Addressing the Environmental Impact of Kidney Care

Policy Forum:FEATURE EDITOR:Daniel E. WeinerADVISORY BOARD:L. Ebony BoulwareKevin EricksonEduardo Lacson JrBruce M. RobinsonWolfgang WinkelmayerPolicy Forum highlights aspects of nephrology relating to payment and social policy, legislation, regulation, demographics, politics, ethics, contextualizing these issues as they relate the lives practices members kidney community, including providers, payers, patients. Forum: FEATURE EDITOR: Daniel Weiner ADVISORY BOARD: L. Boulware Kevin Erickson Eduardo Jr Bruce Robinson Wolfgang Winkelmayer Over last 2 centuries, world population has increased exponentially reach 7.7 billion in 2019.1Roser Ritchie H. Ortiz-Esbena World growth. Our Data. 2020.https://ourworldindata.org/world-population-growthGoogle Scholar The same period seen economic prosperity all regions but particularly developed nations.2Roser Economic 2020.https://ourworldindata.org/economic-growthGoogle This combination growth led unsustainable levels natural resource consumption.3Global Footprint NetworkEarth overshoot day. 2020.https://www.overshootday.org/Google It also escalating carbon emissions climate change, with latter now considered one greatest threats public health, economies, way life, worldwide.4Costello A. Abbas Allen et al.Managing health effects change.Lancet. 2009; 373: 1693-1733Abstract Full Text PDF PubMed Scopus (1695) Google Scholar,5Watts N. Adger W.N. Agnolucci P. al.Health change: policy responses protect health.Lancet. 2015; 386: 1861-1914Abstract (1097) Climate change presents specific challenges for community. Numerous studies have shown associations extreme heat events acute injury.6Barraclough K.A. Blashki G.A. Holt S.G. Agar J.W.M. diseases-threats opportunities.Kidney Int. 2017; 92: 526-530Abstract (36) Increased ambient temperature is a well-recognized risk factor stone formation.5Watts Although causation disease entity known chronic unknown origin remains enigmatic, there general consensus that stress dehydration are involved, either primary drivers or exacerbating injury from an unidentified environmental infectious toxin.6Barraclough Scholar,7Sorensen C. Garcia-Trabanino R. A new era medicine: addressing triggerred renal disease.N Engl J Med. 2019; 381: 693-696Crossref (43) As global temperatures continue climb during rest this century, we can expect see vastly numbers conditions. We frequency severity climate-related disasters such tropical cyclones flooding events, associated disruptions care delivery, care.6Barraclough socially economically disadvantaged populations will be disproportionately affected by effects, no immune them.4Costello Alongside this, caring patients diseases involves substantial use greenhouse gas emissions. Specifically, hemodialysis (HD) water- power-hungry therapy produces vast amounts waste.8Barraclough Green nephrology.Nat Rev Nephrol. 2020; 16: 257-268Crossref (50) Data United Kingdom suggest emission effect thrice-weekly in-center HD more than 7 times average patient UK care.8Barraclough Scholar,9Connor Lillywhite Cooke M.W. footprints home maintenance Kingdom.Hemodial 2011; 15: 39-51Crossref (74) peritoneal dialysis (PD) uses less water power HD, it requires regular transport plastic-packaged fluid across between countries point manufacture care. Thus, although its impact been poorly studied, likely large. limited number services worldwide worked test implement strategies minimize (Table 1).10Agar Simmonds R.E. Knight Sommerville C.A. Using wisely: new, affordable, essential conservation facility hemodialysis.Hemodial 13: 32-37Crossref Scholar, 11Agar Perkins Tjipto Solar-assisted hemodialysis.Clin Am Soc 2012; 7: 310-314Crossref (24) 12Connor Milne S. Owen Toward greener dialysis: case study illustrate encourage salvage water.J Ren Care. 2010; 36: 68-72Crossref (22) 13Heart England NHS Foundation TrustDiversion waste recycling stream through baling machines. Centre Sustainable Healthcare.https://map.sustainablehealthcare.org.uk/heart-england-nhs-foundation-trust/diversion-waste-recycling-stream-through-use-baling-machinesGoogle 14NHS Greater Glasgow ClydeWaste management unit – & how-to guide. Healthcare.https://map.sustainablehealthcare.org.uk/nhs-greater-glasgow-and-clyde/waste-management-renal-dialysis-unit-case-study-how-guideGoogle 15Piccoli G.B. Nazha Ferraresi Neve Vigoti F. Pereno Barbero Eco-dialysis: financial ecological costs products: ‘cradle-to-cradle’ model feasible planet-friendly haemodialysis management?.Nephrol Dial Transplant. 30: 1018-1027Crossref (30) However, uptake “green nephrology” practice far widespread.Table 1Examples Environmental Improvement Initiatives Undertaken Benefits ObtainedMeasuresCosts BenefitsIndividual Dialysis ServicesAustraliaInstallation RO reject capture reuse infrastructure hospital settingsInvestment ~AUD $5,500 setting AUD $1,500-$2,000 setting; savings ~350 L per treatmentaFinancial not reported quantified.AustraliaInstallation solar system on unitInvestment cost $16,219; 91% reduction grid consumption; 76.5% costs; return investment 7-8 yUKInstallation buildInvestment £2,500; annual 4,492,000 £10,558bAssuming running at full capacity.UKInstallation machine compact cardboard plastic wasteInvestment £3,500 £587; diversion 1 ton 4.2 tons landfill; 8.665 CO2e £4,150UKImproved clinical domestic streams 6 unitsAnnual 86 £15,567ItalyEmptying residual receptacles before their disposal; staff training best managementUp kg hazardous generated €10 saved treatmentFresenius Medical Care (NephroCare)cInvestment reported.ElectricityIndividualized meters measuring per–dialysis treatment electricity upgrade energy-efficient lighting; progressive replacement machines alternatives; installation motion detectors timers automatically control reduced sizedWhile remaining within regulated floor surface chair ratio France.; air conditioning programming; downsizing administration offices; movement high