https://orcid.org/0000-0003-1027-1851
ABSTRACT
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.
INTRODUCTION
How to start a manuscript, which should trigger change with the necessary feeling of time pressure without causing a paralysis of despair? A delicate balance, as we witness dramatic change around the increasingly visible negative impact of global warming. The environmental movement, which started in the sixties of the last century, has failed many of its goals and in 2018, a new generation began to make its voice heard with the “Fridays for future movement”. This attracted a lot of attention, but the real wake-up call came with a war and a gas crisis which rendered energy so expensive that governments, business, and individuals were forced to think very quickly about alternatives. In this context, many nephrologists started to rethink our use of resources when treating patients with kidney diseases.
Owing to human activities, current projections predict a trajectory of global warming, which will result in uninhabitable areas, extinction of species, and very significant costs [1]. Greenhouse gases (such as CO2, CH4, N2O, and others) trap heat in the atmosphere and cause global warming and heatwaves. CO2 is produced by burning fossil fuels and waste. Unfortunately, the health-care sector contributes significantly to this development by causing ∼4.4% of global greenhouse gas emissions worldwide [2].
Chronic kidney disease (CKD) is a global burden for patients, physicians, and the health-care systems with an estimated 850 million patients worldwide [3]. In its most severe form, renal replacement therapy (dialysis or transplantation) is necessary for survival. Inversely, dialysis has a significant environmental impact, in particular haemodialysis as it is used to treat ∼90% of the 2 million dialysis patients worldwide [4]. Haemodialysis consumes large amounts of water and energy, additionally it produces a significant amount of waste. The transport of patients and staff to and from the dialysis centres also results in significant CO2 emissions.
Therefore, the treatment of kidney diseases adds significantly to global warming. On the other hand, the importance of heat waves as a cause of both acute kidney disease and CKD has been well documented [5]. It is therefore not difficult to imagine a vicious cycle in which the negative impact of our treatment on the environment will increase the number of patients who then require the treatment in our facilities.
Currently, the nephrology community is coming together in various country-specific and international (ERA and ISN) working groups to develop a sustainable future for the treatment of kidney diseases. John Agar, one of (if not the) founder of this movement coined the term ‘green nephrology’ [6]. ‘Green dialysis’ or ‘green nephrology’ focuses on improving the environmental impact of the treatment. We termed our working group of the Swiss Society of Nephrology ‘Sustainable Nephrology’ to include the two additional pillars of sustainability, i.e. the social and financial impact. We did so, as we think that this broader view will reduce hurdles for a greener and sustainable future.
Many review papers have summarized the literature and have proposed recommendations [7–,12]. This paper is not one of them. The first goal of our working group was to provide a checklist for the Swiss nephrology centres to start improving the ecological and social impact of our treatment. As John Agar beautifully summarized, it is not easy to improve the impact of our doing even with a strong will, particularly as this is not part of the professional training of nephrologists and nurses [6]. Based on the discussions in the working group, we have formulated a set of 10 Action points that, we believe, are relatively easy to implement and may be of help to get started, without the requirement for large scale funding, infrastructure, or governmental support. The suggestions are based on a consensus between experts of our working group, and basically apply to the Swiss situation. The single suggestions are not new, but we believe that similar problems are encountered by nephrology centres around the world, and hope that our 10 suggestions may also be of use for others.
OVERVIEW
The 10 Action points are summarized in Table 1 and Fig. 1. Some of the Action points build on each other, whereas others can be developed in parallel. As mentioned in the Introduction, the Action points are the result of a consensus between Swiss working group members. They try to integrate recommendations from the literature, local experiences, common sense, and opinions from the authors. We fully acknowledge that these points may not apply to every situation, and they are therefore not imperative. Next, we will discuss the points in further detail.
Building a solid nephrology unit based on ongoing improvement for a ‘greener’ and more sustainable treatment of patients with kidney disease.
Ten points to develop a sustainable care system for kidney diseases.
| Action 1: Organize the effort and aim to change the mindsetWe suggest that every nephrology unit should have a dedicated team (or in smaller centres a person) responsible for questions about sustainability. In larger centres it is helpful to have an interdisciplinary working group. In hospitals, the existing working groups for sustainability should be contacted to coordinate the efforts. At the very least, nurses and doctors should come together to discuss methods of improvement. For the efforts to be effective, we suggest implementing a continuous improvement system. To get started, smaller changes are more likely to be adhered to. These steps should be regularly reviewed in scheduled meetings. |
| Action 2: Status quo and where to go. Gather information about current practices, and collect and review ideas for a more sustainable practice. Many ideas for smaller or even bigger improvements develop during a busy daily routine. These ideas pop-up during work, and are sometimes discussed with colleagues; unfortunately, these are very regularly lost as fast as they appear. Find an easy way to collect these ideas for review. Digital solutions could include a ‘sustainability chat site’ or a central document in which suggestions could be dropped and the person with the idea could be contacted later for details. Importantly, everybody in the working process should have a voice. |
| Action 3: Medical review The medical review should be performed independently from ecological ideas. The suggested review will optimize the patient's treatment and improve the sustainability of nephrology. A systematic pre-dialysis information will help to choose the best treatment option (in-centre HD, home HD, PD). This may increase the rate of home dialysis (thus diminishing travelling to the centre) and assure the best treatment method according to the needs of each patient. Dialysis should be started when uremic symptoms warrant it (life-threatening laboratory results should be avoided). Starting dialysis early according to renal function does not provide a proven benefit for the patient. Incremental dialysis could be considered in patients with sufficient residual kidney function. |
