Environmentally Sustainable Kidney Care: Are We There Yet?

Climate change is a growing concern and is now regarded as a formidable threat to the well-being of all forms of life on Planet Earth. Global warming is but one facet of this change in climate and has cascading effects on the environment, including pattern and quantity of rainfall, melting of glaciers, floods, famines, and wildfires. The consequences of this are enormous, affecting food production, food quality, population migration, and other socioeconomic aspects affecting our lives. Climate change is closely related to human activity. Large-scale industrialization and urbanization have led to enormous combustion of fossil fuel. This in turn is associated with worsening air and water pollution with negative impact on all aspects of life.[1-3] The recent discussion in the mainstream media and social media regarding the pollution of the Yamuna River and the alarmingly high air quality index in New Delhi should alert us all to the bigger picture of the widespread effects that environmental changes can have on our existence.[4] According to the 2024 report of the Lancet Countdown, people all around the world are facing record-breaking threats to their well-being, health, and survival from the rapidly changing climate. Of the 15 indicators monitoring climate change-related health hazards, exposures, and impacts, 10 reached concerning new records in their most recent year of data.[5] Of these, it is human health that is of most concern to us. Climate change is now recognized as one of the key players affecting physical and mental health and is a threat multiplier. The environmental impact due to climate change is so huge that it threatens to negate all the positive measures on public health that have happened with the scientific progress on this earth so far.[1] The consequences can be far-ranging and can affect us in unimaginable ways. In the recent hurricane Helene affecting the southern states of Florida, Texas, etc., in the US, one of the manufacturing plants in North Carolina state suffered damage and this resulted in an acute shortage of intravenous fluids and peritoneal dialysis (PD) fluids.[6] The effects were felt in the whole of the US with a nationwide disruption of health services. Many centers had to cancel elective surgeries and nephrologists had to chalk out alternative treatment plans for their patients on PD.[7] Another remote effect that has been well documented is the spread of vector-borne diseases to regions that did not see the infection before. Studies show that with the worsening global warming, insect vectors migrate and proliferate to new regions with hot, humid weather conditions.[8] In European countries such as Spain, Portugal, and France, autochthonous cases of vector-borne diseases such as malaria, dengue, and chikungunya have been reported.[9] Interestingly, healthcare establishments also contribute to global warming and climate change.[10] The impact of healthcare systems on the environment is estimated to range between 7% and 10%.[11] Hospitals and allied sectors contribute to 5%–7% of the total greenhouse gas (GHG) emissions.[12] Use of nonrenewable energy, enormous usage of water, and the plastic waste generation in healthcare establishments are enormous. Manufacturing replacements for disposable items such as surgical equipment, blood pressure cuffs, and bed linen generate a large amount of emissions. The consumption of single-use items has become an even bigger concern with the occurrence of the COVID-19 pandemic.[13] Renal services are among the most significant contributors to carbon footprint among all health services. A UK study revealed that renal services contributed to a carbon footprint of 3006 tons of carbon dioxide equivalents per annum, with dialysis services contributing 62.5% of carbon emissions.[14] The water consumption in a hemodialysis unit is of staggering proportions. Current RO systems are inefficient; between 50% and 70% of the source water at the RO membrane is rejected. Thus, in a typical 4-h dialysis session, water consumption in each session of hemodialysis may be as high as 500 liters. Similarly, power consumption is also huge. It is estimated that 2.5 kg of hazardous waste is generated per hemodialysis treatment, of which 38% is plastic. In addition, manufacture and transport of pharmaceuticals and dialysis consumables also result in large-scale GHG emissions.[15] Although PD is much more sustainable than HD, still there is a large amount of plastic waste generation.[16] Understanding these challenges also brings with it an opportunity for us to participate individually and as a community to mitigate climate change. How best can we mitigate the environmental hazards due to dialysis? Employing green nephrology measures of “Reduce, reuse and recycling” is the need of the hour.[16] Incremental dialysis is to be considered in patients with sufficient renal reserve. Renewable energy sources like solar power can be used. Central dialysate delivery systems, if employed can go a long way in reducing plastic wastage.[15] However, in India, we are still way behind in adopting green dialysis measures. Despite all the compelling arguments, although appearing justifiable, the prevailing dialysis practices appear to be quite opposite to what has been traditionally taught as the standards of clinical care. Nephrologists have traditionally been trained to provide thrice weekly dialysis. Many nephrologists would hesitate to offer incremental dialysis, even with evidence to support it. Studies have shown that incremental dialysis could be sufficient and adequate clearance can be obtained. Studies have also shown that there are better chances for preservation of residual renal function for longer periods compared to thrice weekly conventional dialysis.[17] In most low- and middle-income countries, including India, many patients undergo twice-weekly dialysis. Incremental dialysis is most often offered to patients with end-stage kidney disease mostly for socioeconomic reasons rather than efficacy reasons.[17] Countries like India, have traditionally adopted cotton, “household-like,” reusable hospital material for hospital linen. With the emphasis changing to disposable stuff, hospitals quickly adapted to the use of disposable bed linen and gowns. This has now proved to be an environmentally unsustainable policy. Most dialysis units have not adopted renewable energy sources. Many centers, including public sector hospitals, have started shifting to single-use dialyzers.[18] This policy needs a re-look as the waste generation is considerable. Electronic health records and paperless documentation are still not in wide use. Westernization in diet and lifestyle has negatively impacted the burden of noncommunicable diseases, including CKD. What then is the right way forward? While we can intuitively agree that the prevention of CKD is the most sustainable way forward, promotion of kidney transplantation is the next best solution.[16] However in the “less than ideal” real world, we face the inimitable challenge of choosing the best possible way to offer dialysis to our patients. The dialysis centers are also increasing in number and reach, with centers opening even in taluka places. However, there is a need for policy making, keeping the best interests of the patient in mind, at the same time, considering more sustainable ways of dialysis. We need to revisit our age-old practices of incremental dialysis, cotton linen and multiple-use dialyzers. Till we understand better ways to perform sustainable dialysis, it may be prudent to argue that the wisdom lies in believing that “less is more” in the management of kidney disease. One must remember “The proper use of Science is not to conquer nature, but to live in it.”