Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

Climate Change, Kidney Health, and Environmentally Sustainable Kidney Care: A Multinational Survey of Health Care Professionals

Key Points

Background

Given the threat of climate change to kidney health and the significant environmental effect of kidney care, calls are increasing for health care professionals and organizations to champion climate advocacy and environmentally sustainable kidney care. Yet, little is known about their engagement, and existing literature is primarily emerging from high-income countries.

Methods

We conducted a cross-sectional survey to understand the knowledge, attitude, and practice of health care professionals on the interconnectedness of climate change and kidney health; to identify personal and organizational initiatives in sustainable kidney care and strategies to increase their engagement; and to compare responses by their country's income level as classified by the World Bank.

Results

Participants (n=972) represented 108 countries, with 64% from lower- or middle-income countries. Ninety-eight percent believed that climate change is happening, yet <50% possessed knowledge about the effect of climate change on kidney health or the environmental effect of kidney care. Only 14% were involved in climate change and kidney health initiatives (membership, knowledge/awareness, research, and advocacy), 22% in sustainable kidney care initiatives (education/advocacy, preventative nephrology, sustainable dialysis, promoting transplant/home therapies, and research), and 26% reported organizational initiatives in sustainable kidney care (sustainable general or dialysis practices, preventative/lean nephrology, and focused committees). Participants from lower-income countries generally reported higher knowledge and variable level of concern. Engagement in sustainable kidney care did not vary by income level. Guidance/toolkit (79%), continuing education (75%), and opportunities (74%) were the top choices to increase engagement. National initiatives (47%), preventative measures (35%), and research endeavors (31%) were the top avenues for organizational engagement. These varied by income level, suggesting that the vision and priorities vary by baseline resource setting.

Conclusions

We have identified knowledge and practice gaps among health care professionals on the bidirectional relationship between kidney disease and climate change in a multinational context and several avenues to increase their engagement.

Hemodialysis water reuse within a circular economy approach. What can we add to current knowledge? A point of view

The ongoing climate change and the ecological challenges call for sustainable medicine and, in our field, sustainable kidney care. Dialysis is life-saving and resource-consuming, and high water consumption is one of the main concerns. Circular water economy, meaning reuse and recycling of water, and recovering resources can help reducing emissions and enhancing resilience to climate change. Several actions are possible including reusing reverse osmosis reject water, employable for gardening, aquaponics or even simply for toilet flushing, or in sterilization settings, reusing spent dialysate, at least for toilet flushing, but with wider use if microbiologically purified, recovering thermal energy from spent dialysate, that can probably be done with simple devices, or using phosphate-rich spent dialysate for producing fertilizers, namely struvite. All these options may be economically sound, and all help reducing the final dialysis carbon footprint. There is room for open-minded innovative approaches to improve water-related sustainability in hemodialysis, ultimately reducing ecological impact and increasing availability.

Ten tips from the Swiss Working Group on Sustainable Nephrology on how to go green in your dialysis unit

The health-care system and particularly renal replacement therapy has a significant carbon footprint adding to global warming and extreme weather conditions. Improving sustainability has become the focus of national and international working groups. Many reviews underline the need for improvement of sustainability in nephrology, in particular dialysis, and provide recommendations on how to reduce waste, energy, and water consumption. However, how to implement these recommendations, and where to start, is not always clear. This paper summarizes discussions within the 'working group on sustainable nephrology' of the Swiss Society of Nephrology. We do not provide a detailed review of the topic but instead present a practical 10-point action plan to help health-care workers in nephrology make a start and improve the carbon footprint of their dialysis centres. We emphasize the importance of ongoing research, cooperation, and dialogue, and welcome additional ideas from the wider renal community.

Green Dialysis From the Indian Perspective: A Systematic Review

Global warming and climate change represent the most significant threats to humanity in the 21st century, both of which are manmade catastrophes. Addressing climate change requires corrective action across all aspects of modern human life and work, including the medical field. Among healthcare sectors, dialysis units stand out as major contributors to plastic waste and excessive water consumption. It is imperative for hemodialysis units to lead by example in the judicious use of natural resources. This systemic review is aimed to establish a bare minimum of recommendations for environmental sustainability across Indian dialysis units, and to guide future initiatives to reduce the environmental impact of dialysis process. A literature search was conducted on PubMed, and Google to retrieve articles or studies related to green dialysis. The predefined keyword search yielded a total of 291 studies. A total of 54 studies and articles which were relevant to study question, and fulfilled inclusion criteria, were retrieved and analyzed to form opinions on the implementation of green dialysis initiatives from an Indian perspective. Green dialysis initiatives are much-needed reforms to be adopted by the Indian dialysis community. Through careful planning and minimal efforts, substantial amounts of water used in hemodialysis can be conserved and repurposed for other hospital activities. Similarly, the vast majority of discarded plastic waste can be recycled or reused. Despite controversy, reconsidering the risk-benefit aspects of dialyzer reuse is essential, particularly in the context of resource-limited developing nations like India.