| Action 4: Waste handling and reductionWe suggest to review the ‘Waste Process’ in your centre. Strictly separate non-hazardous from hazardous (potentially infected) waste. The definition of hazardous waste might differ from country to country. The volume of hazardous waste is very important as it is expensive to discard and commonly additional plastic containers are necessary for the transport. Decrease the weight of hazardous waste by correctly purging the lines and the filter after use. Consideration should be given to the correct channel for special waste from care activities, e.g. in needle boxes ONLY sharps should be collected.Steps to reduce the non-hazardous waste: ➢ Reduce single use plastic/cardboard cups (use glass). ➢ Omit plastic cups to provide drugs given in the centre (e.g. use the blister). ➢ Use a washable dishcloth for all cleaning to reduce the use of wipes. ➢ Start machines up right on time (this reduces the amount of electricity, dialysate, and waste water). |
| Action 5: Recycling and waste recovery The materials to be recovered vary a lot at different sites. We suggest to plan which materials can be recycled; usually paper (careful with patient information), cardboard, PET bottles, glass, metals, and electric devices can be recycled and therefore should be separated from the rest of the waste. Plastic covers can increasingly be recycled, therefore these should also be collected separately. Review the unpacking of materials in your centre to help separate materials. Steps to increase recycling: ➢Evacuate and recycle PET (where is the PET recycling box?). ➢ Sorting of paper (develop a process for paper with patient information). ➢ Cardboard (collection at the site of unpacking?). ➢ Collect non-contaminated plastic waste (when there is a recycle plan available). |
| Action 6: Energy consumption We suggest to review the energy consumption in the centre. If possible, natural resources of energy should be used (e.g. solar panels on new buildings). A major part of the energy consumption is consumed by heating up the water/dialysate to the temperature used in the machine. Potential steps towards energy conservation: ➢ Switching off the machine when not in use to reduce energy and water consumption. ➢ Be vigilant on the lighting in the common rooms and corridors. Lower the light intensity whenever possible. ➢ Switch off the lights whenever possible in smaller rooms (e.g. in toilets, archives, material rooms etc.). ➢ Reduce dialysate temperature (e.g. 36°C are generally feasible, many centres use 35.5°C). ➢ Adjust dialysate flow when possible. If a blood flow > 300 ml/min is provided, flows higher than the blood flow have not been proved to be superior to a 1:1 flow (but more information is needed). In this case of uncertainty, recheck dialysis quality. ➢ Use the heat-energy before it goes to waste. Some machines are equipped with heat exchangers. Speak to your provider. ➢ If possible, use a more efficient technology than an electrical heater to heat the fluid. For example, the use of heat exchangers at a larger scale. ➢ For ambulatory consultations of non-dialysis CKD patients or PD patients, avoiding transport to the centre results in important reduction in energy use (fossil fuel burning). Online outpatient clinics can have a major impact. |
| Action 7: Water consumption We suggest to perform a review of the water system. Modern reverse osmosis systems reduce the amount of water needed significantly. Performance of the system should be analysed and optimized by an expert. The number of thermal disinfections should be reviewed. Weekly thermal disinfections are suitable for most systems. Reuse of water (including rejected water of reverse osmosis) according to hygienic and legal standards whenever it is possible should be discussed. Several steps that reduce water consumptions are also mentioned under Action point 6. In addition: ➢ Review indications and obtained substitution volumes of HDF. Consider using ‘Auto Sub’ function, if your machines provide this function. In case of substitution volumes <23 l/session, consider switching to HD or HDx (additional data are necessary). ➢ Use ecoflow/standby function before the patient is connected to the machine. ➢ Choose the optimal volume for bicarbonate ‘bottles’ for each patient, depending on the duration of the dialysis, HD vs HDF, dialysate flow. ➢ Avoid unnecessary disinfection, and discuss with suppliers the maximum time a machine can remain without disinfection (generally 72 h). Many machines are disinfected every day and are not used. ➢ Prescribe bag sparing/optimizing PD regimes. |
| Action 8: Human resourcesWe live in times of decreasing human resources. The workforce is shrinking due to lower birthrates and higher drop out rates for nurses. Patients are older, multimorbid, and need more support. This results in working conditions that are at times not sustainable. Furthermore, the working conditions are under financial pressure.Therefore, to help provide sustainable working conditions we suggest to: ➢ listen to needs of the team members ➢ empower team members to design processes (bottom up) ➢ support a continuous improvement process (see lean management) ➢ invest resources in better working conditions. |
| Action 9: Sustainable leadership We suggest that sustainability should not be viewed as an add-on to regular business, but should be part of the leadership of the unit. Developing sustainability into long-term profits is necessary. The efforts need to become financially lucrative as costs for energy, water, and waste will be reduced. A stable team due to sustainable human resource management forms the basis for a successful business. |
| Action 10: Promote discussion, consider your congress habits, and improve the carbon footprint of daily life Work cannot be separated from the daily life when it comes to sustainability. To leverage the efforts, the private sector needs to be involved. Small changes by us all in the private sector will add exponentially to the efforts to reduce CO2 emissions. To reduce private CO2 emissions: ➢ review private transport to work (carpooling for employees and patients? Train? Bicycle?) ➢ consider online attendance in international meetings ➢ review traffic and travelling (rethink flying) ➢ consider consumption of meat (reduce by 50%), consume local produce according to the season ➢ avoid ordering from foreign countries (see the full costs, not just the price for item) ➢ invest in sustainable resources. |
| Action 1: Organize the effort and aim to change the mindsetWe suggest that every nephrology unit should have a dedicated team (or in smaller centres a person) responsible for questions about sustainability. In larger centres it is helpful to have an interdisciplinary working group. In hospitals, the existing working groups for sustainability should be contacted to coordinate the efforts. At the very least, nurses and doctors should come together to discuss methods of improvement. For the efforts to be effective, we suggest implementing a continuous improvement system. To get started, smaller changes are more likely to be adhered to. These steps should be regularly reviewed in scheduled meetings. |
| Action 2: Status quo and where to go. Gather information about current practices, and collect and review ideas for a more sustainable practice. Many ideas for smaller or even bigger improvements develop during a busy daily routine. These ideas pop-up during work, and are sometimes discussed with colleagues; unfortunately, these are very regularly lost as fast as they appear. Find an easy way to collect these ideas for review. Digital solutions could include a ‘sustainability chat site’ or a central document in which suggestions could be dropped and the person with the idea could be contacted later for details. Importantly, everybody in the working process should have a voice. |
