В мире диализа объявлен переход к экологически устойчивым технологиям и новым моделям лечения

In the past 4 years, there has been growing adoption of green dialysis initiatives in the United Kingdom, European Union, Australia, and many other countries, according to the Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference report on Green dialysis: environmentally sustainable care, growth, and innovation. However, significant barriers still exist. The report cites an urgent need for new technologies and changes in models of care. Participants included physicians, nurses, patients, and engineers who examined how existing hemodialysis (in-center and at home) and peritoneal dialysis practices might be optimized to promote environmental sustainability. The report states that key areas for innovation include the development of more efficient water purification systems and energy-saving equipment in hemodialysis (HD). Point-of-care dialysate generation for peritoneal dialysis (PD) could significantly reduce carbon emissions associated with transport. Across both modalities, the introduction of novel bioplastics or other strategies to reduce harmful disposable materials could greatly mitigate the environmental impact. The Role of the Medical Community Green dialysis isn’t a single fix. It’s a shift in mindset, applied across many small and large decisions. “It requires staff education, standardized monitoring, and transparent reporting. Broader integration of sustainability into routine dialysis care represents a critical opportunity to reduce the environmental footprint of kidney replacement therapy without compromising patient safety or treatment efficacy,” said Jennifer Flythe, MD, professor of medicine and chief of the University of North Carolina (UNC) division of nephrology and hypertension, Chapel Hill, North Carolina. “For nephrologists, that starts with recognizing environmental sustainability as a genuine domain of care quality, on par with safety and effectiveness, not a side project.” In clinical practice, this involves personalizing dialysis initiation and considering incremental dialysis where clinically appropriate. Dr Flythe said clinicians should question routine high dialysate flow rates (Qd) that offer little clinical benefit. Nephrologists should also push procurement decisions, both their own and their institution’s, toward equipment and products that use less water, energy, and packaging. “It also means becoming comfortable citing the evidence. Many green changes, like lowering Qd to 500-600 mL/min or adopting incremental PD, are backed by outcome data showing no compromise in care, which should reassure clinicians who worry sustainability efforts might mean cutting corners,” Dr Flythe said. Rupesh Raina, MD, who is the co-chair of the International Pediatric Nephrology Association (IPNA) green dialysis working group and a member of the International Society of Nephrology (ISN) dialysis working group, noted that dialysis is one of the most resource-intensive therapies in medicine. From water and energy use to plastics and transportation resources, millions of patients on dialysis will utilize enormous amounts of resources over their lifetimes. He said dialysis organizations can quantify and publicly report metrics on their environmental impact as they do with infections and clinical outcomes. “Green dialysis starts with awareness. Clinicians can begin by tracking and assessing opportunities to decrease waste, conserve water and energy, minimize unnecessary laboratory tests and supplies, and encourage evidence-based medicine that limits over-utilization of healthcare resources without negatively affecting outcomes,” said Dr Raina, an adult and pediatric nephrologist at Akron Children’s Hospital and Cleveland Clinic Akron General Medical Center, Akron Ohio. “Over time, green dialysis should be ingrained into daily clinical decision-making just like we consider cost, access, quality, and other patient-centered measures when striving to provide the best care possible.” He said clinicians can practice evidence-based medicine, minimize waste, support home dialysis and telehealth options when feasible, and promote early initiation of chronic kidney disease management and transplantation. “Educating patients about medication adherence, vascular access preservation, home dialysis when applicable, and sustainability efforts within their dialysis organization are also crucial. Industry partners can aid in this effort by developing recyclable materials, biodegradable components, more efficient dialysis machines, and greener manufacturing processes,” Dr Raina said. Dialysis patients, providers, and industry leaders are not the only ones who can drive environmental sustainability in kidney care. “Researchers, professional societies, and lawmakers play a critical role as well. By working together to advance green dialysis innovation without compromising patient safety and clinical outcomes, we can make sustainability an inherent part of providing exceptional care to our patients rather than treating it as an inconvenient afterthought,” said Dr Raina. Mihran Naljayan, MD, who is chief medical officer of clinical