Chronic kidney disease, dialysis and climate change

Chronic Kidney Disease is a serious public health problem and in clear relation to Climate Change and ecosystem maintenance. Renal health is particularly vulnerable to the impacts of climate change, and dialysis therapy (hemodialysis and PD) has a significant environmental footprint, conditioned by energy consumption and greenhouse gas production. In the last 50 years, people have changed ecosystems faster and more extensively than in any other period in human history. It is a consequence of ever-increasing demand for food, fresh water, fuel, industry, etc. and the result has been a substantial and largely irreversible loss of the diversity of life on Earth. Since 1979, human activities have caused the extinction of 60% of mammals, birds, fish and reptiles. There is an urgent need to adopt "Green Nephrology" measures by developing sustainable environmental solutions for the prevention and treatment of kidney diseases.

Relationship between number of daily exchanges at CAPD start with clinical outcomes

BACKGROUND

Peritoneal dialysis (PD) continues to be demanding for patients affected by kidney failure. In kidney failure patients with residual kidney function, the employment of incremental PD, a less onerous dialytic prescription, could translate into a decrease burden on both health systems and patients.

METHODS

Between 1st January 2009 and 31st December 2021, 182 patients who started continuous ambulatory peritoneal dialysis (CAPD) at our institution were included in the study. The CAPD population was divided into three groups according to the initial number of daily CAPD exchanges prescribed: one or two (50 patients, CAPD-1/2 group), three (97 patients, CAPD-3 group) and four (35 patients, CAPD-4 group), respectively.

RESULTS

Multivariate analysis showed a difference in term of peritonitis free survival in CAPD-1/2 in comparison to CAPD-3 (hazard ratio (HR): 2.20, p = 0.014) and CAPD-4 (HR: 2.98, p < 0.01). A tendency towards a lower hospitalisation rate (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.11 and 0.13, respectively) and decreased mortality (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.13 and 0.22, respectively) in patients who started PD with less than three daily exchanges was detected. No discrepancy of the difference of the mean values between baseline and 24 months residual kidney function was observed among the three groups (p = 0.33).

CONCLUSIONS

One- or two-exchange CAPD start was associated with a lower risk of peritonitis in comparison to three- or four-exchange start. Furthermore, an initial PD prescription with less than three exchanges may be associated with an advantage in term of hospitalisation rate and patient survival.

Ibuprofen-Immobilized Thin Films: A Novel Approach to Improve the Clearance of Protein-Bound Uremic Toxins

Chronic kidney disease (CKD), a pressing global health issue, affects millions and leads to end-stage renal disease (ESRD). Hemodialysis (HD) is a crucial treatment for ESRD, yet its limited efficiency in removing protein-bound uremic toxins (PBUTs) results in high morbidity and mortality rates. A high affinity of pharmaceutical drugs for human serum albumin (HSA) can be leveraged to compete effectively with PBUTs for the same HSA binding sites, thereby enabling them to be capable of displacing these toxins. One such drug is ibuprofen (IBF), known for its very high affinity for HSA and sharing the same binding site as indoxyl sulfate (IS). This study explores the development of IBF-immobilized cellulose acetate-based (CA-based) thin films. The films were created by reacting CA with IBF-modified silica precursors at varying concentrations. The presence of IBF in CA/TEOS/APTES-IBF-3 and CA/TEOS-IBF-25 films, containing 3 and 25 wt % IBF, respectively, was confirmed through 1H NMR spectra. Competitive displacement binding assays indicated that while the incorporation of 3 wt % IBF showed no significant enhancement in IS displacement, the 25 wt % IBF film increased the dialyzed IS by 1.3 when normalized to non-IBF films. Furthermore, there was a 1.2-fold decrease in the total percentage of IS, and the free percentage of IS increased 1.3 to 3.0 times. Although direct systemic infusion of IBF in HD patients achieves a 2.4 times higher removal of IS, it is impractical due to the risks it poses to ESRD patients. The IBF-immobilized films offer the advantage of localized binding, thus eliminating the need for systemic exposure. This innovative approach lays a foundation for developing more efficient HD membranes, aiming to address the challenging issue of PBUT elimination and potentially enhance the quality of life and treatment outcomes for ESRD patients.