| Action 3: Medical review The medical review should be performed independently from ecological ideas. The suggested review will optimize the patient's treatment and improve the sustainability of nephrology. A systematic pre-dialysis information will help to choose the best treatment option (in-centre HD, home HD, PD). This may increase the rate of home dialysis (thus diminishing travelling to the centre) and assure the best treatment method according to the needs of each patient. Dialysis should be started when uremic symptoms warrant it (life-threatening laboratory results should be avoided). Starting dialysis early according to renal function does not provide a proven benefit for the patient. Incremental dialysis could be considered in patients with sufficient residual kidney function. |
| Action 4: Waste handling and reductionWe suggest to review the ‘Waste Process’ in your centre. Strictly separate non-hazardous from hazardous (potentially infected) waste. The definition of hazardous waste might differ from country to country. The volume of hazardous waste is very important as it is expensive to discard and commonly additional plastic containers are necessary for the transport. Decrease the weight of hazardous waste by correctly purging the lines and the filter after use. Consideration should be given to the correct channel for special waste from care activities, e.g. in needle boxes ONLY sharps should be collected.Steps to reduce the non-hazardous waste: ➢ Reduce single use plastic/cardboard cups (use glass). ➢ Omit plastic cups to provide drugs given in the centre (e.g. use the blister). ➢ Use a washable dishcloth for all cleaning to reduce the use of wipes. ➢ Start machines up right on time (this reduces the amount of electricity, dialysate, and waste water). |
| Action 5: Recycling and waste recovery The materials to be recovered vary a lot at different sites. We suggest to plan which materials can be recycled; usually paper (careful with patient information), cardboard, PET bottles, glass, metals, and electric devices can be recycled and therefore should be separated from the rest of the waste. Plastic covers can increasingly be recycled, therefore these should also be collected separately. Review the unpacking of materials in your centre to help separate materials. Steps to increase recycling: ➢Evacuate and recycle PET (where is the PET recycling box?). ➢ Sorting of paper (develop a process for paper with patient information). ➢ Cardboard (collection at the site of unpacking?). ➢ Collect non-contaminated plastic waste (when there is a recycle plan available). |
| Action 6: Energy consumption We suggest to review the energy consumption in the centre. If possible, natural resources of energy should be used (e.g. solar panels on new buildings). A major part of the energy consumption is consumed by heating up the water/dialysate to the temperature used in the machine. Potential steps towards energy conservation: ➢ Switching off the machine when not in use to reduce energy and water consumption. ➢ Be vigilant on the lighting in the common rooms and corridors. Lower the light intensity whenever possible. ➢ Switch off the lights whenever possible in smaller rooms (e.g. in toilets, archives, material rooms etc.). ➢ Reduce dialysate temperature (e.g. 36°C are generally feasible, many centres use 35.5°C). ➢ Adjust dialysate flow when possible. If a blood flow > 300 ml/min is provided, flows higher than the blood flow have not been proved to be superior to a 1:1 flow (but more information is needed). In this case of uncertainty, recheck dialysis quality. ➢ Use the heat-energy before it goes to waste. Some machines are equipped with heat exchangers. Speak to your provider. ➢ If possible, use a more efficient technology than an electrical heater to heat the fluid. For example, the use of heat exchangers at a larger scale. ➢ For ambulatory consultations of non-dialysis CKD patients or PD patients, avoiding transport to the centre results in important reduction in energy use (fossil fuel burning). Online outpatient clinics can have a major impact. |
| Action 7: Water consumption We suggest to perform a review of the water system. Modern reverse osmosis systems reduce the amount of water needed significantly. Performance of the system should be analysed and optimized by an expert. The number of thermal disinfections should be reviewed. Weekly thermal disinfections are suitable for most systems. Reuse of water (including rejected water of reverse osmosis) according to hygienic and legal standards whenever it is possible should be discussed. Several steps that reduce water consumptions are also mentioned under Action point 6. In addition: ➢ Review indications and obtained substitution volumes of HDF. Consider using ‘Auto Sub’ function, if your machines provide this function. In case of substitution volumes <23 l/session, consider switching to HD or HDx (additional data are necessary). ➢ Use ecoflow/standby function before the patient is connected to the machine. ➢ Choose the optimal volume for bicarbonate ‘bottles’ for each patient, depending on the duration of the dialysis, HD vs HDF, dialysate flow. ➢ Avoid unnecessary disinfection, and discuss with suppliers the maximum time a machine can remain without disinfection (generally 72 h). Many machines are disinfected every day and are not used. ➢ Prescribe bag sparing/optimizing PD regimes. |
| Action 8: Human resourcesWe live in times of decreasing human resources. The workforce is shrinking due to lower birthrates and higher drop out rates for nurses. Patients are older, multimorbid, and need more support. This results in working conditions that are at times not sustainable. Furthermore, the working conditions are under financial pressure.Therefore, to help provide sustainable working conditions we suggest to: ➢ listen to needs of the team members ➢ empower team members to design processes (bottom up) ➢ support a continuous improvement process (see lean management) ➢ invest resources in better working conditions. |
| Action 9: Sustainable leadership We suggest that sustainability should not be viewed as an add-on to regular business, but should be part of the leadership of the unit. Developing sustainability into long-term profits is necessary. The efforts need to become financially lucrative as costs for energy, water, and waste will be reduced. A stable team due to sustainable human resource management forms the basis for a successful business. |
| Action 10: Promote discussion, consider your congress habits, and improve the carbon footprint of daily life Work cannot be separated from the daily life when it comes to sustainability. To leverage the efforts, the private sector needs to be involved. Small changes by us all in the private sector will add exponentially to the efforts to reduce CO2 emissions. To reduce private CO2 emissions: ➢ review private transport to work (carpooling for employees and patients? Train? Bicycle?) ➢ consider online attendance in international meetings ➢ review traffic and travelling (rethink flying) ➢ consider consumption of meat (reduce by 50%), consume local produce according to the season ➢ avoid ordering from foreign countries (see the full costs, not just the price for item) ➢ invest in sustainable resources. |
Ten points to develop a sustainable care system for kidney diseases.
