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Medical alert bracelet: an effective way to preserve veins for future dialysis vascular access in patients with chronic kidney disease.

To the Editor: 
 
Chronic kidney disease (CKD) is an emerging public health problem and is rapidly transforming in to an epidemic. A recent study reported that nearly 26 million Americans suffer from CKD.[1] Additionally 20 million Americans are at risk of developing CKD. CKD eventually can progress to end-stage renal disease (ESRD) requiring expensive therapies such as regular dialysis therapy and renal transplantation. Currently 485,000 Americans have been diagnosed with ESRD and are undergoing dialysis therapy. The number of Americans needing dialysis therapy is expected to grow to 700,000 by 2020.[2] The predicted increase in the CKD population coupled with ever-increasing ratio between the CKD patients and nephrologists places greater demands on the primary care physicians. To provide optimal care to patients with CKD, the primary care physician will remain an important team player along with the nephrologist. 
 
Patients with CKD need timely planning to be ready for dialysis when they reach ESRD. A normal vein cannot supply an adequate volume of blood required for the dialysis therapy. A surgeon connects an artery and vein in the upper extremity to create a fistula, which then can accommodate a large needle required for dialysis therapy. The dialysis vascular access (or fistula) becomes a lifeline when patients with CKD eventually start dialysis. Typically, these patients have several other comorbidities requiring frequent hospitalizations and blood draws, which can damage the superficial and deep veins in the arms that are used for creating a fistula. Patients are often discharged from a hospital with a peripherally placed intravenous central catheter, which can really ruin the veins for future use. It is essential that both patients with CKD and their primary care physicians are aware of this potential need to preserve the veins whenever possible for future fistula creation. Ideally, patient education should be started long before the patient is seen by a nephrologist. Patients with stage 3 or higher CKD should be made aware of this possibility and should be prepared accordingly, both mentally and physically. Recently, the American Society of Diagnostic and Interventional Nephrology released guidelines for venous access placement in patients with CKD with emphasis on vein preservation and timely planning and education.[3] 
 
As part of the education a simple intervention that the primary care physicians can implement while seeing patients with CKD stage 3 or higher is providing a “Medic Alert” bracelet. The bracelet can have the diagnosis and simple instruction engraved on it, such as “CKD- NO NEEDLE STICKS OR BP” and can be worn on 1 arm by the patient at all times. The advantage of using this bracelet is multifold. First and foremost the patient has enough time to think and educate himself about the disease process and be mentally prepared for the eventual change in life. It provides an avenue for primary care physicians to discuss the relevance of close monitoring and prognosis of CKD. And finally, the veins on at least 1 extremity would be preserved for future fistula placement, if and when needed. 
 
The fistula, which is the lifeline for patients with ESRD, is also an “Achilles heel.” If placed in a timely fashion with good well-preserved veins, the fistula can last forever, but if placed late in the disease process can be fraught with multiple interventions to keep it flowing. And sometimes, despite several interventions, the fistula may not remain patent to provide adequate dialysis therapy. The expense of maintaining these fistulae is a tremendous economic burden on the healthcare system. Currently, the annual cost of treating patients with ESRD patients is more than $32 million and a significant portion of this is spent on dialysis access-related issues. A healthy fistula created in a timely fashion can avoid some of the associated morbidities and expenses, benefiting both the patient as well as society. 
 
Vascular access guidelines from National Kidney Foundation - Kidney/Dialysis Outcome and Quality Initiative have suggested use of a medic alert bracelet for vein preservation, but unless these guidelines are widely publicized among the primary care physicians, who are more likely to see patients with early CKD, the issue will remain unresolved.[4] The primary care physician's role is equally important and their inclusion in the team to fight against this epidemic of CKD is vital.