Efforts to confront these challenges are underway, and some progress is being made. Yet, despite widespread recognition of the scale of the crisis, global action remains fragmented and inadequate, and business as usual persists. This disconnect is mirrored in nephrology. Awareness of the environmental impact of kidney care is growing and opportunities to reduce harm have been identified, but implementation remains slow. Promising innovations are emerging, but in most settings, funding and readiness for adoption continue to lag far behind.
Two decades ago, environmental sustainability was absent from nephrology discourse. This situation began to change in the late 2000s, as life cycle assessments, audits and clinician advocacy highlighted the disproportionate environmental footprint of dialysis. Subsequent studies on multiple continents confirmed that the carbon footprint of in-centre haemodialysis far exceeds that of most other chronic therapies. Home dialysis therapies have a smaller footprint but still impose a sizeable burden. Single-use plastics are the primary source of carbon emissions across dialysis modalities. Pharmaceuticals are also likely to contribute substantially, but quantification is hindered by restricted proprietary data. The patient transport required for in-centre haemodialysis increases the carbon footprint by ~20% and accounts for much of the higher burden compared with home dialysis. In dialysis facilities, reverse osmosis systems are major drivers of water and energy consumption, using up to 750 l and 8.7 kW h per 4-h session. All dialysis modalities generate vast amounts of waste, with limited recycling.
In response to these findings, attention has increasingly turned to identifying systemic, operational and technical solutions to lessen the environmental impact of kidney care. Prevention, early detection and slowing progression of kidney disease, kidney transplantation, and optimized supportive care offer the greatest reductions by deferring or avoiding the need for dialysis. The emergence of disease-modifying therapies such as SGLT2 inhibitors, finerenone and GLP-1 receptor agonists has increased the scope for impact. A secondary analysis of the CREDENCE trial in patients with type 2 diabetes mellitus and chronic kidney disease (CKD) reported that addition of canagliflozin to usual care resulted in an estimated 20% reduction in carbon emissions due to avoidance of dialysis and hospitalizations.
When dialysis is required, strategies such as incremental or delayed initiation; use of low dialysate flow, autoflow or ecoflow systems for haemodialysis; and use of targeted icodextrin in peritoneal dialysis can reduce the environmental impact. Compared to haemodialysis, haemodiafiltration may be water-saving when aiming for equivalent small and middle molecule clearance owing to its higher efficiency per litre of dialysate or substitution fluid. Optimization of reverse osmosis settings, disinfection schedules, packaged acid and bicarbonate concentrate volumes, peritoneal dialysis effluent disposal systems, waste segregation, recycling and pathology testing schedules as well as use of remote monitoring and telehealth approaches can also improve the sustainability of kidney care.
Infrastructure choices are also important. Some haemodialysis machines and reverse osmosis systems are substantially more efficient than others and should be prioritized during upgrades. Further gains come from use of renewable energy, reuse of reverse osmosis reject water and use of central acid concentrate delivery (preferably via dry powder formulations).
Technological solutions include digital tools that target modifiable risk factors, such as wearable devices for physical activity tracking, cuffless blood pressure monitoring and platforms that support medication adherence. eHealth platforms can integrate data from these devices into electronic medical records. Point-of-care blood testing using microsampling devices may further support decentralized, lower-footprint care. In haemodialysis facilities, digital tools enable detailed monitoring of water and energy consumption to optimize resource use and operational efficiency. Portable regenerative devices for home haemodialysis and peritoneal dialysis hold promise for water, energy and transportation savings, though the ecological footprint of the regeneration cartridge may offset these benefits. Similarly, generation of peritoneal dialysate in patients' homes could reduce packaging, transport emissions and waste.
Technologies that enable reuse of spent dialysate are rarely applied in healthcare but may be of increasing importance as water scarcity intensifies. Forward osmosis is a potential water- and energy-efficient strategy for reuse of spent dialysate and dialysate production. Waste management innovations include on-site decontamination of biohazardous waste for conversion into recyclable resources and dialyzer regeneration machines that use environmentally safe cleaning processes.