Eco-dialysis: the financial and ecological costs of dialysis waste products: is a 'cradle-to-cradle' model feasible for planet-friendly haemodialysis waste management?

Loading Self-Assembly Siliceous Zeolites for Affordable Next-Generation Wearable Artificial Kidney Technology

The global demand for dialysis among patients with end-stage kidney disease has surpassed the capacity of public healthcare, a trend that has intensified. While wearable artificial kidney (WAK) technology is seen as a crucial solution to address this demand, there is an urgent need for both efficient and renewable toxin-adsorbent materials to overcome the long-standing technological challenges in terms of cost, device size, and sustainability. In this study, we employed screening experiments for adsorbent materials, multimodal characterization, and Monte Carlo adsorption simulations to identify a synthetic self-assembly silicalite-1 zeolite that exhibits highly ordered crystal arrays along the [010] face (b-axis) direction, demonstrating exceptional adsorption capabilities for small molecular toxins such as creatinine and urea associated with uremia. Moreover, this metal-free, cost-effective, easily synthesized, and highly efficient toxin adsorbent could be regenerated through calcination without compromising the performance. The simulated toxin adsorption experiments and comprehensive biocompatibility verification position it as an auxiliary adsorbent to reduce dialysate dosages in WAK devices as well as a potential adsorbent for small-molecule toxins in dialysis. This work is poised to propel the development of next-generation WAK devices by providing siliceous adsorbent solutions for small-molecule toxins.

Monitoring and maintaining quality in the paediatric haemodialysis unit

Chronic kidney disease in children is being increasingly recognised and reported worldwide, and the focus of paediatric dialysis planning has changed from acute care alone to encompass chronic care. In many parts of the world, haemodialysis for children is performed in adult units and is based on standards established for adults. This review proposes standards for paediatric haemodialysis, incorporating special requirements for children while simultaneously drawing from the adult experience. We discuss the optimum requirements, including space utilisation, equipment needed, water treatment facilities, disposables, safety standards, staffing needs, monitoring and maintenance, infection prevention, waste disposal and quality indicators. We also review recent advancements in the field that should be incorporated into future dialysis units and the steps required for achieving carbon neutrality and protecting the environment.

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.

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.

Do medical devices contribute to sustainability? The role of innovative polymers and device design

Sustainability of a medical device has not yet become a major issue in public discussions compared to other topics with impact to material performance, clinical application, production economy and environmental pollution. Due to their unique properties, polymers (plastics) allow for multiple, flexible applications in medical device technology. Polymers are part of the majority of disposable and single use medical device and contribute with 3% to the worldwide production of plastics. The global medical polymer market size was valued 19.9 billion US-$ in 2022 and its value projection for 2023 is expected to reach 43.03 billion US-$ Here, a wider concept of related sustainability is introduced for medical devices and their polymer components. A close look on medical device specification reveals that additional properties are required to provide sustainability, such as biodegradability, quality by device design (QbD), as well as an inbuild performance service for patients, healthcare professionals and healthcare providers. The increasing global numbers for chronic and non-communicable diseases require a huge demand for single use medical devices. A careful look at polymer specification and its performance properties is needed, including possible chemical modifications and degradation processes during waste disposal. Bioengineers in charge of design and production of medical devices will only be successful when they apply a holistic and interdisciplinary approach to medical device sustainability.

Do medical devices contribute to sustainability? Environmental, societal and governance aspects

Sustainability of a product or device is currently primarily related to its environmental footprint. Here, a wider concept of sustainability is introduced for medical devices and their components in healthcare provision. Such devices sustain healthcare and patient wellbeing due to their quality specifications for material composition, product design and performance. The term quality must be intended in the most comprehensive term, including purity and biocompatibility of materials, device reliability, limited number of recalls and reduced risks as well as acceptability for patients. A close look on medical device specification shows, however, that additional parameters, such as societal, demographic and economic factors also determine medical device sustainability. The medical device life cycle, from design phase, production process to clinical application and the final disposal, also determines its impact. Recommendations for healthcare operators and managers will complete the hypothesis of this paper, that a thoroughly outlined device choice and operation together with a careful waste management of spent medical devices and their components positively affects medical device sustainability. As an example, the limited quantity of wastes and the reduced risks for adverse reaction have a positive impact on both the environmental pollution and on the costs sustained by the healthcare organisations and by the community. These factors determine both, the success of healthcare manoeuvres and the related environmental footprint.

