Scielo RSS http://scielo.pt/rss.php?pid=0872-016920230003&lang=en vol. 37 num. 3 lang. en http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300127&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300129&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300130&lng=en&nrm=iso&tlng=en http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300132&lng=en&nrm=iso&tlng=en ABSTRACT Introduction: Healthcare services have a significant environmental impact (EI). The increasing prevalence of chronic kidney disease makes nephrology one of the clinical areas with higher EI. The aim of this study was to document Portuguese nephrologists’ current practice regarding environmental sustainability. Methods: Two surveys were developed: one for chiefs of departments and another for all nephrologists registered in the Portuguese Society of Nephrology. Results: There were 153 responders (25.5% response rate): 17 (11%) were chiefs of departments, 36 (23.5%) nephrologists in coordination roles, 60 (39%) nephrologists and 40 (26%) nephrology fellows. The median priority attributed to environmental sustainability was 4 (IQR 3-5). Only one department had established a green group, but 13 were currently undertaking at least one green project (76.5%). Only 6% of responders (8/136) had received formal training on this topic, but more than 90% would like to have more information. The most reported barriers to environmental sustainability practices were inadequate information, lack of adequate facilities, concerns about security and legal norms. Only two facilities (11.8%) declared that environmental sustainability was considered in procurement decisions. More than 70% of the Units did not have regular access to any kind of environmental sustainability audit. Only 3 surveyed units (17.6%) have set up systems to reuse the reverse osmosis rejected water and only half had local on-line dialysate production (9/17, 53%). Conclusion: Portuguese nephrologists wish to incorporate environmental sustainability in their daily practice, however there is a big gap between their intention and current behavior, likely because of the identified barriers. Keywords: Environment; Medical Waste; Nephrology; Renal Dialysis http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300139&lng=en&nrm=iso&tlng=en ABSTRACT Introduction: Healthcare facilities are among the greatest contributors to resource consumption and waste generation. Nephrology is one of the most polluting medical areas, mostly due to hemodialysis (HD). Incremental hemodialysis (iHD) has gained attention due to several clinical advantages, by decreasing the number of sessions while the patient still has residual kidney function. Beyond these benefits, this regímen might also be both more economical and environmentally friendly. The aim of this study was to evaluate the potential reduction of resource consumption, waste generation and carbon footprint associated with the implementation of iHD. Methods: We conducted a single-center retrospective analysis of 157 incidental patients initiating HD in our centre in 2019 (pre-pandemic). Retrospectively, a set of criteria identifying eligibility for an iHD program were applied to those patients. Results: Twenty-three patients (15%) would have been eligible for iHD instead of starting a standard HD program. In that scenario, iHD implementation would have reduced from 36 to 85 tons of CO2 equivalent emissions and 4186 kg of contaminated waste yearly, at our unit. iHD would also allow savings of almost 60 000€ and a reduction in water consumption of 418 600 L in one year. Conclusion: This study shows that iHD can significantly attenuate the environmental and economic impact of HD. These findings encourage kidneycare programs and policymakers to adopt greener options but should never be detrimental to the clinical decision of referencing a patient to iHD. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300143&lng=en&nrm=iso&tlng=en ABSTRACT The rising prevalence of patients living with kidney disease and the recognition of the huge environmental impact of kidney care (mainly dialysis treatments) points to the unsustainability of nephrology in the near future, which has forced the nephrology field to define its sustainability as a priority for this century. In order to face this issue, nephrologists need to recognize the dimension of the environmental footprint of their activities and what topics are associated with a bigger carbon footprint or resource consumption. Nephrologists should be in the center and the driving force for the changes needed. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300147&lng=en&nrm=iso&tlng=en ABSTRACT The reutilization and valorization of wastewater contributes to water saving and improve the energetic efficiency of hemodialysis facilities. Moreover, it has the added benefit of reducing environmental impact and providing economically interesting added value products. This review discusses the most recent approaches for the valorization of this type of wastewater. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300150&lng=en&nrm=iso&tlng=en ABSTRACT Dialysis treatment consumes a significant amount of water and energy, which entails an important waste management effort. Those variables play a relevant role on the total cost of a dialysis session. Strict dialysis water and ultrapure dialysis fluids standards were established as a pre-requisite for online convective therapies (e.g., hemodiafiltration), improving biocompatibility of the dialysis system, reducing inflammation profile of the dialysis patients, enhancing the responsiveness to erythropoiesis-stimulating agents and thus having the potential for improved survival. The main purification step of a dialysis water treatment system is the reverse osmosis. Fouling of reverse osmosis membranes remains a major issue and all effort should be made to reduce it, to ensure a constant output. Naturally occurring waterborne filamentous fungi, yeasts, bacteria and fragments may contaminate dialysis water and, consequently, dialysis fluids. To maintain the dialysis water treatment system under proper conditions and fulfilling the dialysis fluids quality standards there is a need of a significant effort, namely in terms of cleaning and disinfection procedures of the reverse osmosis, distribution systems and dialysis machines. Improving the reverse osmosis inlet water quality profile by installing an Ultrafiltration system as a pre-treatment, could have na impact in terms of dialysis water quality outcomes, water and energy consumption, and disinfection frequency. The water treatment system efficiency is strongly influenced by the system design and reverse osmosis setup. System design (i.e., not over dimensioned) with a clear focus on increasing efficiency is mandatory if one wants to decrease the carbon footprint. Dialysis prescription (namely dialysis fluid flow rates) plays an important role in the dialysis fluid consumption and consequently the water consumption. A more environmentally friendly dialysis can be influenced by optimization of the current technology and development of innovative technology, and by the adoption of a conscious and coherent behavior of all persons involved in the daily routine of a dialysis unit. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300157&lng=en&nrm=iso&tlng=en ABSTRACT While medical health professionals are trained to detect, treat, and comfort, they are not trained to consider the environmental impact of the services they provide. Healthcare contributes significantly to resource depletion and greenhouse gas emissions. Not only are healthcare institutions, whose mission is to protect and promote health, major polluters that use large amounts of energy and water, but the production, transport, use and disposal of medications and other medical consumables also leave considerable carbon footprints. In nephrology practice, dialysis programs have a particularly large carbon footprint with recurrent, per capita, resource consumption and waste generation profiles that are disproportionately high compared to other medical therapies. A close relationship between renal healthcare professionals and manufacturers is fundamental for the development of sustainable ecofriendly technologies, devices, and machines. Such collaboration is essential to reduce the environmental burden of renal therapies and maintain good quality of treatment. Renal units should register and evaluate their environmental performance and make an initial diagnosis of their environmental processes, to provide locally adapted recommendations for areas of additional improvement through environmental management programs. Regular auditing of these programs must be also performed aiming at continuous improvement with the setting of increasingly ambitious goals for reducing environmental burden of nephrology. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300162&lng=en&nrm=iso&tlng=en ABSTRACT Chronic kidney disease prevalence is increasing worldwide and is responsible for important morbidity, mortality and poor quality of life. Progression to end stage renal disease leads to major sustainability burden with high consumption of human and material resources. Hemodialysis particularly is associated with high rates of water consumption, waste production and greenhouse gas emissions. The nephrology community is gaining environmental awareness and several international societies are creating specific groups focusing on green nephrology. The first concerns are centered in the impact of hemodialysis, but it is unanimous that chronic kidney disease prevention and delayed progression are the most important measures to sustainability. New drug classes such as SGLT-2 inhibitors, selective mineralocorticoid receptors antagonists and GLP-1 analogues are revolutionizing the treatment of proteinuric and non-proteinuric chronic kidney disease. Large randomized clinical trials have proved strong and sustained benefits in renal and cardiovascular outcomes, and these drugs are now first and second-line therapy for the treatment of diabetic and non-diabetic kidney disease. In this mini-review article we explore the prevalence of chronic kidney disease, its environmental impact and resume the major strategies to prevent and delay its progression, including recent evidence on pharmacotherapy. Implementing prevention strategies and adopting environmentally-friendly practices, is the key to a better patient care and a greener nephrology. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300168&lng=en&nrm=iso&tlng=en ABSTRACT Chronic kidney disease (CKD) is highly prevalent and is predicted to become the fifth highest cause of premature mortality globally by 2040. There are several risk factors for CKD and the environmental conditions play an important role on the development of kidney injury. Due to increasing use of earth’s natural resources and pollutants emissions, extreme weather events are becoming more frequent and severe. These events, such as hurricanes or floods, cause infectious diseases outbreaks that increase the risk of acute kidney injury and chronic kidney disease. In addition, rising average temperatures and heat waves cause a higher incidence of acute kidney injury and nephrolithiasis. Patients with CKD are particularly prone to these events, with a special focus on patients undergoing peritoneal dialysis or hemodialysis. Mitigation plans are needed to reduce the effect of climate change on kidney health. Nephrologists have an important role in both reducing the environmental impact of nephrology and in preparing patients for the effect of climate changes on their diseases and for the accessibility problems to health institutions. http://scielo.pt/scielo.php?script=sci_arttext&pid=S0872-01692023000300171&lng=en&nrm=iso&tlng=en ABSTRACT Chronic kidney disease (CKD) is highly prevalent and is predicted to become the fifth highest cause of premature mortality globally by 2040. There are several risk factors for CKD and the environmental conditions play an important role on the development of kidney injury. Due to increasing use of earth’s natural resources and pollutants emissions, extreme weather events are becoming more frequent and severe. These events, such as hurricanes or floods, cause infectious diseases outbreaks that increase the risk of acute kidney injury and chronic kidney disease. In addition, rising average temperatures and heat waves cause a higher incidence of acute kidney injury and nephrolithiasis. Patients with CKD are particularly prone to these events, with a special focus on patients undergoing peritoneal dialysis or hemodialysis. Mitigation plans are needed to reduce the effect of climate change on kidney health. Nephrologists have an important role in both reducing the environmental impact of nephrology and in preparing patients for the effect of climate changes on their diseases and for the accessibility problems to health institutions.