| Action 1: Organize the effort and aim to change the mindsetWe suggest that every nephrology unit should have a dedicated team (or in smaller centres a person) responsible for questions about sustainability. In larger centres it is helpful to have an interdisciplinary working group. In hospitals, the existing working groups for sustainability should be contacted to coordinate the efforts. At the very least, nurses and doctors should come together to discuss methods of improvement. For the efforts to be effective, we suggest implementing a continuous improvement system. To get started, smaller changes are more likely to be adhered to. These steps should be regularly reviewed in scheduled meetings. |
| Action 2: Status quo and where to go. Gather information about current practices, and collect and review ideas for a more sustainable practice. Many ideas for smaller or even bigger improvements develop during a busy daily routine. These ideas pop-up during work, and are sometimes discussed with colleagues; unfortunately, these are very regularly lost as fast as they appear. Find an easy way to collect these ideas for review. Digital solutions could include a ‘sustainability chat site’ or a central document in which suggestions could be dropped and the person with the idea could be contacted later for details. Importantly, everybody in the working process should have a voice. |
| Action 3: Medical review The medical review should be performed independently from ecological ideas. The suggested review will optimize the patient's treatment and improve the sustainability of nephrology. A systematic pre-dialysis information will help to choose the best treatment option (in-centre HD, home HD, PD). This may increase the rate of home dialysis (thus diminishing travelling to the centre) and assure the best treatment method according to the needs of each patient. Dialysis should be started when uremic symptoms warrant it (life-threatening laboratory results should be avoided). Starting dialysis early according to renal function does not provide a proven benefit for the patient. Incremental dialysis could be considered in patients with sufficient residual kidney function. |
| Action 4: Waste handling and reductionWe suggest to review the ‘Waste Process’ in your centre. Strictly separate non-hazardous from hazardous (potentially infected) waste. The definition of hazardous waste might differ from country to country. The volume of hazardous waste is very important as it is expensive to discard and commonly additional plastic containers are necessary for the transport. Decrease the weight of hazardous waste by correctly purging the lines and the filter after use. Consideration should be given to the correct channel for special waste from care activities, e.g. in needle boxes ONLY sharps should be collected.Steps to reduce the non-hazardous waste: ➢ Reduce single use plastic/cardboard cups (use glass). ➢ Omit plastic cups to provide drugs given in the centre (e.g. use the blister). ➢ Use a washable dishcloth for all cleaning to reduce the use of wipes. ➢ Start machines up right on time (this reduces the amount of electricity, dialysate, and waste water). |
| Action 5: Recycling and waste recovery The materials to be recovered vary a lot at different sites. We suggest to plan which materials can be recycled; usually paper (careful with patient information), cardboard, PET bottles, glass, metals, and electric devices can be recycled and therefore should be separated from the rest of the waste. Plastic covers can increasingly be recycled, therefore these should also be collected separately. Review the unpacking of materials in your centre to help separate materials. Steps to increase recycling: ➢Evacuate and recycle PET (where is the PET recycling box?). ➢ Sorting of paper (develop a process for paper with patient information). ➢ Cardboard (collection at the site of unpacking?). ➢ Collect non-contaminated plastic waste (when there is a recycle plan available). |
| Action 6: Energy consumption We suggest to review the energy consumption in the centre. If possible, natural resources of energy should be used (e.g. solar panels on new buildings). A major part of the energy consumption is consumed by heating up the water/dialysate to the temperature used in the machine. Potential steps towards energy conservation: ➢ Switching off the machine when not in use to reduce energy and water consumption. ➢ Be vigilant on the lighting in the common rooms and corridors. Lower the light intensity whenever possible. ➢ Switch off the lights whenever possible in smaller rooms (e.g. in toilets, archives, material rooms etc.). ➢ Reduce dialysate temperature (e.g. 36°C are generally feasible, many centres use 35.5°C). ➢ Adjust dialysate flow when possible. If a blood flow > 300 ml/min is provided, flows higher than the blood flow have not been proved to be superior to a 1:1 flow (but more information is needed). In this case of uncertainty, recheck dialysis quality. ➢ Use the heat-energy before it goes to waste. Some machines are equipped with heat exchangers. Speak to your provider. ➢ If possible, use a more efficient technology than an electrical heater to heat the fluid. For example, the use of heat exchangers at a larger scale. ➢ For ambulatory consultations of non-dialysis CKD patients or PD patients, avoiding transport to the centre results in important reduction in energy use (fossil fuel burning). Online outpatient clinics can have a major impact. |
| Action 7: Water consumption We suggest to perform a review of the water system. Modern reverse osmosis systems reduce the amount of water needed significantly. Performance of the system should be analysed and optimized by an expert. The number of thermal disinfections should be reviewed. Weekly thermal disinfections are suitable for most systems. Reuse of water (including rejected water of reverse osmosis) according to hygienic and legal standards whenever it is possible should be discussed. Several steps that reduce water consumptions are also mentioned under Action point 6. In addition: ➢ Review indications and obtained substitution volumes of HDF. Consider using ‘Auto Sub’ function, if your machines provide this function. In case of substitution volumes <23 l/session, consider switching to HD or HDx (additional data are necessary). ➢ Use ecoflow/standby function before the patient is connected to the machine. ➢ Choose the optimal volume for bicarbonate ‘bottles’ for each patient, depending on the duration of the dialysis, HD vs HDF, dialysate flow. ➢ Avoid unnecessary disinfection, and discuss with suppliers the maximum time a machine can remain without disinfection (generally 72 h). Many machines are disinfected every day and are not used. ➢ Prescribe bag sparing/optimizing PD regimes. |
| Action 8: Human resourcesWe live in times of decreasing human resources. The workforce is shrinking due to lower birthrates and higher drop out rates for nurses. Patients are older, multimorbid, and need more support. This results in working conditions that are at times not sustainable. Furthermore, the working conditions are under financial pressure.Therefore, to help provide sustainable working conditions we suggest to: ➢ listen to needs of the team members ➢ empower team members to design processes (bottom up) ➢ support a continuous improvement process (see lean management) ➢ invest resources in better working conditions. |
