Year: 2021
Type: article
Abstract: Since its establishment in 1988, the Intergovernmental Panel on Climate Change, a United Nations body assessing the science related to climate change, has published several reports warning about global warming and emphasizing the fact that human activities clearly contribute to the observed climate changes. Indeed, in its last 2021 report [1], the panel notes once again that the global surface temperature has increased faster since 1970 than in any other 50-year period over at least the last 2000 years. The authors also consider that human-induced climate changes account for many of the weather and climate extreme fluctuations that we are experiencing, including heat waves, heavy rain events, floods and droughts. With time, global warming will not only change weather, but will also impact our way of life, affecting all aspects of the economy as well as the global health of populations. For a long time, climate changes have generated little concern among the scientific and medical communities, as suggested by a review of 11 944 climate abstracts from 1991 to 2011 matching the topics ‘global climate change’ or ‘global warming’, although the percentage of publications denying global warming in this review was extremely low [2]. This trend appears to have changed after 2015, as reported in a synthesis of systematic reviews of health impacts of climate change [3]. The collected reviews covered 10 health outcome categories, the three most common being infectious diseases, mortality and respiratory, cardiovascular or neurological outcomes. As mentioned by the authors, ‘most reviews suggested a deleterious impact of climate change on multiple adverse health outcomes, although the majority also called for more research’ [3]. Unexpectedly, healthcare itself represents an environmental burden that contributes to global climate changes. The impact of healthcare systems on the environment is estimated to range between 7% and 10% [4, 5]. Thus if nothing improves with time, at a certain point the fantastic benefits of recent medical developments might be offset by the health risks and the negative economic impacts caused by global warming. Nephrology does not escape from this duality, saving millions of lives through kidney replacement therapies (KRTs) but creating an important burden on the natural environment while running dialysis programmes. As with many other medical specialists, nephrologists are at the forefront of global warming health issues. Clinically they are increasingly exposed to the consequences of elevated temperatures induced by heat waves. Indeed, elevated temperatures can lead to severe dehydration and its consequences and increases in the severity and frequency of heat injuries, causing acute kidney diseases, including the newly defined clinical entity heat stress nephropathy [6]. This latter may actually represent one of the first epidemics due to global warming. In addition, nephrologists performing dialysis are faced with several major ecological challenges in their daily practice, as haemodialysis (HD) is a resource-hungry procedure consuming very high volumes of water (350–500 L of water per dialysis), producing substantial amounts of waste products (1.5–8 kg per dialysis) [7] and using a large amount of energy (∼7 kW per dialysis) [8]. For instance, in the dialysis centre of Lausanne University taking care of 80 HD patients, the 1-year consumption of water was calculated to be equivalent to the content of two Olympic-size swimming pools and 55 tons of wastes were produced [9]. Considering that >3.3 million patients receive KRT worldwide [10, 11], mainly HD (89%), it becomes increasingly urgent to reconsider the ecological impact of HD in all future developments and to implement new strategies to reduce water consumption, increase the availability of recyclable disposables and increase the use of renewable energies. One of the first initiatives to avoid wasting dialysis water came from Morocco, an arid country, where Tarrass et al. [12] demonstrated that HD wastewater could be cost-effectively recycled for irrigation use, such as watering gardens and landscape plantings. Agar (who commented on Tarrass et al.’s paper) [13] has published several papers promoting practical solutions that could be implemented in hospitals and dialysis centres in order to obtain a more ‘environment-friendly’ dialysis, renamed today as green dialysis [11, 14, 15]. Table 1 summarizes some of these suggestions. Today, the increased ecological awareness of the nephrology community as well as of industrial partners involved in the development of HD has resulted in some substantial improvements, mainly in terms of water consumption. For example, in the French NephroCare programme, the replacement of obsolete water treatment systems with more efficient devices enabled them to reduce the proportion of rejected water (from 60% to 20%), and with the introduction of the newest dialysis machines, the average water consumption per treatment has dropped by ~50% in 13 years [16]. However, the amount of water used per dialysis treatment still remains very high. Therefore new systems using sorbent cartridges are now considered, in particular for home dialysis [11]. In this context, a collaborative project between the Dutch Kidney Foundation and industry is ongoing under the name NextKidney (https://www.nextkidney.com). The main goal of this project is to develop a new home dialysis device using the sorbent approach, with the dialysate being regenerated and reused during the treatment. Hence only 6 L of dialysate would be required for each dialysis. Regarding the production of waste and its disposal, some improvements have been made as illustrated by the work of Piccoli et al. [7] However, a large percentage of disposables (>70%) remains neither recyclable nor reusable. In this domain, a closer collaboration with manufacturers should be encouraged, as ways of improvement exist to ameliorate the ecological quality of disposable materials used in HD and peritoneal dialysis [7, 17]. Today, as much as 90% of metal parts and tires from manufactured cars can be recycled [18]. Recently the European community mandated recycling of at least 50% of electric car batteries. Finally, in order to save energy, along with using renewable energy such as solar energy, new approaches are becoming available. One of these enables recovery of the heat energy contained in the wasted dialysate to warm the entering water through efficient heat exchangers. Today, the number