#NephMadness 2020: Consumable Waste in Hemodialysis

Katherine Barraclough 

Katherine Barraclough is a Consultant Nephrologist at the Royal Melbourne Hospital, Melbourne, and an Associate Professor of the School of Medicine, University of Melbourne, Australia. Her research focuses on the relationship between human health and the natural environment and pathways to environmentally sustainable healthcare. She is also the Selection Committee Member for the Green Nephrology Region. 

Competitors for the Green Nephrology Region

Climate Change and AKI vs Climate Change and CKD

Consumable Waste in HD vs Disposable Waste in HD

The crowd is roaring and the tension is mounting. The words ‘CONSUMABLE WASTE IN HD, CONSUMABLE WASTE IN HD!!” are reverberating off the stadium walls. Why? Because the crowd has realized that we cannot continue to endlessly devour resources and emit greenhouse gases through hemodialysis without consequence. The crowd has seen that there are smarter and more thoughtful ways of delivering care than the way we are delivering it now.

Currently, little consideration is paid to the fact that with each hemodialysis treatment, dialysis providers take upwards of 500 liters of tap water, extensively purify it, then send the majority of the product down the drain as reverse osmosis ‘reject water’.  This discard is out-and-out thoughtless waste of a finite and precious resource.

In drier regions of the world (for instance, in parts of regional Australia), it also has major implications for the ability to provide hemodialysis at all. As water scarcity increases in parts of the US and globally, there is a vital need for the nephrology community to rethink the value of water and to consider ways to conserve it.

Similarly, hemodialysis machines and reverse osmosis systems guzzle power, which for the main part is derived from fossil fuels. This is responsible for substantial greenhouse gas emissions which contribute to climate change. Indeed, it has been suggested that HD may be one of the most carbon intensive of all medical therapies on a recurrent per capita basis.

Ironically, we know that climate change is already impacting the incidence, patterns and distribution of kidney disease and will increasingly do so into the future. On a broader scale, experts tell us that climate change is the greatest global health threat of this century. Thus, in the course of caring for our patients, we are inadvertently causing harm.

And, this resource usage is expensive, and will become more so as water resources decline and regulatory limits are imposed on the amount of carbon we are able to emit over time. In its current form, hemodialysis is both financially and environmentally unsustainable.

“But it doesn’t have to be this way!!” screams the crowd. A wide range of measures exist to conserve water and power in HD. Around the globe, individual dialysis units are capturing reverse osmosis reject water and using it for other purposes: to steam sterilize hospital equipment, service hospital janitor stations, flush toilets, and more.

Importantly, they are also saving money in the process. Some researchers have considered ways to use nutrient-rich dialysis effluent (i.e. the uremic waste that exits the dialyser) to help gardens and crops grow! Others have shown water savings from modifying dialysis water treatment systems, while still others have shown that reducing dialysate flow rates can reduce water usage without reducing dialysis adequacy.

Because dialysis units typically operate in the day when the sun is shining, they are perfectly placed to utilise solar energy. Thanks to ever-falling solar energy costs, return on capital investment from solar system installation is likely to be short, with free power provided for the life of the solar array thereafter.

Even more exciting, innovators are developing entirely new water purification and dialysis treatment systems that use vastly less water and power, thereby offering hope that we may be able to provide environmentally friendly and affordable dialysis care into the future.

As the world pivots towards a more thoughtful, lower carbon future, we have two choices. We can wait for the heavy hand of scarcity and/or regulators to force us to act, more than likely compromising our ability to provide care to our patients in the process. Or, we can take proactive steps to reduce our impact, protect our patients and our planet, and maximise our contribution to global health.

– Guest Post written by Katherine Barraclough 


As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.


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