Providing environmentally sustainable nephrology care: focus in low- and middle-income countries

Health care on a global scale significantly contributes to carbon emissions, with high-income countries being the primary culprits. Within health care, dialysis plays a significant role as a major source of emissions. Low- and middle-income countries have a high burden of kidney disease and are facing an increasing demand for dialysis. This reality presents multiple opportunities to plan for environmentally sustainable and quality kidney care. By placing a stronger emphasis on primary and secondary prevention of kidney disease and its progression, within the framework of universal health coverage, as well as empowering patients to enhance self-care, we can significantly reduce the need for costly and environmentally detrimental kidney replacement therapy. Mandating the adoption of lean and innovative low-carbon dialysis practices while also promoting the growth of kidney transplantation would enable low- and middle-income countries to take the lead in implementing environmentally friendly nephrology practices and reducing costs, thus optimizing sustainability and the well-being of individuals living with kidney disease.

The climate impact of dialysis

PURPOSE OF REVIEW

A reciprocal relationship currently exists between climate change and healthcare, mutually influencing each other. There have been significant planetary shifts in recent decades, marked by escalating temperatures, frequent natural calamities, a disturbing surge in climate-linked fatalities, and a heightened incidence of kidney disease diagnoses.

RECENT FINDINGS

Dialysis, a life-preserving treatment for kidney failure, extends to 2-3 million patients globally, mainly through in-centre haemodialysis. This treatment exerts an environmental toll, contributing to the healthcare sector's carbon footprint through water usage, energy consumption, waste generation, and current procurement practices. Diligent scrutiny and data collection of these facets have spurred sustainability initiatives, beginning at the local level with water, energy, and waste management. Still, this represents just the tip of the iceberg, with a pressing need for more comprehensive and habitual sustainable dialysis practices.

SUMMARY

This review examines the carbon footprint from dialysis, probes its ecological ramifications, and underscores potential solutions to lessen its climate impact.

Roadmaps to green nephrology: a mediterranean point of view

PURPOSE OF REVIEW

Green nephrology is a movement whose aim is to find ways to reduce the environmental impact of kidney care. The question is of particular concern in this field since haemodialysis is one of the major contributors to waste generation, energy use and water consumption in healthcare. Although several ways for improving sustainability have been advocated, they are all context sensitive. This review aims to analyse the interventions that have been proposed to improve the ecologic sustainability and reduce the carbon footprint of nephrology care adapting to specific settings, and taking advantage of local expertise.

RECENT FINDINGS

Green hospitals are becoming a reality in several high-income settings, thanks to new building guidelines, with greater awareness of climate change and users' demands. Water saving is feasible, and is increasingly done, in different ways (improving hardware, reducing and adapting dialysate flows). Recycling noncontaminated plastic waste is feasible, but is still rarely performed. However, ecological transition has been slow even in high-income countries, while in low and middle-income countries lack of resources limit the ability to cope with the planet's urgent needs. Conversely, where man-power cost is low, some time-consuming tasks, such as separation of various components for recycling may be affordable. Theoretically, implementation of all clinical tasks aiming to avoid or retard dialysis, should be a priority.

SUMMARY

There is no single roadmap for achieving green nephrology. Each setting should start from those feasible interventions most in line with its specific needs and priorities.