transformation, home modalities and pediatrics at DaVita, said it is important to call attention to this issue for a host of reasons. “As nephrologists, we can work together to adopt and encourage intentional behaviors like prioritizing water and energy efficiency in daily operations and ongoing education on initiatives like facility recycling programs for non-medical waste, reducing general water and energy use, and other sustainable practices to support patients with their care,” said Dr Naljayan. At DaVita, they have started a new focus with 3 main initiatives to help offset the environmental impact of delivering life-sustaining care. One is water conservation: DaVita saved hundreds of millions of gallons of water over the past 5 years through initiatives to reduce water consumption. “Another is energy efficiency, including updates like LED lighting, modernized water heaters, and advanced HVAC heat pump technology to optimize energy use while keeping patients comfortable. We also have a focus on renewable energy, which led to the launch of our first ever net-zero dialysis center in Georgia.” Dr Naljayan said. Geovana Basso, MD, who is head of medical affairs at Vantive, a vital organ therapy company with a 70-year legacy of kidney care innovation in Deerfield, Illinois, said it is also necessary to view green dialysis through the lens of health care sustainability, which is the capacity of a health system to deliver care over time. “This requires measuring health outcomes relative to social, financial, and environmental costs,” Dr Basso said. “Because sustainable kidney care requires progress across clinical practice, technology, infrastructure, policy, and patient engagement, continued collaboration among clinicians, academic societies, providers, manufacturers, patients, researchers, and policymakers will be important.” Patients’ Role For patients, engagement looks different but is just as important. Dr Flythe said patients are the ones who live daily with the volume of supplies and waste that dialysis generates, and the report specifically highlights how patient perspectives shaped the conference’s conclusions. “Patients being treated with home therapies can participate in recycling programs where available, such as peritoneal dialysis bag recycling schemes now operating in several countries, ask their care teams about incremental or personalized prescriptions, and importantly have a voice in shared decision-making about modality and treatment frequency, where environmental impact is now recognized as a legitimate factor alongside clinical suitability and personal preference,” Dr Flythe said. Patient Safety Remains a Top Priority Both clinicians and their patients need to understand that the green changes are meant to be additive to care, not subtractive. The report repeatedly frames sustainability as something to pursue without compromising, and ideally while improving, patient outcomes. Stefano Stuard, MD, PhD, senior vice president and global clinical officer for hemodiafiltration (HDF) at Fresenius Medical Care, said before adopting new green products it is important to look at their effects on care quality and patient safety. “Nephrologists and clinical staff should be involved in decisions about equipment, supplies, and clinical practices. A product or process should not be adopted simply because it is described as environmentally friendly. It must also be safe, reliable, supported by evidence, and capable of consistently meeting the required standards of care,” said Dr Stuard. “Meaningful progress will require health care providers, manufacturers, policymakers, and the wider kidney care community to work together. Environmental impact should become part of the routine assessment of dialysis care, alongside treatment quality, patient experience, and clinical outcomes.” He said awareness of this issue is also increasing among clinicians, dialysis providers, manufacturers, patients, and policymakers. However, the environmental impact of a technology cannot be assessed on the basis of a single feature. Its entire life cycle, including manufacturing, transportation, clinical use, and disposal, must be considered. A product that reduces transportation or waste, for example, may require more energy or materials during production. Cost, availability, and feasibility in different health care settings must also be taken into account. Dialysis facilities can reduce their environmental footprint by using water and energy more efficiently, improving waste separation, reducing unnecessary packaging, and better managing supplies and transportation. Dr Stuard said facilities should regularly monitor environmental indicators, including water and energy consumption and the amount and type of waste generated. These measures should be integrated into continuous quality improvement and supported by clinic-level benchmarking to identify variation, set realistic targets, share effective practices, and track progress. “Across Fresenius Medical Care’s NephroCare network in Europe, water consumption, energy consumption, and waste generation are already included in the Balanced Scorecard and routinely monitored at clinic, country, and