Abstract
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.
This is a preview of subscription content, access via your institution
Access options
Access Nature and 54 other Nature Portfolio journals
Get Nature+, our best-value online-access subscription
$29.99 / 30 days
cancel any time
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Roser, M. et al. Life expectancy. Our World in Data. https://ourworldindata.org/life-expectancy (2013).
Roser, M. et al. Child and infant mortality. Our World in Data. https://ourworldindata.org/child-mortality#global-decline-of-child-mortality (2013).
Roser, M. & Ritchie, H. Maternal mortality. Our World in Data. https://ourworldindata.org/maternal-mortality (2020).
Roser, M., & Ritchie, H. Burden of disease. Our World in Data. https://ourworldindata.org/burden-of-disease (2020).
Roser, M. & Ortiz-Ospina, E. Global extreme poverty. https://ourworldindata.org/extreme-poverty (2013).
Scholes, R. et al. The assessment report on land degradation and restoration: summary for policymakers. Intergovernmental Panel on Biodiversity and Ecosystem Services. https://ipbes.net/sites/default/files/spm_3bi_ldr_digital.pdf (2018).
Foley, J. A., Monfreda, C., Ramankutty, N. & Zaks, D. Our share of the planetary pie. Proc. Natl Acad. Sci. USA 104, 12585–12586 (2007).
Intergovernmental Panel on Biodiversity and Ecosystem Services. Summary for policymakers of the global assessment report on biodiversity and ecosystem services. https://www.ipbes.net/system/tdf/spm_unedited_advance_for_posting_htn.pdf?file=1&type=node&id=35275 (2019).
Jambeck, J. R. et al. Marine plastic. Plastic waste inputs from land into the ocean. Science 347, 768–771 (2015).
Costello, A. et al. Managing the health effects of climate change. Lancet 373, 1693–1733 (2009).
Watts, N. et al. Health and climate change: policy responses to protect public health. Lancet 386, 1861–1914 (2015).
The Board of the Millenium Ecosystem Assessment. Living beyond our means: natural assets and human well-being. Summary for policy makers. https://wriorg.s3.amazonaws.com/s3fs-public/pdf/ma_board_final_statement.pdf?_ga=2.182554598.1541968820.1560082215-757632405.1556766277 (2005).
Eckelman, M. J. & Sherman, J. Environmental impacts of the U.S. health care system and effects on public health. Ahmad S, ed. PLoS One 11, e.0157014 (2016).
Malik, A. et al. The carbon footprint of Australian health care. Lancet Planet. Health 2, e27–e35 (2018).
Sustainable Development Unit. Carbon footprint update for the NHS in England 2015. https://www.sduhealth.org.uk/policy-strategy/reporting/nhs-carbon-footprint.aspx (2016).
Lim, A. E. K., Perkins, A. & Agar, J. W. M. The carbon footprint of an Australian satellite haemodialysis unit. Aust. Health Rev. 37, 369–374 (2013).
Connor, A., Lillywhite, R. & Cooke, M. W. The carbon footprints of home and in-center maintenance hemodialysis in the United Kingdom. Hemodial. Int. 15, 39–51 (2011).
Brown, L. H., Buettner, P. G. & Canyon, D. V. The energy burden and environmental impact of health services. Am. J. Public Health 102, e76–e82 (2012).
World Health Organsiation. Climate change and human health. https://www.who.int/globalchange/global-campaign/cop21/en/ (2019).
Barraclough, K. A. et al. Climate change and kidney diseases-threats and opportunities. Kidney Int. 92, 526–530 (2017).
Barraclough, K. A., Holt, S. G. & Agar, J. W. Climate change and us: what nephrologists should know. Nephrology 20, 760–764 (2015).
Hansen, A. L. et al. The effect of heat waves on hospital admissions for renal disease in a temperate city of Australia. Int. J. Epidemiol. 37, 1359–1365 (2008).
Knowlton, K. et al. The 2006 California heat wave: impacts on hospitalizations and emergency department visits. Env. Health Perspect. 117, 61–67 (2009).
