I’m happy to buy the handbook for myself if I can do so without having to pay for an annual subscription. It’s worth the price. This way I can make sure my clinic gets to see it.
Just ask your local library to obtain a copy of the article for you. If they don’t have the journal or a database containing the journal themselves, they will request a copy of the article from another library. US copyright law protects the right of libraries to exchange (a limited number of) articles per journal. Most libraries do not charge for this service, or a most charge a low reproduction fee.
Thanks…I’ll see what my local library can offer.
I have a question, and I HAVE done a search on this site and on the sustainablehealthcare site but have found nothing. Apologies if this is a redundant question, though. I have read that patients should not accept reuse of dialyzors if/when they are dialyzing in a clinic and that they should insist upon a new dialyzor at each treatment. How does this square with the attempts to reduce waste from dialysis? What should the environmentally aware patient do in this regard?
As always, an interesting point!
Here, my answer comes from a position of personal ignorance as here, in Australia, we legislated in the early 1990s to ban re-use of medical items and as a result, I have only a distant personal memory of re-use. As it has not been applicable to our national practice, I have not therefore kept pace with any ‘developments’ or changes that may have occurred in re-use practice in the 20 years since we last re-used our dialysers. This given, my comments are thus made in general terms, rather than with specific re-use awareness.
Re-use, as I recall it, required the (then) use of a chemical called Renalin’ (peracetic acid, if I remember correctly) … is this still the preferred agent?
Renalin, itself,was (is) a potent ‘nasty’, such that re-use nurse had to wear protective eye-wear and the process or reconstituting the dialyser was carried out in a laminar flow ‘fume cupboard’ to protect the operators from exposure to the chemicals. So, Renalin, too, has pollutant qualities - both to waste-water and as an airborne pollutant. Adding the effluent of Renalin to the drains, the aerosol or Renalin to the atmosphere, has (to me) uncertain but potentially significant negative environmental outcomes … certainly I remember that adding Renalin to the respiratory tracts of the nurse-operator wasn’t a nice thing to do!
Yes … a new dialyser - one for each treatment - adds to waste … there is no doubt about it. But, re-use adds its own polluting problems, too.
Which is worst? Which wins (or loses) in the pollution stakes? Hmmmm … …
Earlier in this thread (towards the bottom of the 1st page of responses), an ‘unidentified’ respondent wrote (of a different part of the discussion) …
… 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 waste-water treatment 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.
This comment – though then directed to a discussion regarding the issue of sorbent re-use – applies equally to the re-use of dialysers. However, I agreed with him/her in the swings-and-roundabouts discussion then … and I agree (again) that in this context, too, is IS a topic worthy of an energy economist. While I don’t have the required skills to answer with any certainty, I suspect the apparent ‘advantage’ to re-use or dialysers against the use of a new dialyser each treatment might be less clear - especially if our ‘energy economist’ were to do the sums for us.
What is true is that there are always trade-offs and juxtaposed arguments for and against. Here, on this one … which wins? An interesting contest! But, regarding to answer your question re: “what the 'environmentally aware patient should do?” … I don’t know.
What IS important is that we start to think of these issues and begin to seek answers that can stand scrutiny.
I confess to not knowing how dialyzers are made “reusable”, ie, what kind of chemicals make them “safe” for reuse. I’ve never heard of Renalin and have no idea if it is used here in the US or anywhere else, for that matter. Maybe someone can come along and enlighten us.
Re-use and the environment
I cant but think that reuse isn’t ideal for the environment - though, as I noted in the post-but-last, not re-using means the addition of a greater number of used dialysers to the waste disposal chain.
Again - which is the greater or lesser environmental insult … I don’t know … but its the sort of thing that we should know, but that I don’t think we do know - for no environmental economist (to my knowledge) has undertaken the study!
Re-use requires the (liberal) use of either formaldehyde (yes, embalming fluid) or, more commonly I think, peracetic acid. the post re-use direction of these agents to waste seems, to an inexpert eye in this area, potentially yukky … in the extreme.
So, too, are there issues with committing stacks of single use dialysers to landfill!
Remember, we haven’t re-used in my country for two decades, so I speak from vague knowledge rather then certainty.
Your own NKF has a brochure (in pdf format) about re-use. It can be found at:
On the assumption that this is up-to-date (I should hope so) … this will give you a better understanding of re-use.
Which ‘wins’ (or loses) the environmental stakes … re-use or single use … is for others to answer.
'day John; I’ve just read your thread on the aspect of"green (er) dislysis) A subject in which I have a lot of interest being a reitered electricl power gen and and distribution engineer now on haemodialysis. The huge amount of water used in dialsysis and the consequent usage of electrical power per person dialysing is as you indicate horrendous, plus of course the impact upon the environment with all of the material plastic waste.