Supplemented Very Low Protein Diet (sVLPD) in Patients with Advanced Chronic Renal Failure: Clinical and Economic Benefits

The supplemented very low-protein diet (sVLPD) has proven effective in slowing the progression of stage 5 chronic renal failure and postponing the start of the dialysis treatment. However, sVLPD could expose the patient to the risk of malnutrition. This diet is also difficult to implement due to the required intake of large number of keto-analogue/amino acid tablets. In our Center, the Department of Nephrology and Dialysis of Azienda Sanitaria Territoriale n 1, Pesaro-Urbino, of Italy, respecting the guidelines of normal clinical practice, we prescribed sVLPD (0.3 g/prot/day) supplemented with only essential amino acids without the use of ketoanalogues in stage 5 patients and verified its efficacy, safety and clinical and economic effects. Over the 24 months period of observation the progression of chronic kidney disease (CKD) slowed down (mean eGFR 11.6 ± 3.3 vs. 9.3 ± 2.7 mL/min/1.73 m2, p < 0.001) and the start of the dialysis treatment (adjusted HR = 0.361, CI 0.200-0.650, p = 0.001) was delayed without evidence of malnutrition, in compliant vs. non-compliant patients. This led to a substantial cost reduction for the National Health System. This non-interventional longitudinal observational study is part of standard clinical practice and suggests that VLPD supplemented with essential amino acids could be extensively used to reduce the incidence of dialysis treatments, with a favorable economic impact on the NHS.

Water implications in dialysis therapy, threats and opportunities to reduce water consumption: a call for the planet

Water is a dwindling natural resource, and potable water is wrongly considered an unlimited resource. Dialysis, particularly hemodialysis, is a water-hungry treatment that impacts the environment. The global annual water use of hemodialysis is approximately 265 million m3/yr. In this reference estimate, two-thirds of this water is represented by reverse osmosis reject water discharged into the drain. In this review, we would like to draw attention to the complexity and importance of water saving in hemodialysis. We propose that circular water management may comply with the "3R" concept: reduce (reduce dialysis need, reduce dialysate flow, and optimize reverse osmosis performance), reuse (reuse wastewater as potable water), and recycle (dialysis effluents for agriculture and aquaponic use). Awareness and sustainability should be integrated to create positive behaviors. Effective communication is crucial for water savings because local perspectives may lead to global opportunities. Besides the positive environmental impacts, planet-friendly alternatives may have significant financial returns. Innovative policies based on the transition from linear to circular water management may lead to a paradigm shift and establish a sustainable water management model. This review seeks to support policymakers in making informed decisions about water use, avoiding wasting, and finding solutions that may be planet friendly and patient friendly in dialysis, especially in hemodialysis treatments.

Incremental peritoneal dialysis allows to reduce the time spent for dialysis, glucose exposure, economic cost, plastic waste and water consumption

BACKGROUND

Incremental peritoneal dialysis (incPD) as the initial PD strategy represents a convenient and resource-sparing approach, but its impact on patient, healthcare and environment has not been thoroughly evaluated.

METHODS

This study includes 147 patients who started incPD at our institution between 1st January, 2009 and 31st December, 2021. Adequacy measures, peritoneal permeability parameters, peritonitis episodes, hospitalizations and increase in CAPD dose prescriptions were recorded. The savings related to cost, patient glucose exposure, time needed to perform dialysis, plastic waste, and water usage were compared to full-dose PD treatment.

RESULTS

During the study follow-up 11.9% of the patients transitioned from incremental to full dose PD. Patient cumulative probability of remaining on PD at 12, 24, 36, 48 and 60 months was 87.6, 65.4, 46.1, 30.1 and 17.5%, respectively. The median transition time from 1 to 2 exchanges, from 2 to 3 and 3 to 4 exchanges were 5, 9 and 11.8 months, respectively. Compared to full dose PD, 1, 2, and 3 exchanges per day led to reduction in glucose exposure of 20.4, 14.8 or 8.3 kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4 day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6 kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year.

CONCLUSIONS

In comparison with full-dose PD, incPD allows to reduce the time spent for managing dialysis, glucose exposure, economic cost, plastic waste, and water consumption.

Home-Based Exercise in Elderly Patients with Claudication and Chronic Kidney Disease Is Associated with Lower Progressive Renal Function Worsening: A 5-Year Retrospective Study