Climate crisis and nephrology: a review of climate change's impact on nephrology and how to combat it

Climate change is worsening with tangible effects on our healthcare system. This review aims to examine the repercussions of the climate change on nephrology and explore potential strategies to mitigate its impact. This review examines dialysis's environmental impact, resource recycling methods, and plant-based diets for kidney health. Recent research highlights the advantages of plant-based diets in managing and preventing chronic kidney disease (CKD) and its complications. Integrating these practices can significantly lessen the environmental impact of nephrology.

PURPOSE OF REVIEW

The aim of this study is to discuss the bidirectional relationship of climate change and kidney disease and the impact of nephrology on climate change and to discuss potential solutions.

RECENT FINDINGS

Each dialysis session consumes significant amounts of resource; reusing them will aid the environment. Plant-based diets slow renal disease and have a lower carbon footprint, making them ecologically friendly.

SUMMARY

Climate change is a growing threat to population health and healthcare. Rising temperatures raise the risk of kidney problems. Dialysis treatments also impact the environment through its high resource requirements while generating high volumes of waste and greenhouse gases. Opportunities exist to reduce the environmental impact of dialysis treatments. Plant-based diets serve to benefit both kidney disease and the environment.

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.

Green Dialysis: Let Us Talk about Dialysis Fluid

BACKGROUND

Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to obtain the expected outcomes. The most frequent source of dialysis fluid is production from liquid concentrate (delivered in containers or plastic bags) in dialysis machine. Alternatively, concentrates for dialysis may be produced in dialysis center by dilution in mixing devices dry or semidry premixed compounds connected with system of central dialysis fluid delivery system. Dialysate consumption depends on various factors like type of hemodialysis machine, session duration, prescribed flow, etc. Summary: Modern hemodialysis machines are equipped with the modules which automatically reduce flow rate of dialysis fluid to the patient blood flow and minimize dialysate consumption during preparation and after reinfusion. Smart using of available options offered by manufacturers allows to save additional portion of acid concentrate and water. The weight of concentrates to be delivered to the dialysis center is the major factor influencing the cost (financial and environmental) of transportation from the manufacturer to the final consumer. The crisis on the energy carriers market and extremely high fuel prices made the transportation cost one of the significant costs of the treatment, which must be bear by supplier and finally influence on the price of goods.

KEY MESSAGES

The careful choice of the concentrate delivery system can improve cost-effectiveness of dialysis. Such solutions implemented in dialysis unit helps make significant savings and decrease the impact on natural environment by carbon footprint reduction.

Waste audits in healthcare: A systematic review and description of best practices

Healthcare generates large amounts of waste, harming both environmental and human health. Waste audits are the standard method for measuring and characterizing waste. This is a systematic review of healthcare waste audits, describing their methods and informing more standardized auditing and reporting. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE, Embase, Inspec, Scopus and Web of Science Core Collection databases for published studies involving direct measurement of waste in medical facilities. We screened 2398 studies, identifying 156 studies for inclusion from 37 countries. Most were conducted to improve local waste sorting policies or practices, with fewer to inform policy development, increase waste diversion or reduce costs. Measurement was quantified mostly by weighing waste, with many also counting items or using interviews or surveys to compile data. Studies spanned single procedures, departments and hospitals, and multiple hospitals or health systems. Waste categories varied, with most including municipal solid waste or biohazardous waste, and others including sharps, recycling and other wastes. There were significant differences in methods and results between high- and low-income countries. The number of healthcare waste audits published has been increasing, with variable quality and general methodologic inconsistency. A greater emphasis on consistent performance and reporting standards would improve the quality, comparability and usefulness of healthcare waste audits.

