'Eco-dialysis' or 'Green Dialysis'

Ask Our Experts Dr. John Agar, Nephrologist
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Some may be unaware … and a few (I hope) may be interested to learn … of the progress we are (slowly) making in developing our unit theme of ‘eco-dialysis’ or ‘green dialysis’.

My intention is to alert you, the users, to the disproportionate footprint that dialysis leaves on our landscapes with its’ rapacious use of natural resources - water and power in particular - and to the paltry efforts we have traditionally made to understand, control, minimizse or re-use the wastes we generate by the processes of dialysis.

You need to demand of your dialysis service that it takes more cognizance of the environmental mark it leaves. If we were to assume that there were ~2,000,000 dialysis patients world-wide, and all used the same amount of water and power that our service used to use - clearly a ‘broad’ assumption - then our ‘world dialysis service’ would consume about 156 billion litres of water and 1.62 billion kWh or power per year of dialysis.

That’s a lot of water and power!

We have sought to address some of these issues in some of our publications in recent years.

The most recent of these publications deals with our effort to trial solar-assisted systems to augment the power requirements of dialysis. This blindingly simple concept has proved to be remarkably easy and cost efficient and we are left wondering why none of us had tried it before.

To fill you in on where we have gone with all this …

On January 5th, the Clinical Journal of the American Society of Nephrology (CJASN) forward-published the abstract (by eoi release) of a paper entitled “Solar-assisted Hemodialysis”.

If you Google the 3 words <solar assisted hemodialysis> this will lead you to some of the associated press releases. The full paper will be released (also as an eoi) on 19th January and will formally appear in print format in an upcoming edition of CJASN. This is the first report - anywhere - of solar power assisted haemodialysis program.

In addition - and perhaps giving a better overview of our progress towards eco-dialysis - a paper will appear in the next edition of Hemodialysis International, in an easy, lay-readable format, entitled …

“Personal viewpoint: Hemodialysis—Water, power, and waste disposal: Rethinking our environmental responsibilities”
… the abstract for this paper is at http://onlinelibrary.wiley.com/doi/10.1111/j.1542-4758.2011.00639.x/abstract

This second paper documents our journey, here in Geelong, from our first introduction of nocturnal haemodialysis into Australia in 2000, to our realisation of the utility impact this home program was exerting on our home patients, then through to the steps we took to lessen that impact. It should be remembered that here, in Australia, our home patients do not have access to the more water-efficient NxStage system … but even in the US, this system is used by a tiny fraction of the whole dialysis population (a little > 4000 out of 400,000 … so, perhaps only 1%). The remainder, like we do here, use water-guzzling, power-bleeding, single-pass equipment.

We resolved to lobby (successfully) for a government subsidy to defray the utility costs of home dialysis for home dialysis patients (both HD and PD). Concurrently, we introduced a range of both home and facility-based water conservation practices - simple, effective, water re-use and re-cycling programs - which have made a huge impact on water use for both our home and our facility-based programs.

To understand more specifically our program for water conservation, see another of our papers, also in HDI …

Agar JWM, Simmonds RE, Knight R. “Using water wisely: New, essential and affordable water conservation practices for both facility and home hemodialysis”. Hemodialysis International 13(1):32-37, January 2009.

This was the second reported program water conservation program in HD. Tarrass et al (from Morocco) published the 1st reported program in the same year in AKJD … a paper for which I was invited to write the AJKD editorial in the same edition …

Agar JWM. Recycling Dialysis Wastewater: ‘The Elephant in the Room’. Editorial: Am J Kid Dis. 2008. 52(1):10-12.

The success of these initial water-conservation programs led us on to consider options in power reduction. This led to the introduction of our solar-assisted power program (as above) and, more recently still, to plans (still to be fully realised, but in progress) to revise of our waste management systems. While these latter steps are yet to be developed to a reportable level, our waste management concepts are described ‘in overview’ in the up-coming HDI ‘Personal Viewpoint’ publication.