quality buildingReduction 23.11 16.26 kWh/session 92,400 over 13-y periodWaterIndividualized water-efficient upgrades systemsReduction 801 382 L/session 17.5 periodCare-related wasteStaff optimum management; caregiver sorting; auditsReduction 1.77 1.11 kg/session 10,000 periodUK Nephrology ProgrammeInfrastructure projectsRO reuse; recycling; central delivery acid HD; retrofitting exchangers machines; plantInvestment £121,000; 12 million water, 84 CO2e, £57,000Process innovationsPaperless laboratory reporting; reductions food, linen, consumables; improved segregationNo capital 183 £186,000Model innovationsIncreased telecommunicationsSavings were estimated 3 projects pilot phaseaFinancial quantified.Based data al,10Agar al,11Agar Connor al,12Connor Heart Trust,13Heart Clyde,14NHS Piccoli al,15Piccoli Bendine al,16Bendine G. Autin Fabre B. al.Haemodialysis sustainable growth: corporate experience France [published online ahead print 2020]. Nephrol Transplant.https://doi.org/10.1093/ndt/gfz284Google Limb.20Limb could save 1bn adopting green used units.BMJ. 2013; 346: f588Crossref (9) ScholarAbbreviations: dioxide equivalents; hemodialysis; RO, reverse osmosis; UK, Kingdom.a Financial quantified.b Assuming capacity.c Investment reported.d While France. Open table tab Based Abbreviations: Kingdom. rates demand grow globally, need fundamental shift delivered. focus must reducing while realizing rewards come lower use. only improve long-term sustainability ensure delivered without inadvertently contributing environment-related harm health. In our view, key steps progress field include awareness building, collection pertaining range therapies, solutions-focused research, regulatory environment. Only concerted effort domains transformative required. Increasingly, medical schools embedding planetary theory into curricula. similar teaching postgraduate education training. Structured incorporation programs would trainees develop mindset consider environment-health links everyday practice. knowledge skills required them enact change. There role societies play. Actions build prioritizing inclusion topic papers society journals environmentally themed educational sessions meetings, designing tools programs, identifying supporting “champions” spearhead movement. Whereas some taken preliminary direction, much further go other follow. clear better characterization baseline therapies. very available mainly facility-based many years old, consequence fail reflect inputs outputs current osmosis systems. PD examined each, transplantation.8Barraclough Targeted research should encouraged incentivized national international governments alike. Without understanding use, cannot it. reporting services. 2005, NephroCare (the European network units belonging Fresenius Care) began documenting consumption care-related production each centers France.16Bendine allowed development performance indicators improvement targets, well formation action plans meet them. By 2018, had decreased 29.6%, 52.0%, 38.9%, respectively 1), yearly doubled, demonstrating reporting. Furthermore, alternate models service provision, home-based therapies transplantation, examined. Ideally, work commissioned government level results alongside outcome inform decision making planning. gains maximized resources time. Notably, year US President signed Executive Order sweeping set initiatives collectively Advancing American Kidney Health (AAKH).17Mehrotra Health.Clin 14: 1788Crossref (31) AAKH aims, among things, markedly increase incident transplantation. design AAKH, seems consideration was given proposed models. Given constraints doubt time costs, view major omission. little decades regard technologies. efficiency systems somewhat, remain voracious. Consumable both high, most items designed single ability recycled, repurposed, biodegrade end life. exists meaningful collaboration industry groups, disciplines aim finding solutions. Again, bodies assist facilitating collaboration, ensuring firmly agenda, allocating funding accordingly. above all, supportive environment needed drive widespread disrupt entrenched attitudes provide confidence guidance those leading Supportive legislation typically accelerate implementation spread normalize socially. Illustrating Change Act 2008 country reduce net zero 2050 1990 levels. legally binding targets every 5 prepare report proposals meeting imposed requirement own targets. creation Development Unit tasked developing tools, deliver result remarkable time, generation >£90 annually.18UK UnitSustainable sector check 2018.https://www.sduhealth.org.uk/policy-strategy/reporting/sustainable-development-in-health-and-care-report-2018.aspxGoogle Within context, “Green Programme” established 2009 improvements With support Unit, program surveyed practice, drove focused stakeholders, delivering local level, projects, process innovations, alternative 1).19Centre HealthcareGreen Programme 2009-10 summary report.https://networks.sustainablehealthcare.org.uk/networks/green-nephrology/green-nephrology-programme-2009-10-summary-reportGoogle Scholar,20Limb so doing, succeeded dramatically shifting culture degree previously. Unfortunately, still lacking countries, countries. due ideologies backed dubious arguments surrounding decarbonization protection potential acting losses inaction. ours, follow pressure civil society. professionals powerful advocates part because standing message requisite National advocacy push platforms. absence environment, reform occur institutional and/or level. For instance, policies mandate data, require when procuring goods services, contracts provider companies clauses, specify facilities redevelopments performance, applying proven energy measures principles passive ecobuilding design. crisis accelerates grows, pressing address profile delivery. changes attitudes, institutions, practices. large community play building driving leadership vital. When lacking, incumbent this.