I investigated this aspect with great interest when Roger Greenwood introduced the NxStage m/c for HHD patients here in England, pursuaded my NHS region to allow me to pioneer the systm at my home and must report that the use of water and consequent fall in my usage of electrical power is highly significant - 20 to 25litres only of water per dialysis session dependant on patient wieght with the NxStage m/c is well worrth consideration. Additionally the m/c is theoretically portable although at 35kg is too heavy for me or my wife to lift
I look to see you on 4-5th October in Manchester
Regards
David
Dear David
Yes! hooray! Someone is reading (and broadly concurring with) my ‘green’ direction - and, a dialysis patient too!
I just wish (and had hoped - maybe unrealistically) that more might have read, thought about, and acted - or responded as you have done - than perhaps have.
It’s a topic that, oddly, seems hard to “sell” or get any interest in or traction for.
It HAS gained support in the UK, but the US remains oddly silent. Ah well …
Why? … well, it beats me, as I believe better water, power and waste managment is a no- brainer and we should all be discussing it, researching it, and acting to redress our poor (collective) performance to date.
Yes … I agree, the NxStage system - whether System One or PureFlow dependent - is water and power efficient … at least when compared to the standard single pass equipment we most commonly use nowadays.
Andy Connors innovative paper (a first) from the Dorset Dialysis Unit, that plotted the carbon footprint of various dialysis systems and regimens, showed that the NxStage leaves a carbon signature between 1/3rd and 1/4 of that left by the other single pass dialysis equipment currently in use. The sorbent systems (they are coming) promise even greater water efficiency (4-6L) though there is no current information available regarding their power use.
I was not aware that you were a patient at the Lister (Stevenage) and of my friend and much admired colleague - he of the gravely Rock 'n Roll voice - Roger G!
Give him my very, very best!
And, yes, I look forward immensely to meeting like minds in Manchester in October. I remain in awe of what the UK has done - in a such a short time frame, spurred on by Donal O’Donohue and Charlie Tomson, with things ‘green’ and concepts ‘sustainable’. They have shamed the rest of us, and would there but be the will, here and elsewhere, to emulate their lead.
Hi John
Seems to me that we now have a situation where most all of us have always had water on tap, flush toilets and light etc at flick of a switch; so it’s so simple and readily available at really a relatively cheap price we all just use it without much thought. Due to my profession I am aware of the huge capital investment in power and water supply but shared by the millions of us the per person price is easily paid for also, I am of an age when I can remember electricity and water in the home being installed. We’re not genereally aware that 50HZ 240v electricity was not available as a norm across the U K until the 1930’s so the older generation took more care of it compared to the normal acceptance of these things by todays people It is I think real shortage of items and therefore cash and employment that make us think harder and work more to obtaining whatever and conserving what we have. Maybe the credit card culture and instant availabilty for all has a lot to answer for!
So far as haemodyalysis is concerned having personally progressed through the stages of renal failure, unit HD and now HHD my conclusion is that great savings and better health would be obtained by all renal patients if the choice was limited to HHD or reanl unit HD only in exceptional cases where the patient just have to have assistance from medical staff
I think this because my own experince is that since commencing HHD although I now spend 3 or 4 hors 5 or 6 days a week dedicated to dialysis I actually have more usable time - no longer the horrible post dialysis agonies that incapacitated me, I feel better look better and ma better. Trouble is that I find that in talking with fello ERF patients only an extremely small minority are prepared to come away from the reanl unit and try HHD. We need more and better eduactation pre-dialysis on this subject and the medics also need to be convinced of the benefits to the patient and the system. The nursing staff appear to have a sense of non beleive of the difference between 3 and 5 or 6 times pw dialysis to the feeling of better health of the patient. There is a need to get away fromm the practice of one size fits all and that the norm is in unit
Then there is the green issue as the NxStage and shortly Quanta and Baxter will be producing greener m/c’s for home use
So Fresenius will probably have to react to competiton but I beleive that the Renal staff - (Technicians !?! ) - also need education and then to pressurise for greener more efficient dialysis m/c’s
Incidentally I was predialysis at Lister so from that met Roger but relocated to the countryside of Northamptonshire when I retired but still meet him now and then. If only more would be a bit adventurous and like him look outside the box !
David
Dear David
I agree that we have come to think of many of the finite (and costly) resources we use as ‘infinite’ - or as our ‘right’ to have - rather than as our privilege. We could ‘use’ far more wisely, and ‘abuse’ far less rapaciously - if only we thought about it a bit more and applied some quite simple, sensible conservation principles to our daily lives … and this includes to dialysis!