What all this means is that we, as a profession, and as the users of dialysis systems, may be very adept at diagnosis, treatment and support (though I know some may even question that statement) and utilisation of these systems … but we have paid scant (if any) attention to the environmental impact those systems exert.

The purpose of our more recent work has been to seek ways to lessen that impact, protect (where we can) our environment and to make dialysis a more sustainable and resource-thoughtful process into the future.

I hope some of you take the time to read these papers … and we have others - though mainly in our Asia-Pacific nephrology literature … none of which require an extensive medical knowledge.

The purpose of alerting the dialysis community to the need for resource and material management in dialysis is to try to arouse a ground-swell demand from you (the users) of your providers (us) to get our act together and do our bit to make the planet we live in just a little safer and more habitable into the future.

Ask your service what they are doing to conserve the resources - power and water - and manage the disposal and/or degradation pathways associated with their spent equipment and consumables.

It’s just a little favour you can do for your planet … and one worth doing.

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I’m kind of surprised that no-one has commented on this! Do any of you do any sort of conservation with regard to dialysis? IMHO, in the US Southwest, solar power would make tons of sense…

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I was surprised too – thanks Dori

I was rather hoping this post might stimulate some discussion and/or thoughts and I am saddened that there has been absolutely no comment - beyond your own.

Ah well … it won’t deter me from thinking that environmental issues are important and require a great deal more innovative thinking.

Maybe someday …

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Dear John, actually, I believe a lot of folks have taken notice of your work and your writing on these issues. I have posted more than one article on the work you have done on eco friendly dialysis which I believ is something that we all should support. I believe that most eco friendly dialysis as far as water anyway is the sorbent technology which we are all waiting to see unveiled, hopefully soon as you point out. So, sorry I didn’t comment, but I did read and agree.

God bless,

Peter

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Dr Agar, I read your post and, like Dr. Laird, have recognized your work in this regard. I didn’t reply because I don’t have any answers other than the promotion of water saving technology as discussed by yourself and Dr. Laird. I’ve read up on this sorbent technology, and I am hopeful.

Over on I Hate Dialysis, there have been several discussions amongst home dialysis patients on how to be more environmentally friendly, and unfortunately, the only practical suggestion that’s been offered is the recycling of the cardboard boxes in which supplies are shipped. Many home D patients recognize the polluting effects of dialysis and are trying to minimize its environmental impact. To be fair, though, most patients are just trying to survive.

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Dear MooseMum and Peter

It is not the recognition of our work but the concept of conservation that I had hoped to see discussed.

I really do know and understand that ‘most patients are just trying to survive’ - and I have always tried to help them in that struggle when and how I can … and I did not mean to imply that conservation/ecological/environmental issues should take any sort of precedence over that struggle - far from it.

However, I do think there is much we can do to clean up our act, make dialysis more sustainable, give due cognizance to our planet and its finite resources - for it, too, is in something of a struggle for survival and if we can make a difference there, too, then we should. This should not be to compromise the care we give out patients, but rather should compliment it.

I think there is a great deal of room to both improve the dialysis experience and delivery for our patients, yet, concurrently, improve the processes by which we deliver that care.

My paper in the out-coming edition of HDI deals not only with water and power, but, perhaps even more urgently, the ways we use to dispose of the mountains of waste dialysis creates.

As for sorbent systems … I, too, am excited by the concept of sorbent dialysis. I published a ‘primer’ paper on sorbent dialysis in 2010 in Nephrology to alert to and start the education process on sorbents for the new generation of dialysis teams in Aust + NZ, most of whom are broadly unfamiliar with sorbent technology. We must recognise that it is ~2 decades since sorbent dialysis was clinically used in the REDY system and it only old and crusty nephrologists (like me) who can remember it - or can claim passing understanding of its capabilities. Those who have trained in the 20 years since sorbents ‘passed’ into history have no compass for the concepts of sorbent based dialysate regeneration … hence my introductory paper for the Australian scene, given the impending re-emergence of sorbent technology as a dialytic mechanism.