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.

Switching from high-flux dialysis to hemodiafiltration: Cost-consequences for patients, providers, and payers

Hemodiafiltration (HDF) achieves a more efficient reduction of the uremic toxic load compared to standard high-flux hemodialysis (HF-HD) by virtue of the combined diffusive and convective clearances of a broad spectrum of uremic retention solutes. Clinical trials and registry data suggest that HDF improves patient outcomes. Despite the acknowledged need to improve survival rates of dialysis patients and the survival benefit HDF offers, there is little to no utilization in some countries (such as the US) in prescribing HDF to their patients. In this analysis, we present the healthcare value-based case for HDF (relative to HF-HD) from the patient, provider, and payor perspectives. The improved survival and reduced morbidity observed in studies conducted outside the US, as well as the reduced hospitalization, are attractive for each stakeholder. We also consider the potential barriers to greater utilization of HDF therapies, including unfounded concerns regarding additional costs of HDF, e.g., for the preparation and microbial testing of quality of substitution fluids. Ultrapure fluids are easily attainable and prepared from dialysis fluids using established "online" (OL) technologies. OL-HDF has matured to a level whereby little additional effort is required to safely implement it as all modern machine systems are today equipped with the OL-HDF functionality. Countries already convinced of the advantages of HF-HD are thus well positioned to make the transition to OL-HDF to achieve further clinical and associated economic benefits. Healthcare systems struggling to cope with the increasing demand for HD therapies would therefore, like patients, be beneficiaries in the long term with increased usage of OL-HDF for end stage kidney disease 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.

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.

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.

Updates on hemodialysis techniques with a common denominator: The personalization of the dialytic therapy

Hemodialysis (HD) is a life-saving therapy for patients with end-stage renal disease. In dialyzed patients, the prevalence of multi-morbidity is rising driven by various factors, such as the population aging, the incomplete correction of uremia, and the side effects of the dialysis therapy itself. Each dialyzed patient has their own specific clinical and biochemical problems. It is therefore unthinkable that the same dialysis procedure can be able to meet the needs of every patient on chronic dialysis. We have very sophisticated dialysis machines and different dialysis techniques and procedures beyond conventional HD, such as hemodiafiltration (HDF) with pre- and post-dilution, acetate-free biofiltration (AFB), hemofiltration (HF), and expanded HD. Each of these techniques has its own specific characteristics. To solve some intradialytic clinical issues, such as arterial hypotension and arrhythmias, we have biofeedback systems with automatic regulation of the blood volume, body temperature, arterial pressure, as well as potassium profiling techniques in the dialysis bath. New technical innovations, such as citrate-containing dialysate or heparin-coated membranes, could reduce the risk of bleeding. To better address to patient needs, the strengths and weaknesses of each of these systems must be well-known, in order to have a personalized dialysis prescription for each patient.

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

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

Medical waste management - how industry can help us to protect environment and money?

Background

The global climate change and its consequences force us to remodel our processes and rethink the current model of providing the HD treatments. Waste management have a massive impact on the environment and the economy. Every HD session produces above 1 kg of medical waste, which should be properly stored and destroyed. In particular in the pandemia time we should improve the dialysis unit budget as well as decrease CO₂ emission produced during the waste elimination.

Materials and Methods

The checked the weight of different dialyzers used regularly in dialysis centers in Poland. The Kern CM 320-IN scale was used for the measurement. The measurement accuracy was 0.1 g. Also the filling volume of each dialyzer has been taken into consideration.

Results

The dialyzers were divided into four groups depending on the surface. 1,4m2 in group one, 1.5–1.6 m² in group two, 1.7–1.8 m² in group three and finally 2.0–2.2 m² in group four. FX class dialyzers were lightest in every group. The heaviest ones were Polyflux dialyzers. The difference between the lightest and heaviest dialyzers was about 95 g. The filling volume was lowest in FX dialyzers and the highest in Elisio dialyzers. The difference was 20 mL.