Semenza, J. C. et al. Excess hospital admissions during the July 1995 heatwave in Chicago. Am. J. Prev. Med. 16, 269–277 (1999).
Kovats, R. S. & Ebi, K. L. Heatwaves and public health in Europe. Eur. J. Public Health 16, 592–599 (2006).
Borg, M. et al. The impact of daily temperature on renal disease incidence: an ecological study. Env. Health 16, 114 (2017).
Kovats, R. S., Hajat, S. & Wilkonson, P. Contrasting patterns of mortality and hospital admissions during hot weather and heat waves in greater London, UK. Occup. Env. Med. 61, 893–898 (2006).
Conti, S. et al. General and specific mortality among the elderly during the 2003 heat wave in Genoa (Italy). Environ. Res. 103, 267–274 (2007).
Fakheri, R. J. & Goldfarb, D. S. Association of nephrolithiasis prevalence rates with ambient temperature in the United States: a re-analysis. Kidney Int. 76, 798 (2009).
Brikowski, T. H., Lotan, Y. & Pearle, M. S. Climate-related increase in the prevalence of urolithiasis in the United States. Proc. Natl Acad. Sci. USA 105, 9841–9846 (2008).
Ramirez-Rubio, O., McClean, M. D., Amador, J. J. & Brooks, D. R. An epidemic of chronic kidney diseases in Central America: an overview. J. Epidemiol. Community Health 67, 1–3 (2013).
Glaser, J. et al. Climate change and the emergent epidemic of CKD from heat stress in rural communities: the case for heat stress nephropathy. Clin. J. Am. Soc. Nephrol. 11, 1472–1483 (2016).
Sorensen, C. & Garcia-Trabanino, R. A new era of climate medience: addressing heat triggerred renal disease. N. Engl. J. Med. 381, 693–696 (2019).
Dwyer, O. CDC will explore kidney failure epidemic among agricultural workers. Br. Med. J. 348, g3385 (2014).
Xu, X., Nie, S., Ding, H. & Hou, F. F. Environmental pollution and kidney diseases. Nat. Rev. Nephrol. 14, 313–324 (2018).
Intergovernmental Panel on Climate Change. Climate Change 2014: Synthesis Report. https://www.ipcc.ch/pdf/assessment-report/ar5/syr/SYR_AR5_FINAL_full_wcover.pdf (2014).
Jha, V. & Parameswaran, S. Community-acquired acute kidney injury in tropical countries. Nat. Rev. Nephrol. 9, 278–290 (2013).
Fresenius Medical Care. Care and live. Annual report 2018. https://www.freseniusmedicalcare.com/fileadmin/data/com/pdf/Media_Center/Publications/Annual_Reports/FME_Annual-Report_2018.pdf (2018)
Fresenius Medical Care. Outlook. https://www.freseniusmedicalcare.com/en/investors/at-a-glance/outlook/ (2019).
Agar, J. W. M. Green dialysis: the environmental challenges ahead. Semin. Dial. 28, 186–192 (2015).
Damasiewicz, M. J., Polkinhorne, K. R. & Kerr, P. G. Water quality in conventional and home haemodialysis. Nat. Rev. Nephrol. 8, 725–734 (2012).
Tarrass, F. et al. Water conservation: an emerging but vital issue in hemodialysis therapy. Blood Purif. 30, 181–185 (2010).
BCS BioClinical Services. Baxter GAMBRO Water purification units. https://www.bioclinicalservices.com.au/baxter/gambro-water-purification-units [online]. Accessed 2019.
Agar, J. W. M., Perkins, A. & Tjipto, A. Solar-assisted hemodialysis. Clin. J. Am. Soc. Nephrol. 7, 310–314 (2012).
World Energy Council: Energy efficiency indicators. https://wec-indicators.enerdata.net/household-electricity-use.html 2019.
Environment Victoria. The problem with landfill. https://environmentvictoria.org.au/resource/problem-landfill/ (2013).
United States Environmental Protection Agency. Greenhous gas emissions. understanding global warming potentials. https://www.epa.gov/ghgemissions/understanding-global-warming-potentials (2017).