See … Agar JWM. Understanding Sorbent Dialysis Systems. Nephrology (Carlton). 15(4): 406-411. June 2010 … for what I hope is a relatively easy-to-read explanation of how sorbent dialysis works.

However, if we just think it through … if we (all) switched to sorbent dialysis tomorrow (we wont) - or into the future (a distant future, if we do) - each dialysis treatment would generate between 1-2 kg of used sorbent = near-saturated zirconium sulphate + zirconium phosphate + urease + activated carbon, etc.

Let’s assume that there are ~2,000,000 dialysis patients in the world. Now clearly not all are on HD (many are on PD) but, let’s just assume, for the moment, that 2/3rds of this number were using HD (so, say, 1.3 million).

Then …

If each patient had 3 x treatments a week - many around the world do and would not - and if, also just notionally, all these patients were on a sorbent system, then …

156 treatments/week x 1.3 million patients x (say) 1.5 kg of used sorbent per treatment would generate, in one year, 304,200,000 kg = 304,200 tonnes of used sorbent.

What the hell do you do with a used mountain of sorbent? What might be the environmental impact of it?

Re-cycling might be difficult as it would be, notionally, ‘infective waste’. Landfill? … but then there is the ‘leachate’ from the landfill to consider. Other uses? … potentially … but what, and how?

This is one of the issues I have already discussed with the developers of the sorbent dialysis program - encouraging them to try to solve the waste disposal (or reuse) processes for the used sorbent at the start. This would be infinitely better than looking around in a few years at a few Mt Rushmores of piled, used, potentially toxic sorbent waste … and an environmental problem of vast proportions … and only then wondering what the hell to do with it.

Again, I really do know and understand that dialysis is a personal struggle - for each and every patient. But, that should not excuse us from being wise® - and more cautious - with the resources we use, daily, to facilitate that struggle.

I believe we have the capacity to do better - in both!

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Yet sorbent-based systems have potential to reduce water and power consumption on the order of 90%, and hence the power required to produce, purify, deliver, and then purify again so much water. Physical waste without foresight could become a problem–but also a potential industry with 90+% recycling. Net energy use could even come out ahead!, and even if neutral the quality of life considerations shouldn’t be ignored. If competition heats up, superior technologies will come to market.

Otherwise, basic know-how will continue to lie wasted.

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Sorbent systems will reduce water and power consumption … well, water, certainly!

As for power … I think the jury might still be ‘out’ on the net effect on power consumption that sorbent systems might exert. While the machines themselves are likely to be significantly less power-hungry, remember that power is also used to ‘generate’ sorbent from zirconium (a silicon sand by-product) and it might be some time before we fully understand the net effect on total power use in a sorbent-based program. Again, something to ponder from the outset, not when we are round the corner and far down the track.

From the Internet @ … http://www.madehow.com/Volume-1/Zirconium.html …

[I]Extracting and Refining zircon

The sand and gravel that contain zircon mixed with silicate, ilmenite, and rutile are typically collected from coastal waters by a floating dredge, a large steam shovel fitted on a floating barge. After the shovel has scooped up the gravel and sand, they are purified by means of spiral concentrators, which separate on the basis of density. The ilmenite and rutile are then removed by magnetic and electrostatic separators. The purest concentrates of zircon are shipped to end-product manufacturers to be used in metal production, while less pure concentrations are used for refractories.

End-product manufacturers of zircon further refine the nearly pure zircon into zirconium by using a reducing agent (usually chlorine) to purify the metal and then sintering (heating) it until it becomes sufficiently ductile—workable—for industrial use. For small-scale laboratory use, zirconium metal may be produced by means of a chemical reaction in which chloride is used to reduce the zircon.

