Water consumption and chronic haemodialysis therapy: Where do we stand? Where must we go? Review of clinical practices

Chronic hemodialysis therapy is a life-saving procedure requiring large amounts of water whereas this natural resource availability declines with increasing temperatures and the dialysis needs are far from being covered in many world areas. Reducing water consumption in hemodialysis relies on the moto "Reduce, Reuse and Recycle". Because of a significant amount of water is discarded to the drain by the procedure, the efficiency of the reverse osmosis (RO) of the water treatment system is a key factor of water consumption during the hemodialysis session. Along decades, the RO devices have become more efficient, with a decrease of the rejected part of water from around 70 to below 30%. The optimization of the maintenance and disinfection procedures of the water loop, as well as the practice of acid concentrate delivery to the dialysis machine can reduce significantly water needs. Reducing dialysate flow is also effective, even with convective modalities, but more studies are needed to confirm long-term patient safety. The co-decision with the patient on dialysis modality choice including alternatives to hemodialysis must take into account the environmental impact after appropriate information. Other aspects of water sparing are presented including, among others, the reuse of RO water reject and the spent dialysate recycling. Green dialysis including the water preservation must become a "top of the list" priority for all the dialysis stakeholders to preserve the future of this tremendous progress of medical history.