This observational study aimed to monitor the 5-year trends of kidney function in patients with peripheral artery disease (PAD) and concomitant chronic kidney disease (CKD) enrolled or not enrolled into a rehabilitative exercise program. Sixty-six patients (aged 72 ± 10, males n = 52) at KDOQI stages III-IV and PAD at Rutherford's stage I-III were included in the study, with a group (Exercise, EX; n = 32) receiving a 6-month structured pain-free home-based walking program and a group (Control, CO; n = 34) receiving walking advice and optimal nephrological care. Outcomes included kidney function measured through serum creatinine (sCr) and clinical outcomes, including the rate of advance of CKD stages and admission to dialysis, revascularizations, and hospitalizations. At baseline, the two groups were comparable for age, nephropathy, medications, comorbidities, and PAD severity. Patients in the EX group safely completed the exercise program. SCr values were slightly increased in EX (baseline: 2.35 ± 0.32; 5-year: 2.71 ± 0.39 mg/dL) and progressively worsened in CO (baseline: 2.30 ± 0.31; 5-year 4.22 ± 0.42 mg/dL), with a significant between-group difference (p = 0.002). The control group also showed a higher number of dialysis admissions (5 vs. 0, p = 0.025) and advancing CKD stage as well a higher risks for lower limb revascularization (hazard ratio: 2.59; 95%CI: 1.11-6.02; p = 0.027) and for all-cause hospitalization (hazard ratio: 1.77; 95%CI: 1.05-2.97; p = 0.031). PAD-CKD patients enrolled in a low-moderate intensity home-exercise program showed more favorable long-term trends in kidney function and clinical outcomes than patients with usual care. These preliminary observations need to be confirmed in randomized trials.

Waste Management and the Perspective of a Green Hospital-A Systematic Narrative Review

The concept of a "green hospital" is used in reference to a hospital that includes the environment as part of its quality services and one that pays attention to the sustainable design of buildings. Waste disposal represents a potential risk for the environment; therefore, waste collection from healthcare centers is a key environmental issue. Our study aims to systematically review the experiences acquired in worldwide nosocomial settings related to the management of healthcare waste. Nineteen studies, selected between January 2020 and April 2022 on Scopus, MEDLINE/PubMed and Web of Science databases were included in our systematic narrative review. Operating room and hemodialysis activities seem to be the procedures most associated with waste production. To deal with waste production, the 5Rs rule (reduce, reuse, recycle, rethink and research) was a common suggested strategy to derive the maximum practical benefit while generating the minimum amount of waste. In this context, the COVID-19 pandemic slowed down the greening process of nosocomial environments. Waste management requires a multifactorial approach to deal with medical waste management, even considering the climate change that the world is experiencing. Education of health personnel and managers, regulation by governmental institutions, creation of an "environmental greening team", and awareness of stakeholders and policymakers are some of the measures needed for the greening of healthcare facilities.

Sustainable kidney care delivery and climate change - a call to action

The delivery of kidney care, particularly haemodialysis treatment, can result in substantial environmental impact through greenhouse emissions, natural resources depletion and waste generation. However, strategies exist to mitigate this impact and improve long term environmental sustainability for the provision of haemodialysis treatment. The nephrology community has begun taking actions to improve the environmental sustainability of dialysis, but much work remains to be done by healthcare professionals, dialysis providers and professional organisations.

Estimating the cost of home dialysis in Tunisia: Application of the Activity-based costing methodology

INTRODUCTION

In Tunisia, in-centre haemodialysis (ICHD) is the most common type of dialysis. Despite the increasing demand, the number of haemodialysis machines per 100,000 inhabitants is still low. Home Haemodialysis (HHD) is a candidate solution to this problem. Despite its confirmed benefits over ICHD, HHD has not taken place in Tunisia.

AIM

To describe the processes of home dialysis modalities, especially HHD, evaluate their costs, analyse them, in the context of medical practice in public health structures in Tunisia.

METHOD

The Activity-Based Costing technique was applied: the processes of home dialysis modalities were modelled, the main activity and resource cost drivers identified, and cost equations developed. Based on data from the nephrology department of Sahloul hospital, the cost per session and annual costs for each home dialysis modality were calculated and analyzed.

RESULTS

Home Peritoneal Dialysis, already implemented in Tunisia; presented the lowest annual cost per patient 25344 TND versus 29232 TND for Conventional HHD and 54144 TND for Short-Daily HHD. The cost per session of the Short-Daily HHD (188,8 TND) was comparable to ICHD (180 TND). Consumables presented the most expensive resource for these modalities. Finally, the cost structure of HHD was comparable in Tunisia and France as well as in previous costing studies.

CONCLUSION

The cost of one session of HHD is estimated to 188,8 TND. The Tunisian ministry of health could adopt a flexible policy to start HHD program by implementing Conventional HHD first.

