in dialysis patients, and using inappropriate access amplifies this risk 1

The Correct Approach: Tunneled Cuffed Hemodialysis Catheters

For Temporary Access (<3 Weeks)

• Use a noncuffed double-lumen percutaneously inserted catheter placed via internal jugular vein (preferred) or femoral vein 1
• Noncuffed femoral catheters should not remain longer than 5 days and only in bed-bound patients 1

For Access ≥3 Weeks

• Tunneled cuffed double-lumen catheters are the method of choice, placed via internal jugular vein with tips positioned in the superior vena cava or right atrium 1, 4
• These catheters are typically 11.5-14 French with staggered distal tips to prevent recirculation 1
• The cuff induces fibrosis within 3-4 weeks, providing catheter fixation and reducing infection risk compared to nontunneled catheters 1

Vein Selection Priority

1. Internal jugular vein (first choice): Lower infection and thrombosis rates than femoral, avoids central stenosis risk of subclavian 1
2. Femoral vein (second choice): Only for short-term use (<5 days) in bed-bound patients 1
3. Never subclavian vein: The NKF-KDOQI guidelines explicitly recommend avoiding subclavian access in CKD patients due to high central vein stenosis risk (42% incidence) that compromises future access 1, 5

Critical Pitfalls to Avoid

The "No Other Options" Fallacy

• Never rationalize PICC placement based on convenience or perceived lack of alternatives 4
• If a patient needs dialysis, they need proper dialysis access—period 1
• The short-term convenience of a PICC is catastrophically outweighed by permanent loss of future AVF sites 4, 2

Protecting All Arm Veins in CKD Patients

• Even for non-dialysis indications, PICCs are inappropriate in patients with eGFR <45 mL/min 1
• For these patients requiring short-term IV access (≤5 days), use peripheral IVs in the dorsum of the hand only—never forearm veins 1
• For longer durations, use tunneled small-bore central catheters (4-French single-lumen or 5-French double-lumen) via internal jugular vein 1, 4

Hospital System Issues

• Hospitals should implement restrictive processes for PICC placement in patients with GFR <60 mL/min, requiring nephrology consultation before any arm vein access 6
• Despite clear guidelines, PICC use remains inappropriately high in CKD patients, reflecting an urgent need for provider education 7, 6

Duration-Based Algorithm for Dialysis Access

• <5 days: Noncuffed double-lumen catheter via internal jugular vein 1
• 5 days to 3 weeks: Noncuffed double-lumen catheter via internal jugular vein (femoral only if bed-bound) 1
• ≥3 weeks: Tunneled cuffed double-lumen catheter via internal jugular vein 1, 4
• Long-term/permanent: Native AVF is the gold standard; tunneled cuffed catheter only for patients who have exhausted all other options 1