| Action 9: Sustainable leadership We suggest that sustainability should not be viewed as an add-on to regular business, but should be part of the leadership of the unit. Developing sustainability into long-term profits is necessary. The efforts need to become financially lucrative as costs for energy, water, and waste will be reduced. A stable team due to sustainable human resource management forms the basis for a successful business. |
| Action 10: Promote discussion, consider your congress habits, and improve the carbon footprint of daily life Work cannot be separated from the daily life when it comes to sustainability. To leverage the efforts, the private sector needs to be involved. Small changes by us all in the private sector will add exponentially to the efforts to reduce CO2 emissions. To reduce private CO2 emissions: ➢ review private transport to work (carpooling for employees and patients? Train? Bicycle?) ➢ consider online attendance in international meetings ➢ review traffic and travelling (rethink flying) ➢ consider consumption of meat (reduce by 50%), consume local produce according to the season ➢ avoid ordering from foreign countries (see the full costs, not just the price for item) ➢ invest in sustainable resources. |
| Action 1: Organize the effort and aim to change the mindsetWe suggest that every nephrology unit should have a dedicated team (or in smaller centres a person) responsible for questions about sustainability. In larger centres it is helpful to have an interdisciplinary working group. In hospitals, the existing working groups for sustainability should be contacted to coordinate the efforts. At the very least, nurses and doctors should come together to discuss methods of improvement. For the efforts to be effective, we suggest implementing a continuous improvement system. To get started, smaller changes are more likely to be adhered to. These steps should be regularly reviewed in scheduled meetings. |
| Action 2: Status quo and where to go. Gather information about current practices, and collect and review ideas for a more sustainable practice. Many ideas for smaller or even bigger improvements develop during a busy daily routine. These ideas pop-up during work, and are sometimes discussed with colleagues; unfortunately, these are very regularly lost as fast as they appear. Find an easy way to collect these ideas for review. Digital solutions could include a ‘sustainability chat site’ or a central document in which suggestions could be dropped and the person with the idea could be contacted later for details. Importantly, everybody in the working process should have a voice. |
| Action 3: Medical review The medical review should be performed independently from ecological ideas. The suggested review will optimize the patient's treatment and improve the sustainability of nephrology. A systematic pre-dialysis information will help to choose the best treatment option (in-centre HD, home HD, PD). This may increase the rate of home dialysis (thus diminishing travelling to the centre) and assure the best treatment method according to the needs of each patient. Dialysis should be started when uremic symptoms warrant it (life-threatening laboratory results should be avoided). Starting dialysis early according to renal function does not provide a proven benefit for the patient. Incremental dialysis could be considered in patients with sufficient residual kidney function. |
| Action 4: Waste handling and reductionWe suggest to review the ‘Waste Process’ in your centre. Strictly separate non-hazardous from hazardous (potentially infected) waste. The definition of hazardous waste might differ from country to country. The volume of hazardous waste is very important as it is expensive to discard and commonly additional plastic containers are necessary for the transport. Decrease the weight of hazardous waste by correctly purging the lines and the filter after use. Consideration should be given to the correct channel for special waste from care activities, e.g. in needle boxes ONLY sharps should be collected.Steps to reduce the non-hazardous waste: ➢ Reduce single use plastic/cardboard cups (use glass). ➢ Omit plastic cups to provide drugs given in the centre (e.g. use the blister). ➢ Use a washable dishcloth for all cleaning to reduce the use of wipes. ➢ Start machines up right on time (this reduces the amount of electricity, dialysate, and waste water). |
| Action 5: Recycling and waste recovery The materials to be recovered vary a lot at different sites. We suggest to plan which materials can be recycled; usually paper (careful with patient information), cardboard, PET bottles, glass, metals, and electric devices can be recycled and therefore should be separated from the rest of the waste. Plastic covers can increasingly be recycled, therefore these should also be collected separately. Review the unpacking of materials in your centre to help separate materials. Steps to increase recycling: ➢Evacuate and recycle PET (where is the PET recycling box?). ➢ Sorting of paper (develop a process for paper with patient information). ➢ Cardboard (collection at the site of unpacking?). ➢ Collect non-contaminated plastic waste (when there is a recycle plan available). |
| Action 6: Energy consumption We suggest to review the energy consumption in the centre. If possible, natural resources of energy should be used (e.g. solar panels on new buildings). A major part of the energy consumption is consumed by heating up the water/dialysate to the temperature used in the machine. Potential steps towards energy conservation: ➢ Switching off the machine when not in use to reduce energy and water consumption. ➢ Be vigilant on the lighting in the common rooms and corridors. Lower the light intensity whenever possible. ➢ Switch off the lights whenever possible in smaller rooms (e.g. in toilets, archives, material rooms etc.). ➢ Reduce dialysate temperature (e.g. 36°C are generally feasible, many centres use 35.5°C). ➢ Adjust dialysate flow when possible. If a blood flow > 300 ml/min is provided, flows higher than the blood flow have not been proved to be superior to a 1:1 flow (but more information is needed). In this case of uncertainty, recheck dialysis quality. ➢ Use the heat-energy before it goes to waste. Some machines are equipped with heat exchangers. Speak to your provider. ➢ If possible, use a more efficient technology than an electrical heater to heat the fluid. For example, the use of heat exchangers at a larger scale. ➢ For ambulatory consultations of non-dialysis CKD patients or PD patients, avoiding transport to the centre results in important reduction in energy use (fossil fuel burning). Online outpatient clinics can have a major impact. |
