Policlinico S.

Orsola-Malpighi

Bologna - ITALY
Azienda Ospedaliero-Universitaria

Towards a green
hemodialysis

Antonio Santoro MD,FERA

Environment is now an intricate part of
our human life.

We are responsible to keep it as much as

possible in an unchanged shape for the
next generations.

Even small changes made in our everyday

activities could have a big impact on the
ecosystem of our planet
The number of people who
were on kidney replacement
therapy exceeded 3 million
in 2017 and is projected to
grow to 5·4 million by 2030.

However, the growth trend

of dialysis is different in the
various countries with
relevant growth in Asia and
reduced in the United States
and Europe
The Lancet.com Vol 385 May 16, 2015
Around 600 million hemodialysis
procedures are performed annually
around the world
 Geelong ( Victoria) Australia

18 November 2011

Dialysis services must begin to explore eco-dialysis potentials. The

continued plundering of resources without considering reuse or
recycling, exploration of renewable energy options, or the reduction of
the carbon footprint of the dialysis process … is unsustainable.
Sustainable dialysis practices should be a global goal in the coming
decade.
Hemodialysis (HD) is one of the resource hungry
medical interventions

 A huge volume of water (about 500 L)

 Significant amounts of energy (over 7 kW)
 A kilogram or more of waste is produced
during the procedure.
A 4-h HD with Qd 500 mL/min has a
water consumption of about 408 L per
individual session treatment, with
additional 34 L and 51 L being
consumed for a 20-min priming phase
and 30-min rinsing phase, respectively.

A total water consumption for a single

hemodialysis session is nearly 500 L.

For worldwide HD population, daily

water consumption is around
500 million L
 HEMODIAFILTRATION

 The minimum threshold convective dose to ensure patient

benefits starts at 23 L/1.73 m2 per session in post-dilution
HDF mode

 Higher fuid fow is used in HDF than in standard

hemodialysis Qd (553 mL/min in ESHOL Study).

 This means an additional consumption of 70 L of water per

week, 910 L per month and 10,920 L per year in on-line HDF
mode.
• Since the late 90s it has been proposed to increase the Qd
dialysis flow up to 700-800 ml/min to increase dialysis
efficiency; (effectiveness chart)

• Patients with adequate vascular access derive modest

benefits (usually less than 20%) from this practice.
:
Albalate Ramón M et al. 2015. Nefrologia 35(6):533–538
Bhimani JP et al. 2010. Nephrol Dial Transpl 25(12):3990–3995
Ouseph R et al. 2001. Am J Kidney Dis 37(2):316–320
Albalate M et al. 2015. BMC Nephrol 16:20
Alayoud A et al. 2012. Ther Apher Dial 16(2):152–158
Ward RA et al. 2011. Clin J Am Soc Nephrol 6(9):2235–2239
Kashiwagi T et al. 2013. Med Sch 80(2):119–130
Piccoli GB et al. 2018. Clin Med. https ://doi.org/10.3390/jcm71 00331
 Reduction of Qd from 500 to 400 mL/min could
save approximately 24 L of water during 4-h
standard hemodialysis for one patient, especially
in patients with a body mass less than 70 kg.

 Hence, it might result in saving 72 liter of water

a week, 312 a month and 3744  a year

 On a global ecological scale, it would mean

conserving 24 billions of liters of water daily
 "Smart" HD equipment capable of adapting the best treatment
conditions by automatically controlling the dialysis flow

Next-generation equipment allows to set a proportional and blood flow-

related (Qb) Qd value; the Correlation Factor can be used in any type of
treatment.
Patients with limited vascular access and catheters show reductions in
available Qb.
Functions that use this Factor (Qd-link) in treatments with low Qb, can
maintain the same dialytic efficiency and reduce the consumption of H2O and
concentrates;
With Qb=250 ml/min and "Factor" value of 1.5, Qd is 375 ml/min instead of
500 ml/min.
NOTE: compared to treatments with dialysis flow at 500 ml/min, it can determine the savings of H2O for
4,700 liters / year and concentrate per 100 liters / year, approximately, for each patient who has low values of
Qb
"Smart" HD equipment capable of adapting the
best treatment conditions by automatically
controlling the dialysis flow
• Continuous priming : in order to ensure the absence of stagnation (purity and physiology of fluids) and
correct conductivity and temperature values of the infusion fluid, during the patient's connection, waiting
time,the equipment can save on fluid consumption
• Smart equipment offers such a function (Ecoflow / Continuous priming) capable of automatically producing
ultrapure liquid with continuous flow = 100 ml/min (total dialysate flow + online infusion liquid)
• Assuming a time of 30 minutes between end priming and patient connection:
- H2O consumption decreases from 2340 liters in the absence of Ecoflow (ultrapure fluids at Qd = 500 ml /
min) to 468 liters with Ecoflow
- The consumption of acid concentrates decreases from 51.5 liters in the absence of the function Ecoflow to
10.3 liters in the presence of the same (ultrapure fluids at 100 ml / min)