regional levels. Performance is reviewed monthly, and progressively more ambitious annual targets are set to drive continuous reductions in resource consumption and waste generation,” Dr Stuard said. “Changes to equipment, materials, treatment processes, or facility operations must be evaluated to ensure that treatment adequacy, infection control, water quality, and access to care are maintained. The aim is to reduce waste and unnecessary resource use without compromising safe and effective dialysis,” Dr Stuard said. Innovations on the Horizon Dr Raina said in recent years there have been promising innovations and technology improvements in water purification, heat recovery, low-energy dialysis machines, telehealth monitoring, and home-based therapies. “Point-of-care dialysate generation for peritoneal dialysis and research into more environmentally friendly packaging and biomaterials also has the potential to revolutionize how we think about the carbon footprint of kidney replacement therapy,” said Dr Raina. “While several of these technologies are beginning to be used clinically, broader implementation has been slow due to regulatory barriers, infrastructure investments, reimbursement challenges, and lack of universally accepted definitions and reporting standards for sustainability metrics.” The dialysis industry continues to rely heavily on single-use plastics and transportation of large amounts of supplies, especially in-center hemodialysis. “So, while I am very encouraged by the progress we have made over the last several years, we still have a long way to go until dialysis can be considered sustainable,” said Dr Raina. Most transformative technology is still early-stage, including heat energy recovery from dialysis effluent, and shorter bloodlines. “Centralized acid delivery, reverse osmosis reject water reuse, and optimized dialysate flow rates are practical, available-today interventions with demonstrated water, energy, and cost-savings. So, on the operational and clinical practice side, meaningful progress is achievable now, and some centers are already doing it,” said Dr Flythe. The report notes that even promising ideas like bioplastics aren’t automatically greener once you account for land use, water use, and the underdeveloped recycling and composting infrastructure needed to handle them. Currently, there is a lack of standardized environmental metrics and life-cycle-assessment methods. Additionally, dialysis facilities restrict dialyzer reuse or on-site waste sterilization in many jurisdictions. Another major barrier is that reimbursement and procurement systems don’t yet reward sustainable choices. Taking a Step-by-Step Approach The report calls for applying a waste hierarchy (prevention first, then reuse, recycling, recovery, and disposal only as a last resort), and adopting “life cycle thinking” to evaluate any change before adopting it. It is important to not just look at its effect in the treatment room, but its impact from raw materials through disposal. Dr Flythe said US facilities can start with low-risk, well-evidenced changes, such as adjusting dialysate flow rates toward 500-600 mL/min where clinically appropriate, which shows minimal impact on dialysis adequacy. She also recommends auditing and optimizing reverse osmosis system settings and disinfection schedules. It’s important to improve waste segregation, she added, so material isn’t defaulted into costlier and environmentally burdensome hazardous-waste streams. “Facilities considering capital investments should prioritize reverse osmosis systems and dialysis machines with demonstrated lower water and energy use, and should evaluate whether centralized acid concentrate delivery is feasible, since it reduces plastic waste and emissions substantially, especially in larger units,” Dr Flythe said. Clinicians can incorporate personalized and incremental dialysis prescriptions where survival and quality-of-life data support it. When having a shared decision-making conversation about modality it may be that home therapies carry a lower carbon footprint, though that shifts some burden (waste, utility costs) to patients, so this needs to be discussed transparently. Patient safety remains the non-negotiable constraint throughout. The report is careful to distinguish deliberate, evidence-based, patient-centered adjustments (like incremental dialysis) from resource-driven corner-cutting, and it notes that some higher-impact ideas (dialyzer reuse, peritoneal dialysis drain-line reuse, on-site hazardous waste treatment) are currently restricted by US and international regulation because the safety evidence needs further development. Disclosure: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original references for a full list of authors’ disclosures. References: - Barraclough KA, Berman-Parks N, Jha V, et al; conference participants. Green dialysis: environmentally sustainable care, growth, and innovation: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2026;110(1):42-60. doi:10.1016/j.kint.2026.01.015 - Haroon S, Davenport A. Editorial: Moving towards a sustainable and greener dialysis. 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