Probiotics-Supplemented Low-Protein Diet for Microbiota Modulation in Patients with Advanced Chronic Kidney Disease (ProLowCKD): Results from a Placebo-Controlled Randomized Trial

The probiotics-supplemented low-protein diet in chronic kidney disease (ProLowCKD) was a single-centre, double-blind, placebo-controlled, randomised trial that was conducted to investigate whether the association between a low protein diet (LPD) and a new formulation of probiotics (Bifidobacterium longum and Lactobacillus reuteri) was effective at reducing traditional uremic, microbiota-derived, and proatherogenic toxins in sixty patients affected by advanced CKD. After 2 months of a LPD—a reduction in blood urea nitrogen (52 ± 17 vs. 46 ± 15 mg/dL, p = 0.003), total cholesterol (185 ± 41 vs. 171 ± 34 mg/dL, p = 0.001), and triglycerides (194 ± 148 vs. 161 ± 70 mg/dL, p = 0.03) was observed; 57 subjects were then randomized to receive probiotics or a placebo for the subsequent 3 months. A total of 27 patients in the placebo group showed increased serum values of total cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.01), LDL cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.02), lipoprotein-associated phospholipase A₂ (155.4 ± 39.3 vs. 167.5 ± 51.4 nmol/mL/min, p = 0.006), and indoxyl-sulphate (30.1 ± 17.6 vs. 34.5 ± 20.2 μM, p = 0.026), while the 24 subjects in the probiotics group showed a trend in the reduction of microbiota toxins. A reduction of antihypertensive and diuretic medications was possible in the probiotics group. This study shows that associating probiotics to LPD may have an additional beneficial effect on the control and modulation of microbiota-derived and proatherogenic toxins in CKD patients.

OUP accepted manuscript

The world faces a dramatic man-made ecologic disaster and healthcare is a crucial part of this problem. Compared with other therapeutic areas, nephrology care, and especially dialysis, creates an excessive burden via water consumption, greenhouse gas emission and waste production. In this advocacy article from the European Kidney Health Alliance we describe the mutual impact of climate change on kidney health and kidney care on ecology. We propose an array of measures as potential solutions related to the prevention of kidney disease, kidney transplantation and green dialysis. For dialysis, several proactive suggestions are made, especially by lowering water consumption, implementing energy-neutral policies, waste triage and recycling of materials. These include original proposals such as dialysate regeneration, dialysate flow reduction, water distillation systems for dialysate production, heat pumps for unit climatization, heat exchangers for dialysate warming, biodegradable and bio-based polymers, alternative power sources, repurposing of plastic waste (e.g. incorporation in concrete), registration systems of ecologic burden and platforms to exchange ecologic best practices. We also discuss how the European Green Deal offers real potential for supporting and galvanizing these urgent environmental changes. Finally, we formulate recommendations to professionals, manufacturers, providers and policymakers on how this correction can be achieved.

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability

As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

Towards zero liquid discharge in hemodialysis. Possible issues

Scarcity of water and energy, and legal requirements for discharge of waste and wastewater are forcing hemodialysis facilities to change their approach to a more integrated concept of connecting the residual output (in terms of waste, wastewater and energy loss) to the input (in terms of water and energy). Zero liquid discharge is an expanding water treatment philosophy in which hemodialysis wastewater is purified and recycled, leaving little to no effluent remaining when the process is complete, thereby saving money and being beneficial to the environment. This article explores the possible ways to treat hemodialysis wastewater, thus achieving ZLD conditions.

Advanced hemodialysis equipment for more eco-friendly dialysis

Healthcare in general and dialysis care in particular are contributing to resource consumption and, thus, have a notable environmental footprint. Dialysis is a life-saving therapy but it entails the use of a broad range of consumables generating waste, and consumption of water and energy for the dialysis process. Various stakeholders in the healthcare sector are called upon to develop and to take measures to save resources and to make healthcare and dialysis more sustainable. Among these stakeholders are manufacturers of dialysis equipment and water purification systems. Dialysis equipment and consumables, together with care processes need to be advanced to reduce waste generation, enhance recyclability, optimize water purification efficiency and water use. Joint efforts should thus pave the way to enable delivering green dialysis and to contribute to environmentally sustainable health care.