Conclusions

The weight of different dialyzers available on the market differs. The decision-makers should take into account this fact as the additional quality feature. In extreme cases the weight difference reaches 95 g. In yearly perspective, the usage of the lighter dialysis set can cause the 17 million kg decrease of medical waste and significant savings.

Eco-dialysis: fashion or necessity

Hemodialysis (HD) is one of the resource hungry medical interventions. A huge volume of water (about 500 L) and significant amounts of energy (over 7 kW) are used for a hemodialysis session; over a kilogram of waste is produced during this procedure. Thus, HD contributes to global warming while saving patients' lives. In this paper, we showed these crucial points in HD treatment and possible ways (e.g. modifications in dialysate flow rate) to reduce environmental impact maintaining therapy standards.

Green nephrology

Clear evidence indicates that the health of the natural world is declining globally at rates that are unprecedented in human history. This decline represents a major threat to the health and wellbeing of human populations worldwide. Environmental change, particularly climate change, is already having and will increasingly have an impact on the incidence and distribution of kidney diseases. Increases in extreme weather events owing to climate change are likely to have a destabilizing effect on the provision of care to patients with kidney disease. Ironically, health care is part of the problem, contributing substantially to resource depletion and greenhouse gas emissions. Among medical therapies, the environmental impact of dialysis seems to be particularly high, suggesting that the nephrology community has an important role to play in exploring environmentally responsible health-care practices. There is a need for increased monitoring of resource usage and waste generation by kidney care facilities. Opportunities to reduce the environmental impact of haemodialysis include capturing and reusing reverse osmosis reject water, utilizing renewable energy, improving waste management and potentially reducing dialysate flow rates. In peritoneal dialysis, consideration should be given to improving packaging materials and point-of-care dialysate generation.

Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.

Insuffisances rénales aiguës : actes du 5e Séminaire de recherche translationnelle de la Société de réanimation de langue française (Paris, 4 décembre 2018)

Le séminaire annuel de la commission de recherche translationnelle de la SRLF a eu lieu à Paris le 4 décembre 2018. Ce séminaire a pour but de réunir des cliniciens et scientifiques autour de grandes thématiques de recherche en médecine intensive et réanimation. La cinquième édition a porté sur l’insuffisance rénale aiguë, problématique quotidienne importante des réanimateurs. Les interventions se sont intéressées à la physiopathologie des diverses formes d’insuffisance rénale aiguë, à la récupération rénale, aux modèles expérimentaux, à l’hémodynamique régionale ou encore aux innovations technologiques en épuration extrarénale.

Sister Earth, Our Common Home: Toward a Sustainable, Planet Friendly Approach to Dialysis, a Paradigm of High Technology Medicine

In our high-technology, highly polluted world, medicine plays an important role balancing saving lives with the expenses of growing amounts of waste products, not only biologically dangerous (the potentially "contaminated" or "hazardous" waste) but also potentially harmful for the planet (nonrecyclable, plastic waste). Dialysis, the prototype of high-technology medicine, is central to these problems, as the present treatment of about 2 million patients produces an enormous quantity of waste (considering hazardous waste only about 2 kg per session, with 160 sessions per year, that is 320 kg per patient, or about 640,000 tons of hazardous waste per year for 2 million patients, roughly corresponding to 6 nuclear aircraft carriers). Furthermore, obsolete dialysis machines, and water treatments are discharged, adding to the "technological waste." Water produced by the reverse osmosis is also discharged; this is the only nonhazardous, nonpolluting waste, but in particular in dry areas, wasting water is a great ecologic concern. The present review is aimed at discussing strategies already in place and to be further implemented for reducing this particular "uremic toxin" for the earth: dialysis waste, including dialysis disposables, water, and dialysis machines.