Organisation for Economic Co-operation and Development. Improving plastics management: trends, policy responses, and the role of international co-operation and trade. http://www.oecd.org/environment/waste/policy-highlights-improving-plastics-management.pdf (2018).
Hoenich, N. A., Levin, R. & Pearce, C. Clinical waste generation from renal units: implications and solutions. Semin. Dial. 18, 396–400 (2005).
Piccoli, G. B. et al. Eco-dialysis: the financial and ecological costs of dialysis waste products: is a “cradle-to-cradle” model feasible for planet-friendly haemodialysis waste management? Nephrol. Dial. Transplant. 30, 1018–1027 (2015).
Gao, T., Liu, Q. & Wang, J. A comparative study of carbon footprint and assessment standards. Int. J. Low-Carbon Technol. 9, 237–243 (2014).
The World Bank. CO2 emissions (metric tons per capita). https://data.worldbank.org/indicator/en.atm.co2e.pc?view=map (2019).
Sustainable Development Unit. International pharmaceutical and medical device guidelines. https://www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/pharmaceuticals.aspx (2012).
McAlister, S. et al. The Environmental footprint of morphine: a life cycle assessment from opium poppy farming to the packaged drug. BMJ Open 6, e013302 (2016).
Responsible Water Scientists. The water footprint of plastics. https://responsiblewaterscientists.wordpress.com/2017/06/16/the-water-footprint-of-plastics/ (2017).
Chen, M. et al. The carbon footprints of home and in-center peritoneal dialysis in China. Int. Urol. Nephrol. 49, 337–343 (2017).
Agar, J. W. M. Conserving water in and applying solar power to haemodialysis: “green dialysis” through wiser resource utilization. Nephrology 15, 448–453 (2010).
Agar, J. W. M. Reusing and recycling dialysis reverse osmosis system reject water. Kidney Int. 88, 653–657 (2015).
Connor, A. et al. Toward greener dialysis: a case study to illustrate and encourage the salvage of reject water. J. Ren. Care 36, 68–72 (2010).
Agar, J. W. M. et al. Using water wisely: new, affordable, and essential water conservation practices for facility and home hemodialysis. Hemodial. Int. 13, 32–37 (2009).
Ponson, L., Arkouche, W. & Laville, M. Toward green dialysis: focus on water savings. Hemodial. Int. 18, 7–14 (2014).
North West Dialysis Service (Melbourne Health). Handbook for reusing or recycling reverse osmosis reject water from haemodialysis in healthcare facilities. https://waterportal.com.au/swf/images/swf-files/62r-2056-handbook.pdf (2010).
Grimsrud, L. & Babb, A. L. Optimization of dialyzer design for the hemodialysis system. Trans. Am. Soc. Artif. Intern. Organs 10, 101–106 (1964).
Leypoldt, J. K. & Cheung, A. K. Increases in mass transfer-area coefficients and urea Kt/V with increasing dialysate flow rate are greater for high-flux dialyzers. Am. J. Kidney Dis. 38, 575–579 (2001).
Kim, J. C. et al. Effect of fiber structure on dialysate flow profile and hollow-fiber hemodialyzer reliability: CT perfusion study. Int. J. Artif. Organs 31, 944–950 (2008).
Yamamoto, K. et al. Computational evaluation of dialysis fluid flow in dialyzers with variously designed jackets. Artif. Organs 33, 481–486 (2008).
Hirano, A. et al. Evaluation of dialyzer jacket structure and hollow-fiber dialysis membranes to achieve high dialysis performance. Ther. Apher. Dial. 15, 66–74 (2011).
Hirano, A. et al. Experimental evaluation of flow and dialysis performance of hollow-fiber dialyzers with different packing densities. J. Artif. Organs 15, 168–175 (2012).
Ronco, C. et al. Blood and dialysate flow distributions in hollow-fiber hemodialyzers analyzed by computerized helical scanning technique. J. Am. Soc. Nephrol. 13, S53–S61 (2002).
Ronco, C. et al. Dialysate flow distribution in hollow fiber hemodialyzers with different dialysate pathway configurations. Int. J. Artif. Organs 23, 601–609 (2000).