| Action 7: Water consumption We suggest to perform a review of the water system. Modern reverse osmosis systems reduce the amount of water needed significantly. Performance of the system should be analysed and optimized by an expert. The number of thermal disinfections should be reviewed. Weekly thermal disinfections are suitable for most systems. Reuse of water (including rejected water of reverse osmosis) according to hygienic and legal standards whenever it is possible should be discussed. Several steps that reduce water consumptions are also mentioned under Action point 6. In addition: ➢ Review indications and obtained substitution volumes of HDF. Consider using ‘Auto Sub’ function, if your machines provide this function. In case of substitution volumes <23 l/session, consider switching to HD or HDx (additional data are necessary). ➢ Use ecoflow/standby function before the patient is connected to the machine. ➢ Choose the optimal volume for bicarbonate ‘bottles’ for each patient, depending on the duration of the dialysis, HD vs HDF, dialysate flow. ➢ Avoid unnecessary disinfection, and discuss with suppliers the maximum time a machine can remain without disinfection (generally 72 h). Many machines are disinfected every day and are not used. ➢ Prescribe bag sparing/optimizing PD regimes. |
| Action 8: Human resourcesWe live in times of decreasing human resources. The workforce is shrinking due to lower birthrates and higher drop out rates for nurses. Patients are older, multimorbid, and need more support. This results in working conditions that are at times not sustainable. Furthermore, the working conditions are under financial pressure.Therefore, to help provide sustainable working conditions we suggest to: ➢ listen to needs of the team members ➢ empower team members to design processes (bottom up) ➢ support a continuous improvement process (see lean management) ➢ invest resources in better working conditions. |
| Action 9: Sustainable leadership We suggest that sustainability should not be viewed as an add-on to regular business, but should be part of the leadership of the unit. Developing sustainability into long-term profits is necessary. The efforts need to become financially lucrative as costs for energy, water, and waste will be reduced. A stable team due to sustainable human resource management forms the basis for a successful business. |
| Action 10: Promote discussion, consider your congress habits, and improve the carbon footprint of daily life Work cannot be separated from the daily life when it comes to sustainability. To leverage the efforts, the private sector needs to be involved. Small changes by us all in the private sector will add exponentially to the efforts to reduce CO2 emissions. To reduce private CO2 emissions: ➢ review private transport to work (carpooling for employees and patients? Train? Bicycle?) ➢ consider online attendance in international meetings ➢ review traffic and travelling (rethink flying) ➢ consider consumption of meat (reduce by 50%), consume local produce according to the season ➢ avoid ordering from foreign countries (see the full costs, not just the price for item) ➢ invest in sustainable resources. |
ACTION 1: ORGANIZE THE EFFORT AND AIM TO CHANGE THE MINDSET
We suggest that the first step in improving sustainability is to bring the nephrology team together to discuss the situation, and identify motivated team members that will be responsible for sustainability issues. Ideally, one should include not only physicians and nurses in the ‘sustainability team’, but also technicians, logistic experts, cleaning services, waste management, purchasing department, etc.
It could be helpful if the group interacts with national and international working groups on sustainable nephrology, as well as with local groups e.g. within the same hospital. As improvements in sustainability require regular adjustments in daily practice, we suggest to reserve protected time for regular discussions and use a continuous improvement system as suggested in lean management [13]. Regular reviews of the achieved goals will help to maintain them.
ACTION 2: STATUS QUO AND WHERE TO GO
To our experience, many ideas for small or large improvements develop during a busy daily routine. However, while these ideas are sometimes discussed with colleagues, they are often lost as quickly as they appear. We therefore suggest to use easy ways to collect and keep these ideas for review. Digital solutions could be a ‘sustainability chat site’ or a central document where suggestions can be added. The person who wrote down the idea could be invited to the next meeting. In this way, everyone in the working process participates in the process.
ACTION 3: MEDICAL REVIEW
We suggest to perform the medical review independent of ecological and financial aspects, but focused on the medical and personal needs of the patient.
Avoiding or delaying dialysis by offering optimal treatment of CKD patients is probably the most effective way to reduce the environmental impact of nephrology. The systematic treatment of patients with CKD is beyond the scope of this review. We suggest that a systematic information of patients about forms of renal replacement therapy, conservative treatment, and renal transplantation is an integrative part of CKD clinics.
Once end-stage kidney disease has developed, environmental considerations actually have no place in the decision of what treatment should be started for a patient. It should be a shared decision with a focus on the symptoms of the patient, taking into account his/her preferences. This also applies to the use of incremental haemodialysis, or stopping dialysis when the clinical situation requires it or the patient wishes to stop. Incremental dialysis is regularly used in peritoneal dialysis (PD) and discussions are ongoing in HD [14]. Home treatment programmes should be made available as much as possible to patients who prefer home treatment modalities, thus avoiding regular travelling to the centre.
The working group suggests that ethical issues (e.g. reviewed in [20]) in the decision for renal replacement therapy are also important for questions of sustainability. In Switzerland as in other countries (e.g. Germany) there is still a financial incentive towards the use of haemodialysis. The income in Switzerland depends on the number of haemodialysis sessions performed, not necessarily because of a good coverage of haemodialysis, but also because of a poor coverage of the chronic outpatient treatment and under-coverage of the costs for hospitalizations (particularly in the elderly with multiple diseases). This is illustrated by the rapid increase in the number of units focused on haemodialysis even in areas already well covered by nephrologists. This may influence the timing, type, and frequency of dialysis and of course possibly the carbon footprint. Reimbursement structures and/or quality standards may also be a barrier towards incremental haemodialysis. In Germany, for example, thrice weekly haemodialysis is part of the agreed quality standard for most patients, together with a weekly Kt/V with financial penalties if targets are not met [14]. This is probably a reminder that efforts for a more sustainable nephrology practice should include a wide range of stakeholders, including insurance companies, and that sustainability needs to become part of discussions around quality standards.
The organization of ambulatory consultations has a significant environmental impact, and some modifications may lead to considerable reductions in carbon footprint.