Consumption/pt./year Qd=500 Qd=100 ml/min Possible saving

ml/min
Treated H2O 2340 liters 468 liters 1872 liters
Concentrate 52 10,3 104 liters
 Reverse osmosis:
use of the latest generation technologies

 Design and sizing of the plant according to real needs

(number of dialysis stations)

 Systems with "intelligent" permeate recovery

 The new hospital infrastructures should be equipped

with new generation bi-osmosis which, if correctly sized,
through a proportional valve, are able to recover the
unused permeate of re-entry from the distribution ring
Instead of going down the drain, RO reject water could be used
for:

 Steam generation for hospital sterilization

 Laundry services
 Sanitation services
 Landscaping
 Almost anything we already use water for
 Hemodialysis is a power-hungry medical intervention

Hot disinfection of the loop (WT) as

well as hot disinfection of the dialysis
machines are the most energy-
consuming processes during renal
replacement treatment.
(the modern hemodialysis machines are prepared
for providing thermochemical disinfection ,84–
85 °C).
 How to approach the reduction of the consumption of electrical resources

Reverse Osmosis and HD machine:

interventions during the design phase :
 WT systems that do not provide
thermal sanitization have a lower
impact on CO2 production
(better on-line thermal systems
rather than boilers)
 Equipment with optimized
hydraulic circuits allows reduced
power consumption during the
disinfection phase
 Equipment with optimized hydraulic circuits allows
reduced power consumption during the disinfection phase

• The introduction of the heat exchanger inside the hydraulic system as

standard, helps to reduce electricity consumption at every stage of machine
operation

• Equipment with reduced hydraulic volume allows to contain consumption

as well as during the treatment phase even in disinfection: they reach the
temperature earlier, they cool down earlier, managing to limit the
consumption per cleaning cycle to only 0.7 kW per machine
 Haemodialysis wastes

Dialysis wastes that were in contact with the

blood of patients undergoing hemodialysis,
including contaminated disposable equipment and
supplies such as tubing, flters, disposable sheets,
towels, gloves, aprons, and laboratory coats”
 Hemodialysis is one of the medical interventions which produce
relatively high amounts of waste

 During every HD session even more than 2 kg of potentially infective

waste is produced.

 Every year 1 billion kilograms of medical waste produced during dialysis

worldwide must be separated, stored, and burnt

 It causes serious economical impact—the cost of 1 kg waste in Europe is

about two EUR
 Waste Management : Dialysis equipment

Automatic emptying of the filter and of the entire blood circuit

(Reduction of the average weight of hospital special wastes from 327.6 kg to 140.4
kg/year/machine;with also the automatic emptying of the entire blood circuit there could be a
reduction of waste destined for thermodestruction of about 187.2 kg / year / machine)

Use of very small volumes of disinfectant with greater concentration

( There are on the market equipment that can disinfect the monitor with only 26 ml of 50% citric
acid,then lower consumption of plastic containers)

High-performance ultrafilters that ensure the quality of the ultrapure fluid in

accordance with ISO 24500 for a longer life (up to 1800 h).
(This means a year/machine replacement of a pair of ultrafilters compared to the approximately 4
replacements needed with the different equipment on the market)
 Affordable actions

1. Reducing the burden of dialysis (adopting whenever possible an intent to delay

strategy, with wide use of incremental schedules).
2. Favouring natural medicine dealing with lifestyle, exercise and diet and limiting drugs.
3. Supporting reuse of household-type hospital material.
4. Recycling paper and glass.
5. Recycling non-contaminated plastic.
6. Reducing water consumption.
7. Reducing energy consumption, and choosing renewable energy.
8. Introducing environmental impact criteria in checklists when evaluating dialysis
machines and supplies.
9. Supporting wise triage of contaminated and non-contaminated materials.
10.Demanding planet-friendly approaches in the building of new facilities.
 more affordable actions
11.Use lightweight dialysers and other disposables.

12.Empty completely the dialysis set—dialyser and bloodlines. Use HD machines

equipped with automatic function of emptying the dialysis sets.

13.Carefully consider the dialysis fuid flow and use priming with dialysis fuid instead of
saline.

14.If you plan to replace HD machines, choose models consuming less electricity.

15.Use certifed, environment-friendly disposables—without phthalanes and other toxic

plasticizers.

16.Carefully plan patients’ travel routes—you will save time, money and decrease CO2
emission.
 Green aspects in tenders

The inclusion of environmental criteria in the technical evaluation of

the offers has an essential role to proceed in the direction towards an
increasingly green dialysis, with repercussions on the quality of the
offers but also with a reduction in the economic impact of the process
in its entirety.
 CONCLUSIONS
 A large and growing number of treatments year after year make
hemodialysis a serious burden on the natural environment.

 The most important goal of manufacturers of equipment and

medical devices should be the development of technologies that
allow for the most economical use of resources.

 On the other hand, providers should be aware of the impact of

treatment on the environment and choose solutions that
minimize the negative impact on the environment