Albalate, M. et al. Is it useful to increase dialysate flow rate to improve the delivered Kt? BMC Nephrol. 16, 20 (2015).
Molano-Triviño, A. et al. Effects of decreasing dialysis fluid flow rate on dialysis efficacy and interdialytic weight gain in chronic hemodialysis - FLUGAIN Study. Nephrol. Dial. Transplant. 33, i514–i515 (2018).
Alayoud, A. et al. A model to predict optimal dialysate flow. Ther. Apher. Dial. 16, 152–158 (2012).
Kashiwagi, T. et al. Effects of reduced dialysis fluid flow in hemodialysis. J. Nippon Med. Sch. 80, 119–130 (2013).
Molano-Triviño, A., et al. Long term outcomes of lowering dialysate flow (Qd) in a population of chronic haemodialsysis patients in RTS Colombia. Abstract number WCN19-0387 (presented at the World Congress of Nephrology 2019, Melbourne, Australia).
Tarrass, F., Benjelloun, M. & Benjelloun, O. Recycling wastewater after hemodialysis: an environmental analysis for alternative water sources in arid regions. Am. J. Kidney Dis. 52, 154–158 (2008).
International Institute for Applied Systems Analysis. Water futures and solution fast track initiative - final report. http://pure.iiasa.ac.at/id/eprint/13008/1/WP-16-006.pdf (2016).
Renewable Energy Policy Network for the 21st Century. Renewables 2018: global status report. http://www.ren21.net/wp-content/uploads/2018/06/17-8652_GSR2018_FullReport_web_-1.pdf (2018)
World Economic Forum. The cost of generating renewable energy has fallen - a lot. https://www.weforum.org/agenda/2019/05/this-is-how-much-renewable-energy-prices-have-fallen/ (2019).
Deka. Tackling the giant goliath of bad water. http://www.dekaresearch.com/slingshot-2/ (2017).
Agar, J. W. Review: understanding sorbent dialysis systems. Nephrology 15, 406–411 (2010).
Ash, S. R. Sorbents in treatment of uremia: a short history and a great future. Semin. Dial. 22, 615–622 (2009).
Salani, M., Roy, S. & Fissell, W. H. Innovations in wearable and implantable artificial kidneys. Am. J. Kidney Dis. 72, 745–751 (2018).
Gura, V. et al. A wearable artificial kidney for patients with end-stage renal disease. JCI Insight. 72, 745–751 (2016).
Australian Government Department of Energy and Environment. Ecological risk assessment of dioxins in Australia. https://www.environment.gov.au/protection/publications/dioxins-technical-report-11 (2014).
World Health Organisation. Dioxins and their effects on human health. http://www.who.int/mediacentre/factsheets/fs225/en/ (2016).
Vinyl Council of Australia. PVC recycling in hospitals. https://www.vinyl.org.au/pvc-recycling-in-hospitals (2018).
Upadhyay, A., Sosa, M. & Jaber, B. L. Single-use versus reusable dialyzers: the known unknowns. Clin. J. Am. Soc. Nephrol. 2, 1079–1086 (2007).
Engineers Australia. Win-win as dialysis waste reinforces concrete. https://www.engineersaustralia.org.au/News/win-win-dialysis-waste-reinforces-concrete. (2017).
Create Digital. This innovative concrete recipe doubles as a way to recycle medical waste. https://www.createdigitalmagazine.org.au/concrete-doubles-recycle-medical-waste/ (2018).
European Parliament. Circular economy package. Four legislative proposals on waste. http://www.europarl.europa.eu/EPRS/EPRS-Briefing-573936-Circular-economy-package-FINAL.pdf (2016).
Knight, J. & Perkovic, V. The affordable dialysis prize steams ahead. Lancet 387, 1040 (2016).
Ellen Medical Devices. The world’s first affordable dialysis. https://www.ellenmedical.com (2018).
The George Institute for Global Health. World’s first low cost dialysis unveiled. https://www.dialysisprize.org (2015).
Jarl, J. et al. Do kidney transplantations save money? A study using a before–after design and multiple register-based data from Sweden. Clin. Kidney J. 11, 283–288 (2018).