Sustainability in dialysis therapy: Japanese local and global challenge

Human-induced climate change is considered the greatest health threat of the 21st century. The health effects of climate change are becoming increasingly apparent, and there is substantial evidence indicating increased risk of kidney injury due to heat illness and other climate change-related meteorological abnormalities. On the other hand, healthcare itself is responsible for environmental burdens and has been estimated to generate between 3 and 10% of total national CO2 equivalent emissions. Dialysis has been estimated as one of the major contributors to healthcare’s carbon footprint. Especially in Australia and the UK, nations that have high awareness regarding environmental research, “Green Nephrology” has emerged as a new discipline. From both of these countries, a series of papers have been produced outlining the carbon footprint of hemodialysis, the results of surveys of specialists’ awareness of environmental issues, and proposals for how to save resources in dialysis therapy. Following on from this, several national and international nephrology societies have committed themselves to a range of initiatives aiming at “greening” the kidney sector. In Japan, where water and electricity supplies currently are stable, we occasionally are reminded of the potential for shortages of water and energy and of waste disposal problems. These issues particularly come to the fore in times of disasters, when hemodialysis patients need to be evacuated to distant dialysis facilities. Irrespective of the current state of resource availability, however, continuous efforts and the establishment of resource-saving procedures as a part of Japanese culture are highly desirable and would contribute to environmentally friendly healthcare. Japan needs to build awareness of these issues before the country faces a catastrophic situation of resource shortages. This review is intended as a call to action regarding environmental sustainability in kidney healthcare in Japan and the world.

Assessment of environmental sustainability in renal healthcare

The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates comprehensive environmental burdens into a single index-the monetary cost. Previous investigations estimated that therapy for chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the environmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide environmentally friendly healthcare in Japan.

Why and how should we promote home dialysis for patients with end-stage kidney disease during and after the coronavirus 2019 disease pandemic? A French perspective

The health crisis induced by the pandemic of coronavirus 2019 disease (COVID-19) has had a major impact on dialysis patients in France. The incidence of infection with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the first wave of the COVID-19 epidemic was 3.3% among dialysis patients-13 times higher than in the general population. The corresponding mortality rate was high, reaching 21%. As of 19th April, 2021, the cumulative prevalence of SARS-CoV-2 infection in French dialysis patients was 14%. Convergent scientific data from France, Italy, the United Kingdom and Canada show that home dialysis reduces the risk of SARS-CoV-2 infection by a factor of at least two. Unfortunately, home dialysis in France is not sufficiently developed: the proportion of dialysis patients being treated at home is only 7%. The obstacles to the provision of home care for patients with end-stage kidney disease in France include (i) an unfavourable pricing policy for home haemodialysis and nurse visits for assisted peritoneal dialysis (PD), (ii) insufficient training in home dialysis for nephrologists, (iii) the small number of administrative authorizations for home dialysis programs, and (iv) a lack of structured, objective information on renal replacement therapies for patients with advanced chronic kidney disease (CKD). We propose a number of pragmatic initiatives that could be simultaneously enacted to improve the situation in three areas: (i) the provision of objective information on renal replacement therapies for patients with advanced CKD, (ii) wider authorization of home dialysis networks and (iii) price increases in favour of home dialysis procedures.

Towards zero liquid discharge in hemodialysis. Possible issues

Scarcity of water and energy, and legal requirements for discharge of waste and wastewater are forcing hemodialysis facilities to change their approach to a more integrated concept of connecting the residual output (in terms of waste, wastewater and energy loss) to the input (in terms of water and energy). Zero liquid discharge is an expanding water treatment philosophy in which hemodialysis wastewater is purified and recycled, leaving little to no effluent remaining when the process is complete, thereby saving money and being beneficial to the environment. This article explores the possible ways to treat hemodialysis wastewater, thus achieving ZLD conditions.

Unexpected sequelae of the COVID-19 pandemic: A strange case of myoclonus in the Tasmanian winter

Peritoneal dialysis treatment generates significant amounts of waste for disposal from patients' homes. In Australia, in the days after the onset of the COVID-19 pandemic, waste collection from homes was temporarily stopped. Our patient tried to dispose of his waste by burning the used bags and tubing, using paint thinner as an accelerant. We present a case report of the unusual neurological complication he developed.

Reuse of dialysis reverse osmosis reject water for aquaponics and horticulture

BACKGROUND

Water crisis is becoming a threat to the well-being of the human population worldwide and use of water for healthcare contributes substantially to this resource depletion. Hemodialysis consumes large quantities of water. A huge volume of high purity dialysis water is required to safely perform dialysis treatment. In this process, up to 60-70% of source water is discarded. Many strategies have been suggested to promote green dialysis, and these include reuse of water, however, very few dialysis facilities have taken the preliminary steps to employ it.