The less-pure zircon is made into zirconia, an oxide of zirconium, by fusing the zircon with coke, iron borings, and lime until the silica is reduced to silicon that alloys with the iron. The zirconia is then stabilized by heating it to about 3,095 degrees Fahrenheit (1,700 degrees Celsius), with additions of lime and magnesia totaling about five percent.[/I]

NB: I suspect (but don’t know) that the power use in the process may be significant.

As for recycling/re-use of the used sorbents, as I said in my previous post …

"re-cycling might be difficult as it would be, notionally, ‘infective waste’. Landfill? … but then there is the ‘leachate’ from the landfill to consider. Other uses? … potentially … but what, and how?.

These are problems yet to be solved but it would be good to come up with the answers before and not after sorbent technology enters main-stream dialysis - on the assumption, of course, that it does.

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Interesting questions worthy of an energy economist (or entire research project) attempting to untangle the energy costs of zirconium recovery per cartridge, vs. producing, purifying, distributing, purifying, softening, reverse-osmosis to ultra-pure specs of 100-200 liters of water the cartridge will safe, plus the wastewater treatement costs of that much water.

Right now the water probably wins if all we care about is energy, but maybe quality matters enough to justify going forward without feeling so much guilt. In the mean time, cap-and-trade gestures to offset the environmental impact might be a good peace offering. Cell phone and other companies of developed recovery/recycling programs as model, so perhaps FMC and others can do the same for cartridges?

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Though you are ‘unidentified’, I think your premise is correct. And while I agree that cap-and-trade concepts seem a popular escape clause at the moment, I think they are (broadly speaking) “feel-as-if-you-are-doing-something-when-you-really-aren’t” schemes that allow heavy polluters off the hook, 'permit’ting them to dodge the real issues of environmental responsibility for effective reuse or disposal processes.

The hopeful among us might like to think that, rather than offsets and cap-and-trade practices, we might find a true and sustainable reuse for used sorbents at the outset and before they ‘emerge’ as a market option. This would give sorbent technology an edge from the very start, especially if it could be seen that rather than adding to the eco-burden, the used sorbent(s) had an on-use … eg: as a urea nitrogen/potassium/phosphate/magnesium/trace element-rich growth medium in brine-oriented aquaculture

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Oh goodness…this is admittedly above my little toxic head. I do not have the scientific background or education to even begin finding a solution, but I do recognize the enormous amount of waste that dialysis creates, and while I am not sure what to do about it, I am bothered by it. I take a great deal of care in my daily living to conserve energy and water, to recycle whatever I can and to just generally reduce my impact on the planet. I don’t use pesticides in my gardening and I use basic ingredients when cleaning. So when I see that once I start dialysis, I will become a net environmental problem, it really bugs me.

I’ll be very interested in reading your upcoming paper on the subject, and I will be particularly eager to read of specific ways that dialysis patients can help in reducing the environmental impact of dialysis.

I’m still rather hoping that bioidentical kidneys can be constructed in the same way that bladders have been built. I am hoping that the solution lies in the eradication of the need of dialysis in the first place. Beam me up, Scotty!

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Thanks for contributing (again) MooseMum … it is always much appreciated and useful.

I do hope you get to read my paper in Hemodialysis International this month … and the really good, thoughtful and inciteful editorial that Andy Connor and Donal O’Donohue from the UK wrote to accompany it.

Admirably (though it irks me to say it) the UK … and the Europeans … are light years ahead of most of us on this but, also in our own little way here in Geelong, we try to keep up, push the envelope too, and make contributions where we can. And … none of it is rocket science!

Neither paper nor editorial are hard science reads … so have a go.

As you will see in these works, we are just trying to apply common sense approaches to lessen the Eco-burden of what we do.

I just wish others would follow suit.

