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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.

Key points

  • A bidirectional relationship exists between the environment and kidney diseases; environmental change will increasingly have an impact on patterns of kidney diseases, whereas kidney care is responsible for substantial carbon emissions and resource depletion.

  • Haemodialysis consumes vast quantities of water and energy and produces high volumes of waste, whereas peritoneal dialysis requires the use of peritoneal dialysis fluids that are packaged in plastic and transported across and between countries to the point of care.

  • Multiple strategies exist to improve the environmental profile of haemodialysis, including recycling reverse osmosis reject water, reducing dialysate flow rates, utilizing renewable energy sources and optimizing waste management; many of these strategies also apply to peritoneal dialysis.

  • An additional opportunity to reduce the environmental impact of peritoneal dialysis arises from point-of-care dialysate generation.

  • A limited number of dialysis facilities and professional organizations worldwide have taken preliminary steps to improve the environmental profile of dialysis; however, much work remains to be done.

  • A need exists for improved monitoring of dialysis resource usage and waste generation, widespread uptake of environmental improvement opportunities by dialysis facilities, increased environmentally themed research and a greater focus on preventative care.

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Fig. 1: Greenhouse gas emissions, climate change and human health.
Fig. 2: The relationship between climate change and kidney diseases.
Fig. 3: Water treatment in haemodialysis.
Fig. 4: Schematic of a sorbent dialysis system.


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K.B. researched the data for the article and wrote the manuscript. J.A. reviewed and/or edited the manuscript before submission.

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Correspondence to Katherine A. Barraclough.

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Competing Interests

K.B. has received research grants from Fresenius Medical Care and Baxter Healthcare. J.A. has received research grants from Fresenius Medical Care and sits on the Medical Advisory Board for Quanta Dialysis Technologies.

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Nature Reviews Nephrology thanks Melissa Bilec, Peter Blankestijn, Giorgina Piccoli and John Stoves for their contribution to the peer review of this work.

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Barraclough, K.A., Agar, J.W.M. Green nephrology. Nat Rev Nephrol 16, 257–268 (2020).

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