METHODS

We share our experience in a developing country on an innovative reject-water reuse program combining aquaculture, hydroponic and horticulture activities. This is by far the first report on a "green dialysis" project involving aquaponics that reuse dialysis reverse osmosis (RO) reject water.

RESULTS

Our expereince suggests that reject water can be reused to promote water conservation with encouraging results. It provides a good and biosecure environment for fish breeding and vegetable farming . This project promotes a reduction in carbon footprint, a reduction in water waste, a sustainable organic food source, may lead to income generation, and provides a shared purpose and sense of pride among staff and dialysis patients.

CONCLUSIONS

Encompassing "environmental protection" practices into a hemodialysis unit can be done with relatively simple and practical steps.

Development of muffins as dialysis snacks for patients undergoing hemodialysis: results of chemical composition and sensory analysis

Objective

This study aimed to develop two non-industrial food products as financially accessible options to prevent and treat malnutrition in hemodialysis (HD) patients. These food products were developed and intended for use as dialysis snacks.

Methods

This is a cross-sectional and multi-step study. First, 183 adult HD patients (55 ± 14 years; 50.8% males), replied to a questionnaire with their food preferences regarding taste (salty, sweet, bitter, sour) and consistency (liquid, solid, pasty) for a dialysis snack. Most patients preferred a food product with a solid consistency (90%) and a salty flavor (81.4%). Second, three muffin formulations of fine herbs were developed; one enriched with whey protein concentrate (WPC), a second with textured soy protein (TSP) and a third standard formulation without protein for comparison with the protein-enriched muffins, for which the chemical and nutritional compositions were analyzed. In the third step, 60 patients on HD (61 ± 15 years; 53% males) were enrolled in a sensory analysis by applying a 9-point structured hedonic scale, ranging from “extremely liked” (score 9) to “extremely disliked” (score 1).

Results

When compared with the standard formulation, the formulations enriched with WPC and TSP protein had a significantly higher amount of protein/serving (Standard: 5.9 ± 0.3 g vs WPC: 14.5 ± 0.9 g and TSP 10.8 ± 0.7 g; P < 0.05) but a lower amount of carbohydrate (Standard: 13.1 ± 2.2 g vs WPC: 5.6 ± 0.8 g and TSP 6.0 ± 1.2 g vs; P < 0.05). The mineral content/serving of the protein-enriched muffins was low in phosphorus (50 mg) and sodium (180 mg). The potassium content/serving was moderate for the WPC muffin (225.2 mg) and low for the TSP muffin (107.9 mg). The acceptability index (AI) for the enriched protein muffins was higher than 70% and similar to the standard formulation.

Conclusion

The muffins with fine herbs and enriched with protein were well-accepted by all patients and appropriate to serve as dialysis snacks for HD patients.

The osmo-metabolic approach: a novel and tantalizing glucose-sparing strategy in peritoneal dialysis

Peritoneal dialysis (PD) is a viable but under-prescribed treatment for uremic patients. Concerns about its use include the bio-incompatibility of PD fluids, due to their potential for altering the functional and anatomical integrity of the peritoneal membrane. Many of these effects are thought to be due to the high glucose content of these solutions, with attendant issues of products generated during heat treatment of glucose-containing solutions. Moreover, excessive intraperitoneal absorption of glucose from the dialysate has many potential systemic metabolic effects. This article reviews the efforts to develop alternative PD solutions that obviate some of these side effects, through the replacement of part of their glucose content with other osmolytes which are at least as efficient in removing fluids as glucose, but less impactful on patient metabolism. In particular, we will summarize clinical studies on the use of alternative osmotic ingredients that are commercially available (icodextrin and amino acids) and preclinical studies on alternative solutions under development (taurine, polyglycerol, carnitine and xylitol). In addition to the expected benefit of a glucose-sparing approach, we describe an ‘osmo-metabolic’ approach in formulating novel PD solutions, in which there is the possibility of exploiting the pharmaco-metabolic properties of some of the osmolytes to attenuate the systemic side effects due to glucose. This approach has the potential to ameliorate pre-existing co-morbidities, including insulin resistance and type-2 diabetes, which have a high prevalence in the dialysis population, including in PD patients.