The NxStage machine uses +/- 30 L water per treatment c/w a single pass system which uses up to 500 L per treatment and the carbon footprint of the NxStage is 1/3rd to 1/4 of that of most single pass systems. On a per capita basis, it is the most resource and carbon-friendly machine going round.
The Quanta, while smaller than other single pass systems, still depends on RO-dependent, single pass concepts. While its’ power needs may be a little less, its’ water use isn’t really much different to conventional machines … at least that is my understanding of it, as I have not actually been up close and personal yet with the Quanta.
The Baxter home dialysis machine - a machine with which I am well familiar - will, when it comes out in the near future, use a far smaller water ‘tank’ to create the dialysate but, as it depends on hot water sterilization (after and modeled upon the old Aksys machine), its’ total water use (dialysate and sterilization) may still be very significant … and it’s power needs - it must heat the water it uses for sterilization - may also be significant. I don’t have specification data, one way or the other - so I am indulging in pure speculation here - though, I hope, informed speculation.
The most water-efficient system in the near to medium future will be, I think, the new Fresenius PAK sorbent system: 4-6L or water per dialysis. Its’ power requirements are likely to be small too. [NB: I must declare a conflict of interest here, as I have been involved in the genesis of the PAK]. On the deficit side of the PAK, the carbon footprint left during the manufacture of the sorbent cartridge the PAK will use may well offset any gains made at the dialysis ‘coal-face’ by the water and/or power saving of the machine itself. Again, this is conjecture, as the actual data is simply not known.
Certainly, while the greatest gains in ‘green-ness’ are likely to be in the home (another ‘plus’ for home dialysis) due to the water/power ‘friendliness’ of the emerged and emerging home equipment … at least on a per hour of treatment basis … the longer treatments that are now encouraged for those at home will tend to offset this - a fact clearly shown by Andy Connors work on carbon foot-printing.
I agree with you … to me, home dialysis is a no-brainer.
I mean, why wouldnt you, if you could?
And, the data from Australia and New Zealand shows clearly that more than 50% of patients can easily manage home dialysis - either by HD or by PD - if the effort is made at the pre-dialysis education level to make the outcome, survival and wellness benefits of dialysis at home clear … and that effort is matched by an equal effort that sets up and sustains a strong home training and support unit.
That’s what we do - and - truthfully - we have no trouble maintaining +/-30% over the past 7 years since 2005 (range 28-33%) of our HD population at home … plus a further 20-22% of our total dialysis population at home on PD … a summation home penetration of >50%.
And … there are other Australian units who do even better, … to my embarrassment … with up to 65% of their patients at home - though these are units that are more home PD than home HD oriented. One of them is one of the two or three largest units in the nation. We (in Geelong) have been more home HD than home PD directed but have, I think, a higher penetration (read percentage) of HD at home … all nocturnal, with a mean of 8-9hrs/night x 5.2 nights/week … than any other unit.
In New Zealand, where there is a home-only policy in Christchurch in the South Island - they do even better! … and their home-only policy has worked well and effectively for over 3 decades - and is well accepted (and lauded) by their patients.
Back to the subject of ‘green’ … it’s a direction that I believe we will be at our peril if we don’t take it seriously.
You Brits have been doing ‘green’ better than anyone at the moment … and it rots my socks to say that … but your excellent ‘green nephrology’ and ‘sustainable healthcare’ initiatives have been so damn successful that it puts my local Geelong-centric meanderings to shame.
Still, more strength to your collective arm, and I do not begrudge you one jot - I just envy you, from afar!
"Going Green’ just needs someone to think outside the box … as Roger Greenwood has (and does - bless him) … along with some leadership, and some common sense.
Did you see that a clinic in Glen Falls, NY is now using solar power for dialysis? Hopefully this is the start of a trend…http://wnyt.com/article/stories/S2668157.shtml?cat=300.
I didn’t Dori but fully agree with as much use as practical be made of Solar power also I reckon we ought to make more use of water turbines for electrical power generation in fact in preference to wind powered turbine generators but that’s another subject. For dialysis much work does need to be done on the reduction in use of electicity and water not to mention the operational components waste
Dear Dori
I am so pleased that, somewhere, out there … others are beginningto do the inevitable.
Well done, Glen Falls.
May more, and in more ‘solar-obvious’ regions than NY state, think it through and begin to wonder if assisted power option might be worthwhile.
Please, if you have a chance, let them know that others are watching their efforts. They are blazing a trail!
I think you blazed it. They are just the next batch of intrepid trekkers marching along it! 