The following post is meant as food for your thought …
I have never considered myself a ‘greenie’ and, while I have always looked in wonderment at the natural beauty around us, it has been something that I (like most) have rather ‘taken for granted’. But … things seem to be changing! Climate change is upon us. There seems no doubt about it and the contribution of man to the initiation, severity and speed of this change is now the subject of hot debate.
Oddly … my interest in providing and promoting better dialysis has drawn me into the ‘green debate’ and to begin to ‘think green(er)’! How? … well, it goes as follows …
Through the early 90s, I was disillusioned by the outcomes of what was then being called – and is still called by many – ‘adequate dialysis’. I thought there just had to be more! Then by mere chance, I heard of the Uldall and Pierratos program in Toronto. They were offering overnight, long, slow and frequent dialysis at home.
Although in Australia, we (and I) had always been home dialysis-friendly, overnight, long, slow and frequent home dialysis was something new … well … new to me at that time. While experience and knowledge later taught me of many such prior programs of extended hour dialysis at home: Shaldon, De Palma, Charra, Seattles’ vast experience, to name a few … to me, in 96/97, it was news!
A long beach walk changed things for me … this ‘nocturnal home haemodialysis’ made so much sense. I thought … could we duplicate their work here? I answered … yes, why not! This began a journey which became our Geelong nocturnal home haemodialysis program. We, and subsequently others in Australia, have never looked back.
But … our successful home program in Geelong (now 30% of all our haemodialysis, all self-dialysing at home and overnight) led to a new range of problems.
Utilities costs were, at that time, the responsibility of the user – the patients. While water and power were not cheap, we had suddenly shifted our service costs and expenditure from the renal service to the home-based patients. They were not slow to notice … and complain (nicely!) … and so they should have.
We saw this as a threat to the longer term success of our program … a disincentive … a potential barrier to ‘going home’. This led us to two further steps:
(1) representation to government (successful) for utility subsidies for the home program. There is now a $1160 per annum pro rata payment made to all home patients for their utility costs
(2) it made us think about potential ways to lessen the home patient water/power cost burden.
This then led to us on to develop a highly effective water-saving, recycling and re-use program for home patients. Using standard single-pass equipment (NxStage is not available in Australia), we have reduced home water use (and costs) by up to 82%. The capital plant to achieve this water saving is now part of the standard installation we do for all home patients … and, as with all Australian dialysis costs, this is paid by the program – not the patient
Ha! thought we … if it can be done in the home, we can do it for the facilities too! So, we did. We now recycle and re-use ~100,000L of water in our 110 patient haemodialysis service (32 @ home and 78 in-facility) each week … yes … each week. The cost (the so-called RoI or ‘Return on Investment’) of the required plant and equipment is recouped within 18-24/12. From then on … water costs (and wastage) are hugely diminished!
All this has now been published, many times, in the peer-review literature … thus it was that I came to my FIRST GREENING
Next thought was … if we can save water, can we be smarter with power? Geelong is sunny. Australia is sunny. Australia is the driest continent on earth, bar none. Solar power has been in the Australian ‘mind-set’ for a long time … but not for dialysis. A trawl of the Internet and medical literature has not found any references to the use of solar power for dialysis – except for some cartoons of Osama Bin Laden pushing a dialysis machine in a wheelbarrow through the mountains of Afghanistan.
But … why not solar powered dialysis?
I did some reading, drew up some figures, wrote a proposal, had it checked by some solar experts. In theory, they said, it should work … and, after obtaining seed funding from Fresenius, our experiment in solar powered dialysis is now well under way. If successful … all our modeling says it should be … we should, after the repayment of the capital outlay, have an income stream from our power-generation. The next step will be to offer free or subsidized home solar installation for home HD patients as a further incentive for our patients to ‘go home’.
… and so I came to my SECOND GREENING
Hopefully, next cab off our rank will be more efficient waste disposal and waste recycling … we even have some innovative ideas for using spent dialysate … but these are other stories.
The point of all this … ?
Our world has finite resources. We should learn to use them more wisely. Good dialysis goes further than good patient outcomes – though this is clearly the primary objective. Good dialysis should also encompass thoughtful resource utilization. We need to carefully plot the carbon footprint of the dialysis process – both at home and in our centres. Indeed, some colleagues near Oxford in the UK with whom I have long been in contact have already done exactly that with some very exciting work. They have done much, there, in a short time and their work is worth watching closely … Andy Connor and his team in the UK are doing some really imaginative and powerful stuff.
From all this, one thing is clear …
Dialysis should not (as we have allowed it to do) stand still. There is so much to do … not only to improve the outcomes for patients through, in my view, a ‘more is better’ ethos … but, through a range of improvements to equipment and plant and by introducing innovative ways to conserve, reuse, recycle and minimize, improve outcomes for the environment we live in and depend upon.
There is an ‘environmental section’ at my website (see below) where the references to some (but not the most recent) of our papers on this issue can be found. In addition, the NHS in the UK (more strength to its arm) has recently funded a Green Nephrology Fellow and Green Nephrology program. Even a Green Nephrology Summitt is imminent in Birmingham in the UK.
Type ‘Green Nephrology’ into your browser and this will show you the lead the UK has taken in this area … it’s most exciting! Type ‘Green Dialysis’ and you will be taken to our own latest publication in Nephrology.
So …back to my opening sentence … food for your thought … !
John Agar
http://www.nocturnaldialysis.org