The purpose of this thread was to try to awaken the eco-soul of you ‘users’ of dialysis out there … to encourage you to begin to question and push your services too, to ensure that they begin to stand up for our planet - as you already are doing in your own home - and be counted.

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I don’t want to be a cheap git, but is there a way that mere patients can access your article(s) in HDI? There are so many journals I’d love to get my hands on, but there’s always a stonking great subscription fee for those of us not affiliated with medical institutions. I know that many of the articles are stuffed with medical lingo, but there are certain people I like to follow, such as yourself and Dr. Blagg. But all too often, I can’t get access to anything more than the abstract. Thanks!

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Yes, that’s a problem. I agree.

Most journals bind the authors to copyright - certainly before publication in print copy format. After publication - not e-publication but print publication, it is acceptable to request a ‘reprint’ from the author(s), and many still do follow that etiquette. This can come as a formal reprint provided by the journal to the author … but the lead author then has to have bought a stack of reprints - at his/her cost - from the journal, or must be provided in some other way from the author(s).

Otherwise there is always the photocopier at the local medical library (or medical school/hospital library - if they carry the journal).

Ahead of print publication but after e-publication, it’s only by direct purchase of the full PDF from the journal.

Dori … if you read this … any comment? I believe that MEI often has direct entry to journal articles of interest, but at what stage of their publication cycle or at what cost - if any - to the reader, I am not sure.

Dori … would you care to add something here?

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I’ve been seeing a trend recently where more articles are available as full-length PDFs in PubMed (where the medical literature lives online), but since journals make money from subscriptions AND by selling individual articles, I believe that the authors need to pay money up-front (several thousand dollars) for this to happen. Most don’t. Medical libraries and interlibrary loans are ways to get copies of articles. Most larger cities have at least one medical library, either at a university or at a hospital. Often if you email the author of an article, he or she can send you a pdf, too. In the olden days authors used to buy print copies of articles, but these days, journals provide PDFs and, I suspect, hope that they don’t share with too many people. :slight_smile:

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I have in the past contacted authors for a free copy of a specific article, most recently an article in Palliative Medicine by Tom Hutchinson at McGill. But I don’t like doing that too often as I don’t want to deprive anyone of their livelihood.

I check out PubMed quite often, and while that is helpful, it always seems like the articles I want to read are available in abstract form only.

I visit RenalWEB each day, and it gets very frustrating to find an abstract that looks really interesting, only to discover that the abstract is all I’m gonna get.

I’d love to buy subscriptions to all sorts of journals, mainly the Journal of Renal Nutrition, but I have 25 pills a day I have to pay for.

I know that a lot of these articles are filled with medical jargon fit for doctors only, but there are many that a mere patient like me can still get something out of. If you want educated patients, then let us have access to all of the information out there. Can’t we have a “patients’ discount”? LOL!

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Thanks for making that clearer, Dori.

One great thing that this site: www.homedialysiscentral.org … has done over the years is to provide a list of the more innovative, interesting and readable manuscripts - as they apply to home dialysis practice. This has at least winnowed the vast manuscript army down to a platoon of papers-most-likely-to-interest … both at a professional and lay level.

This does not give access, but rather pointers to, papers that may be worth a reader considering for individual purchase (and yes, I know that’s dollars) - or a local medical (university or hospital) library search. It’s probably the best that can be done to solve the problem … but, I agree, it remains a problem for involved but non-professionals, like you, MooseMum.

But … important though this side thread is, can I go back to the green or eco-theme of the original post …

For green-related information, there is none better than the site the Brits have set up - it’s been up and away for 2-3 years now and as I said before, they have really got their act together on this … far more so than we have, collectively, here in Australia - though it galls me to have to admit to that!

Their dialysis services are all coordinated into green programs - be it water conservation, waste disposal or recycling practices and they are art-forming it. I deeply admire the progress they have made … there is something understated and methodical about the Brits! … and I am needled by the fact that they have leap-frogged us (Australia) to clearly lead the world in this area.