of hospitals or centres that have initiated a process of changes and taken important steps to monitor or modify their dialysis programmes remains relatively limited [11]. Nevertheless, it seems that a movement is under way and several initiatives have been established to promote a culture change among dialysis providers. Indeed, some countries and national and international societies, including the European Renal Association [19], have created green networks or have published recommendations or position statements on how to reduce the environmental impact of delivering dialysis care to patients with kidney diseases [20–23]. Interestingly, these recommendations not only address the technical aspects of dialysis discussed above, but also the prevention of acute kidney injuries, the development of home dialysis [24] to lower the grey energy linked to transports, the promotion of new models of care such as telemedicine and a consideration of environmental concerns in all aspects of healthcare management. Moreover, all these recommendations emphasize the fact that the proposed changes are not only highly cost-effective, but are also an opportunity to improve renal care. In support of this ecological transformation of dialysis, several industrial companies are investing in durable and environmently compatible solutions. Regarding water utilization, political decisions are also needed to protect water sources around the world. Water is a precious resource that should not be wasted, and access to clean drinking water around the world has to be a key priority. In this respect, changing the way one delivers dialysis care is not just a fashion, it becomes a necessity. Although much remains to be done, nephrologists should be encouraged to join this movement for the well-being of their patients and the planet. None declared. Some interventions that may contribute to create an environmentally friendly centre (the list is not exhaustive) Raise awareness of the problem among all dialysis caregivers Monitor the carbon footprint of your dialysis centre Use most efficient reverse osmosis systems, rejecting a low percentage of the source water (∼20%). Consider using renewable sources of energy if available Check the energy consumption of your dialysis set-up. If you plan to replace HD machines, choose models consuming less electricity Consider the installation of heat exchangers to recover the wastewater energy Use proper function of HD machine to limit water and electricity consumption Reduce waste as much as possible Choose lightweight dialysers and use preferentially certified, environmently friendly, recyclable disposables Improve waste segregation, separating the recyclable and medical wastes Implement reverse osmosis rejected water reuse within the hospital or centre Carefully plan patients’ travel routes and centre selection to save time, money and decrease carbon dioxide emissions Develop home haemodialysis, possibly using sorbent technologies Develop telemonitoring of home patients Raise awareness of the problem among all dialysis caregivers Monitor the carbon footprint of your dialysis centre Use most efficient reverse osmosis systems, rejecting a low percentage of the source water (∼20%). Consider using renewable sources of energy if available Check the energy consumption of your dialysis set-up. If you plan to replace HD machines, choose models consuming less electricity Consider the installation of heat exchangers to recover the wastewater energy Use proper function of HD machine to limit water and electricity consumption Reduce waste as much as possible Choose lightweight dialysers and use preferentially certified, environmently friendly, recyclable disposables Improve waste segregation, separating the recyclable and medical wastes Implement reverse osmosis rejected water reuse within the hospital or centre Carefully plan patients’ travel routes and centre selection to save time, money and decrease carbon dioxide emissions Develop home haemodialysis, possibly using sorbent technologies Develop telemonitoring of home patients Some interventions that may contribute to create an environmentally friendly centre (the list is not exhaustive) Raise awareness of the problem among all dialysis caregivers Monitor the carbon footprint of your dialysis centre Use most efficient reverse osmosis systems, rejecting a low percentage of the source water (∼20%). Consider using renewable sources of energy if available Check the energy consumption of your dialysis set-up. If you plan to replace HD machines, choose models consuming less electricity Consider the installation of heat exchangers to recover the wastewater energy Use proper function of HD machine to limit water and electricity consumption Reduce waste as much as possible Choose lightweight dialysers and use preferentially certified, environmently friendly, recyclable disposables Improve waste segregation, separating the recyclable and medical wastes Implement reverse osmosis rejected water reuse within the hospital or centre Carefully plan patients’ travel routes and centre selection to save time, money and decrease carbon dioxide emissions Develop home haemodialysis, possibly using sorbent technologies Develop telemonitoring of home patients Raise awareness of the problem among all dialysis caregivers Monitor the carbon footprint of your dialysis centre Use most efficient reverse osmosis systems, rejecting a low percentage of the source water (∼20%). Consider using renewable sources of energy if available Check the energy consumption of your dialysis set-up. If you plan to replace HD machines, choose models consuming less electricity Consider the installation of heat exchangers to recover the wastewater energy Use proper function of HD machine to limit water and electricity consumption Reduce waste as much as possible Choose lightweight dialysers and use preferentially certified, environmently friendly, recyclable disposables Improve waste segregation, separating the recyclable and medical wastes Implement reverse osmosis rejected water reuse within the hospital or centre Carefully plan patients’ travel routes and centre selection to save time, money and decrease carbon dioxide emissions Develop home haemodialysis, possibly using sorbent technologies Develop telemonitoring of home patients
DOI: 10.1093/ndt/gfab260
Authors: Michel Burnier, Denis Fouque
Language: English
Subfield: Health, Toxicology and Mutagenesis
Field: Environmental Science
Domain: Physical Sciences
Open Access status: bronze
OpenAlex ID: W3197844057