The COVID-19 pandemic has shown that virtual consultations (by video-conferencing) are feasible. The concept of virtual consultations predates the pandemic and, not surprisingly, originates from regions where specialized health care is delivered across a large geographical area [15]. In this scenario, a significant contribution to reducing the carbon footprint can be made if patients avoid long (fossil fuel) journeys to routine appointments [16]. In comparison, the concept may be much less attractive for an urban unit where many patients live nearby or commute by public transport. Patients after kidney transplantation are, for obvious reasons, an attractive cohort to implement this approach [17]. To make virtual consultations a success, it is suggested to perform these consultations in dedicated rooms, equipped with video consultation software, a good wireless quality headset and camera, and optimal room design [18]. Finally, we suggest that colleagues be realistic about the time and effort required to set up dedicated video clinics.
ACTION 4: WASTE MANAGEMENT
Dialysis, both peritoneal and haemodialysis, produce a significant amount of waste. The amounts reported vary widely both within and between countries. Figures range from 1.5 to 8 kg of waste per haemodialysis session [19] and about 1.7 kg of plastic waste per day for ‘full dose’ PD (with very little information in this area [20]). Therefore, waste management is particularly important in improving the sustainability of dialysis.
We suggest that a consequent use of the four R principle (reduce–recycle–reuse–repair) will help to achieve this goal. We suggest that the first R, reduce, starts with a careful review of the ‘waste process’. The definition of ‘hazardous waste’ might differ from country to country, but usually concerns materials that have come into contact with body fluids and are potentially infectious. Still, as many processes have been developed in the past without significant efforts to reduce the CO2 footprint, these need to be updated according to current goals and legislation. The volume of hazardous waste is important as it is not only expensive to discard but, commonly, additional plastic containers are necessary to separate it. Therefore, we suggest to strictly separate hazardous from non-hazardous waste. The weight of the hazardous waste can be significantly decreased by correctly purging the lines and the filter after use. Finally, concerning hazardous materials there are special containers for sharps. These containers should only be filled with sharps (not with e.g. plastic syringes). Besides these, reduction of hazardous waste is limited.
The reduction of non-hazardous waste is in general easier. For example, choose the correct volume of bicarbonate bags for each patient. Use blisters instead of non-reusable plastic cups to provide oral medication. Concerning household and cleaning materials consider replacing single use plastic/cardboard cups by glass. The investment required to use reusable glasses and cups is commonly only the change of the process as dishwashers are often available. Reviewing the cleaning process and using washable dishcloths whenever possible will reduce the use of wipes.
ACTION 5: RECYCLING AND WASTE RECOVERY
The materials to be recovered vary greatly between sites within and between countries. We suggest to review the local access to recovery of materials and develop a plan for the materials to be recycled. Paper is usually at the top of the list, followed by cardboard, glass, and PET bottles. These are recycled in most European countries. PET bottles should be collected and evacuated in PET recycling boxes. We noticed that the positioning and number of PET recycling boxes are a major factor in the amount of recovered PET (easy access is pivotal). Electrical equipment, batteries, and non-contaminated metal should also be separated from the rest of the waste.
ACTION 6: ENERGY CONSUMPTION
The energy consumption in the unit should be quantified and reviewed, and can be divided into directly and indirectly dialysis related.
According to French data, a haemodialysis patient uses 2543 kWh per year directly for his or her dialysis treatments, corresponding for a patient on a three-times weekly schedule to 16.3 kWh per session [21]. About 60%–70% of this amount is used by the water treatment systems, whereas the dialysis machines consume 9%–13% [12, 22]. In comparison, an average Swiss household uses 14.2 kWh/day, versus for example 12.9 kWh/day in France and 18.4 kWh in Australia [23].
The price of electricity and fossil energy is expected to increase, and it remains an open question whether the actual structure of in-centre haemodialysis will be sustainable in the long term if no changes are made. Actions should be centred around two strategies: reduce energy consumption and increase the use of energy from sustainable sources (solar panels, wind energy, heat exchangers).
It is difficult, but not impossible to reduce energy consumption. The water treatment system is the major player in energy consumption of the dialysis centre, and any action that reduces the amount of produced dialysis water or reuses used dialysis water will have a positive impact on energy consumption. Concerning the water treatment system, thermal disinfection at a frequency of 1–2 per week instead of once per day may be enough. Here the providers and legal requirements must be followed.
Reducing the dialysis water temperature from 36.5 to 36 or even 35.5°C is technically feasible and without risk [24], and will lead to a considerable reduction in power consumption. However, patients can feel uncomfortable and may be unwilling to collaborate.
Indirectly dialysis-related issues include mainly transportation of patients and health personnel, which accounts for 20%–30% of the total energy consumption of haemodialysis, but also heating of and lighting of the dialysis unit [25, 26].
Substantial reductions may be obtained by reducing the room temperature in the dialysis ward from, for example, 24 to 21°C. However, the comfort of patients and health-care workers could be compromised at this temperature, especially in older patients [27] and such a reduction is therefore not generally recommended.
We suggest to be vigilant on the lighting in common rooms and corridors by lowering the light intensity and switching off lights whenever possible in smaller rooms (e.g. in toilets, archives, material rooms etc.). Replacing older bulbs with light-emitting diodes reduces the amount of electricity significantly.
An often-overlooked aspect of energy consumption is the production of drugs. Dialysis patients must take on average eight different drug classes, and are subject to frequent changes in prescriptions according to their laboratory and clinical results [28]. Many distributed medications may remain unused in the homes of the patients, and could benefit others. Therefore, redispensing of unused oral drugs is an interesting option, and would lead to reductions in both energy consumption and waste. Such a strategy has been implemented with success in some oncological centres [29]. Dialysis centres are well-placed to coordinate similar actions in their patients in collaboration with hospitals or local pharmacies.
