As national health systems transition to net-zero greenhouse gas emissions and climate resiliency, nephrologists collaborating with the International Society of Nephrology, or ISN, emphasize the need for a sectoral approach to develop solutions to the sustainability and resiliency challenges facing regional and global kidney care.
Both acute and chronic kidney diseases, or CKD, are increasing, now affecting 1 in 10 individuals worldwide. This is due, in part, to increasingly entrenched climate risk factors that include increases in global temperatures, water salinity from rising sea level encroachment, and concentrations of environmental toxins including particulate air pollution. All contribute to an increasing prevalence of other noncommunicable diseases, or NCDs, for example, type 2 diabetes that co-occur with kidney disease.
A recent consensus statement by leading nephrology societies worldwide outlined in alarming detail the disproportionate and increasing burden of kidney disease in the global south, where the effects of climate change are most acutely felt. Also highlighted were the enormous financial costs of kidney replacement therapies, or KRTs, such as hemodialysis, or HD, peritoneal dialysis, or PD, and kidney transplantation. KRTs amount to 2%-4% of entire health care budgets in high- and middle-income settings, despite supporting only 0.1%-0.2% of the population. In less-resourced settings, millions die prematurely as KRTs may be unavailable or unaffordable.
Dialysis therapies have a high environmental impact. Considering greenhouse gas emissions alone, in some settings, the impact of a single hemodialysis treatment equates to an average vehicle driving 238 km (149 miles). With over 2 million people receiving more than 150 treatments per year, the impact is substantial. Further, KRTs, dependent on global supply chains and/or health care facilities, are vulnerable to climate shocks. The cycle of climate change exacerbating kidney disease, which in turn results in more environmental harm, must be urgently stopped. Sustainable kidney care aligns with Sustainable Developments Goals, specifically SDG 3 (good health and well-being), SDG 12 (responsible consumption and production), and SDG 13 (climate action). By integrating environmentally sustainable practices, we can improve kidney care outcomes while reducing financial and ecological costs.
Improving kidney health through environmentally sustainable kidney care
Inspired by the interconnectedness of Earth’s life and the reciprocity inherent in Indigenous value systems, and in alignment with the World Health Organization’s 14th General Programme of Work, the ISN-led Global Environmental Evolution in Nephrology and Kidney Care, or GREEN-K initiative seeks to promote and support environmentally sustainable and resilient kidney care globally through advocacy, education, and collaboration. Additional key priorities include developing sustainability resources and curricula for health care professionals and fostering international collaboration to drive systematic changes in kidney care delivery.
All kidney care stakeholders have a role — clinicians, researchers, administrators, industry partners, funders, and, of course, patients and their carers. A patient-centered approach, prioritizing health promotion, early disease recognition, risk factor reduction, and purposeful uptake of nonpharmacologic and pharmacologic therapies to prevent kidney disease progression are top priorities. Preventive care and outpatient management lower costs and have a significantly smaller carbon footprint than hospital-based care, making avoidance of hospitalization a priority.
ISN has toolkits applicable to all settings, designed to support optimal CKD management. These include guidance on newer pharmacotherapies, as well as integrated strategies for NCD prevention and management. ISN advocates for a whole of system approach to public health measures and equitable access to essential medications. This includes newer agents, such as sodium glucose co-transporter-2, or SGLT2, inhibitors, that may lower the risk of CKD progression by up to 37%. SGLT2 inhibitors have demonstrated cost-effectiveness in many settings, supporting their inclusion in the WHO essential medicines list. Planetary health kidney diets, featuring locally sourced ingredients, can be adapted to regional preferences, combining “Food as medicine” and “Food for resilience” concepts. Effective outpatient chronic disease management can be made more accessible, particularly in less developed or remote settings, via appropriate expansion of virtual health technology.
Supporting lower impact nondialysis therapies
Next, we seek to ensure prioritization of expanded access to nondialysis therapies for kidney failure, when appropriate. It has long been known that kidney transplantation offers the best quality of life while being the most cost-effective KRT. Despite this, kidney transplantation is less accessible than both HD and PD in low- and middle-income settings, and hemodialysis remains the most common KRT in the majority of high-income countries. Preliminary data support markedly lower carbon impacts of KT compared to dialysis therapies. Moreover, it is intuitive that transplantation is more climate resilient than dialysis, as it relies primarily on immunosuppressant medications rather than the complex infrastructure required for dialysis.
ISN has outlined the requirements for a successful transplant program in its framework for developing dialysis programs in low-resource settings. Conservative kidney management, which uses medical therapy instead of a KRT, is an essential component of nondialysis care. Though all countries should strive to provide and universally cover dialysis and transplant services, conservative care should be widely accessible to those who reside in regions where KRTs are not available, in addition to being provided to people who are medically ineligible for, or choose not to receive, a KRT. However, according to the ISN Global Kidney Health Atlas, both access to and quality of conservative care vary significantly across world regions, highlighting the need for targeted improvement.
Both HD and PD have significant water, energy, and plastic consumables requirements. A single HD session produces between 1.5 kilograms to 8 kilograms of plastic waste, much of which is hazardous, and all of which is costly to dispose of (€2.20-€16 per treatment in Europe in 2015). In less-developed settings, hazardous waste is more likely to be informally landfilled or burned, with potential harmful health impacts. PD, performed daily in most settings, has even higher plastic waste generation than HD.
Annual global water consumption of HD is approximately 265 million cubic meters, threatening already scarce water resources in many regions. Water used in the production of PD plastics and sterile fluids is also likely substantial, though less clearly defined. Emerging innovations in HD and PD focus on reducing plastic and water consumption and supply chain emissions. We recognize the role industry must play in kidney therapies’ thoughtful reconceptualization — pharmaceuticals, dialysis equipment, and services alike. GREEN-K is broadly engaging with stakeholders via a novel sustainable procurement strategy that aims to enhance product circularity while reducing emissions throughout the entire value chain.
Safeguarding kidney health and Earth’s natural systems
An ambition of GREEN-K is to develop and collect key performance indicators for climate-related kidney health, as well as sustainability metrics of KRT provision to inform process improvement. These data would enhance quality, appropriateness, and effectiveness of environmentally sustainable kidney care, including demonstrating anticipated cost savings from sustainable interventions to encourage widespread adoption, hence ensuring accountability in achieving environmental and health U.N. targets, aligning with global agendas.
As we approach the Fourth high-level meeting of the U.N. General Assembly on the prevention and control of NCDs, or HLM4, in September, GREEN-K exemplifies an innovative, cost-effective and climate-resilient strategy for improving kidney health while safeguarding Earth’s natural systems. Through sustainable interventions, we can simultaneously enhance health outcomes, ensure financial viability, and contribute to more resilient and equitable health care systems.
This opinion piece has been authored on behalf of ISN’s GREEN-K by Caroline Stigant, University of British Columbia; Katherine Barraclough, Royal Melbourne Hospital; David S. Goldfarb, NYU Langone Health and NYU Grossman School of Medicine; and Monica Moorthy, ISN.
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