Green Dialysis: A Framework for Environmentally Sustainable Renal Replacement Therapy

BACKGROUND: Dialysis is a life-sustaining therapy for patients with end-stage renal disease, yet it is among the most resource-intensive treatments in modern healthcare. Hemodialysis requires large volumes of treated water, substantial energy input, and extensive single-use consumables, resulting in significant greenhouse gas emissions and clinical waste when scaled to millions of treatments performed annually. Climate change further threatens kidney health through heat stress, dehydration, and climate-related disruptions, creating a bidirectional relationship in which kidney care both contributes to and is adversely affected by environmental degradation. METHODS: This white paper synthesizes current evidence surrounding environmentally sustainable dialysis practices, collectively termed "green dialysis," reviewing technical and system-level interventions across water stewardship, energy management, waste reduction, and clinical practice innovation. RESULTS: Green dialysis strategies, including dialysate flow optimization, improved reverse-osmosis efficiency and water reuse, energy-efficient infrastructure, renewable energy integration, waste segregation, central concentrate delivery systems, and incremental dialysis, have been shown to reduce water consumption, energy use, waste generation, and operational costs while maintaining dialysis adequacy and clinical outcomes. Adoption remains uneven due to operational complexity, regulatory gaps, and financial constraints, particularly in low- and middle-income countries. CONCLUSIONS: Context-sensitive implementation, staff education, standardized monitoring, and transparent reporting are essential for overcoming these barriers. Broader integration of sustainability into routine dialysis care represents a critical opportunity to reduce the environmental footprint of kidney replacement therapy without compromising patient safety or treatment efficacy.