Increasing the use of energy from sustainable sources such as solar or wind energy is the second pillar, but this requires relatively large investments in the beginning. Nevertheless, these investments are quickly recovered. A pilot project in Australia managed to reduce the power costs of a four-chair home haemodialysis training centre by 77% after the placement of a 24 m² solar array and inverter. The authors calculated that the investment would pay off by the savings in energy consumption after 7.7 years [22]. Most studies have focused on the impact of solar panels, but they have the drawbacks that they are not producing any energy after sunset until the next sunrise, and that their efficacy depends of the number of sunny hours.
An original way to generate electricity and generate power from the sewer was demonstrated using a micro-hydroturbine that works on the water pressure of the reverse osmosis reject water to generate electricity. The hydroturbine generated 1.6 kWh per day, and decreased CO2 emission with 300 kg CO2eq per year [30].
PD is generally considered less energy consuming than haemodialysis, as this is a home treatment without the need for transportation and water consumption is much lower. CAPD can be performed without electricity. However indirectly the production of PD bags is energy hungry. The exact amount needed for the production of one bag is unknown, but Baxter's yearly report mentions that the annual consumption of energy of Baxter was 3.1 million megawatt hours (MWh) in 2022, which was 4.2% more than in 2021 in absolute terms. Baxter announced that they completed 163 energy saving projects, and that 30% of their energy came from renewable sources [31]. Clearly, this is without including transportation costs of the bags to local providers and patients.
At a patient level, it is difficult to reduce energy costs. Patients should be encouraged to invest in renewable energy, and be reimbursed for these investments to cover their electricity costs more easily.
Incremental PD has been integrated in patient care for many years, and has shown outcomes that are identical to those who receive full dose [32]. Hence, nephrologists should continue to do so, and their prescriptions should be guided by symptoms and quality of life, instead of solely achieving Kt/V. For CAPD and APD one may prescribe bag sparing/optimizing PD regimes. Small changes in the prescription can change the number of bags without a significant impact on dialysis quality. Reduction of the bags will reduce not only energy consumption but also water use, which will be discussed next.
ACTION 7: WATER HANDLING
We suggest that the reduction of water consumption starts with a review of the water system and water use. Modern reverse osmosis systems significantly reduce the amount of water needed [33]. The number of thermal disinfections should be reviewed. We recommend to try to reuse water (including rejected water of reverse osmosis) according to hygienic and legal standards whenever it is possible [34].
We suggest to evaluate the indication and obtained substitution volumes of hemodiafiltration (HDF), keeping in mind that the benefits of HDF are clinically relevant only if the substitution fluid is above 23 l/session, which usually requires a blood flow rate >350 ml/min [35, 36]. Use a standby function (if available) before the patient is connected to the machine. Avoid unnecessary disinfections and discuss with suppliers the maximum time a machine not in use can remain without disinfection (generally 72 h). For long-term projects and new buildings, a centralized water preparation system should be used [37]. Many aspects discussed under Action 6 also reduce water consumption.
ACTION 8: HUMAN RESOURCES
The actual situation in Switzerland is characterized by a rapid decline in human resources; this is particularly true for nurses trained in nephrology. The workforce is shrinking due to lower birthrates, part-time work, and increases in ‘burn out’ and absenteeism [38].
Sustainable care for patients with kidney disease depends on a sufficient number of doctors and nurses trained in nephrology. The number of trained nephrologists varies worldwide and a shortage of nephrologists was identified in low-income countries [39]. In Switzerland, the nephrological community is facing a shortage of dialysis nurses. Improving sustainability in nephrology needs dedicated time for nephrology health-care workers who are at the core of this process. It is therefore important to develop (or maintain) attractive training and working conditions for health-care workers in the field of dialysis.
ACTION 9: SUSTAINABLE LEADERSHIP
In many companies, sustainability is no longer viewed as an add-on to regular business, but as a full part of the company's short-and long-term strategy. As the costs for waste management, water, energy, and human resources rise, a sustainable approach is also essential for hospitals and dialysis centres to guarantee affordable care in the long term.
ACTION 10: PROMOTE DISCUSSION, CONSIDER YOUR CONGRESS HABITS, AND IMPROVE THE CARBON FOOTPRINT OF DAILY LIFE
In our experience, implementing sustainable measures in the dialysis unit leads to a more critical look from collaborators and patients towards their carbon footprints outside the dialysis unit. There are of course various and very distinct ways to improve the private carbon footprint, and here we mention three examples.
Private transport to work is an area that offers significant opportunities. The use of carpools for employees and patients should be encouraged. Sometimes, small changes in the daily schedules may allow employees to use the train or public transport.
Conference attendance has always been a cornerstone of continuous professional development through interaction, discussion, and networking. However, any in-person attendance will incur a significant carbon footprint, particularly via air travel [40]. We believe that now is the time to rethink how much in-person congress attendance we really need. The European Renal Association has already committed to making its congresses as environmentally friendly as possible and showcased its efforts during the 2023 congress in Milan [41]. More transparency of congresses’ environmental impact, voluntary personal reflection, online participation, and calculation of individual carbon footprints and optional display on professional development calendars could be important first steps on this journey.
Meat consumption contributes significantly to the personal CO2 footprint [42]. Reducing meat intake will not only lead to reductions in carbon footprint and water consumption, but also leads to a slower decline of renal function in patients with CKD.
CONCLUSION: THIS END IS JUST THE BEGINNING
If recent predictions are correct, then most kidney patients and health-care workers in our specialty will experience a significant impact of climate change in the near future. This will not only affect the spectrum of renal diseases that we see but also the provision of renal care and many aspects of our daily work. Therefore, we believe that it is on all of us to start and make meaningful changes without further delay. In this sense, we hope that our list of 10 Action points will give health-care workers in nephrology, providers, and policy makers an idea of what can be done in a relatively easy way, and on a small scale. Many recommendations are based on common sense and best practice, as only few studies have been performed in this field. More research is urgently needed to develop validated strategies that reduce the environmental impact of dialysis without compromising patient safety and outcome.
DATA AVAILABILITY STATEMENT
No new data were generated or analysed in support of this research.
CONFLICT OF INTEREST STATEMENT
A.W. is member of the Clinical Kidney Journal editorial board.
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