Voelker, R. Cost of Transplant vs dialysis. JAMA 281, 2277 (1999).
Centre for Sustainable Healthcare. Kidney Care. https://sustainablehealthcare.org.uk/what-we-do/sustainable-specialties/kidney-care (2013).
Limb, M. NHS could save 1bn by adopting green strategies used in kidney units. Br. Med. J. 346, f588–f588 (2013).
Blankestijn, P. J. et al. ERA-EDTA invests in transformation to greener health care. Nephrol. Dial. Transplant. 33, 901–903 (2018).
Mouro Neto, J. A., Barraclough, K. A. & Agar, J. W. M. A call to action for sustainability in dialysis in Brazil. J. Bras. Nephrol. https://doi.org/10.1590/2175-8239-JBN-2019-0014 (2019).
Intergovernmental Panel on Biodiversity and Ecosystem Services. Media release: nature’s dangerous decline ‘unprecedented’; species extinction rates ‘accelerating.’ https://www.ipbes.net/news/Media-Release-Global-Assessment (2019).
Connor, A. & Mortimer, F. The green nephrology survey of sustainability in renal units in England, Scotland and Wales. J. Ren. Care 36, 153–160 (2010).
Barraclough, K. A. et al. Green dialysis survey: establishing a baseline for environmental sustainability across dialysis facilities in Victoria, Australia. Nephrology 24, 88–93 (2019).
Liyanage, T. et al. Worldwide access to treatment for end-stage kidney diseases: a systematic review. Lancet 385, 1975–1982 (2015).
King, H., Aubert, R. E. & Herman, W. H. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 21, 1414–1431 (1998).
World Health Organisation. Health co-benefits of climate change mitigation – transport sector http://extranet.who.int/iris/restricted/bitstream/10665/70913/1/9789241502917_eng.pdf?ua=1 (2011).
World Health Organisation. Global health risks: mortality and burden of disease attributable to selected major risks. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf (2009).
Zelle, D. M. et al. Physical inactivity: a risk factor and target for intervention in renal care. Nat. Rev. Nephrol. 13, 152–168 (2017).
Hallan, S. et al. Obesity, smoking, and physical inactivity as risk factors for CKD: are men more vulnerable? Am. J. Kidney Dis. 47, 396–405 (2006).
Friel, S. et al. Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture. Lancet 374, 2016–2025 (2009).
Aston, L. M., Smith, J. N. & Powles, J. W. Impact of a reduced red and processed meat dietary pattern on disease risks and greenhouse gas emissions in the UK: a modelling study. BMJ Open. https://doi.org/10.1136/bmjopen-2012-001072 (2012).
Willet, W. et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 393, 447–492 (2019).
Piccoli, G. B. et al. Low protein diets in patients with chronic kidney disease: a bridge between mainstream and complementary-alternative medicines? BMC Nephrol. 17, 76 (2016).
Author information
Authors and Affiliations
Contributions
K.B. researched the data for the article and wrote the manuscript. J.A. reviewed and/or edited the manuscript before submission.
Corresponding author
Ethics declarations
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.
Additional information
Peer review information
Nature Reviews Nephrology thanks Melissa Bilec, Peter Blankestijn, Giorgina Piccoli and John Stoves for their contribution to the peer review of this work.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Barraclough, K.A., Agar, J.W.M. Green nephrology. Nat Rev Nephrol 16, 257–268 (2020). https://doi.org/10.1038/s41581-019-0245-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41581-019-0245-1
This article is cited by
-
The role of clinical engineers in dialysis therapy in Japan
Renal Replacement Therapy (2024)
-
Eco-dialysis in Italy: where are we? National survey on the eco-sustainability of dialysis across Italian dialysis centers
Journal of Nephrology (2024)
-
A survey of environmental sustainability in Japanese dialysis facilities
Clinical and Experimental Nephrology (2024)
-
Green nephrology: an editor’s journey
Journal of Nephrology (2024)
-
Policy forum in the European Parliament: calling for a paradigm shift towards green kidney care
Journal of Nephrology (2023)