You will find their central website at … www.sustainablehealthcare.org.uk

Here, you can log to the Green Nephrology section and join for free. They will send you bulletins of their projects (awesome stuff) - and, for anyone interested in this area, it’s a must!

NB: when I tried to log just now to check that the site address I have given is working, it seems that they are doing a few hours of site maintenance right now … so if you want to visit there … go back a little later when the site is up and running again. It is a comprehensive site and it maintained and supported by the UK NHS.

The other website well worth visiting - if you want to get a good handle on an overview of environmental factors in dialysis - is the EDTNA (European Dialysis and Transplant Nurses Association) / ERCA (European Renal Care Association) site where their Environmental Guidelines document is available.

This guideline document “Environmental Guidelines for Dialysis - a practical guide to reduce the environmental burden of dialysis” is a ripper document. It is lay-language written and utterly lay-suitable … and it sets out all the things we should be/could be/bur aren’t doing - systematically - to clean up our act. It is a document that EVERY dialysis leader, EVERY dialysis administrator, EVERY involved person should read and have a copy of. Those who read this would do well to draw it to the attention of their parent service … and hound them till the get a copy, read it, and start to put their plans and practice suggestions into place.

Their site is: www.edtnaerca.org

The publication can be found at http://www.edtnaerca.org/pages/education/publications.php … scroll to the 4th listed item under ‘Handbooks’. I can bring a sample copy to the ADC in San Antonio later this month if anyone wants to see it.

I am in the middle honing an Australian draft guideline set which, shamelessly, will draw heavily on the work of Juergen Kastl and Jitka Pancirova - they drew together the EDTNA/ERCA guideline set - and their work is available on the net.

Visit their site, check the Guideline document … you will find it more than worthwhile.

None of this, MooseMum, means to detract from your individual ‘struggle for survival’ … and it has never been my intent to trivialise this core value.

But, we can enhance dialysis delivery, improve care AND do it cleaner, better and with a smaller carbon footprint.

No house, no business … indeed no physical body … works well or efficiently if dirty, untidy or polluted. Simply, I believe that, beyond the arguments of Kt/V, time, frequency, access etc … all vital to enhance where and how we can … dialysis services can further improve the care (and outcomes) they give you by cleaning up their practices.

That’s the aim of this particular thread.

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The website in the UK is still down, but I’ll check back tomorrow.

Is the EDTNA/ERCA handbook you gave us the link to available? I tried downloading it without success. Does one need to subscribe?

I guess even people who are not renal patients are affected by dialysis if its byproducts and wastes are allowed to pollute the environment. I honestly had never really thought past water conservation techniques and cardboard recycling. Thank you for looking at dialysis from a different perspective and taking action accordingly, and thank you for sharing your concerns. I will definitely bookmark the UK website and share that information with those that could make a difference.

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Re the Sustainable Healthcare UK site? … yes … give them a day or so to get up and running again. It’s the first time I have seen them down - and my guess is that it won’t take them long. After all, it’s a professional site of the UK National Health Service! Maybe they have had a winter storm!

Pertinent to your other post in this thread about paying for stuff … yes, you do have to pay for the Guideline book. It is available where I directed (as in the post above) … just click on the ‘order’ form next to the document lead if you want a copy.

It is 15 Euro … maybe 20-25 bucks.

It contains easy, simple, and essential why-didnt-we-do-that-before eco-information and eco-practices that every dialysis unit in every country should (a) purchase and (b) introduce … … as standard practice!

The point of putting it up here is so that those who read this can alert their dialysis services to its’ existence. While it may be beyond the individual to purchase at this price, they can afford 20-25 bucks!

But, my guess is that most dialysis services in the US have neither thought of most of their easy-to-do steps, nor have them as part of their daily functionality … and they should!

So, even if you don’t/can’t get a copy for yourself … pressure your service to.

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There you go! feedstock for algae biofuels production.