Maintenance hemodialysis is lifesaving but demands significant resources resulting in an increasing environmental impact that must be acknowledged. Contemporary hemodialysis requires large amounts of purified water, electrical power and produces substantial plastic and medical waste. Life-cycle studies suggest that one session can use, up to 490 litres of water when accounting for priming, rinsing and reverse osmosis (RO) waste greatly surpassing the daily water use of a single person [1]. Similar analyses from green nephrology initiatives demonstrate that a conventional hemodialysis session may generate more than 300 litres of RO reject water that is commonly discarded [2]. Patients encounter hundreds of liters of dialysate weekly, while 50–70% of the total water is frequently discarded as RO reject, which is typically released straight into drains [3].
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1.Haddad S, et al. Thinking globally, acting locally: Water use in a hospital hemodialysis unit. Kidney360. 2024;5(11):1747–1749. doi:10.34067/KID.0000000590
2.Barraclough KA, Agar JWM. Green nephrology. Nat Rev Nephrol. 2020;16(5):257–268.
3.Centers for Disease Control and Prevention. Water use in dialysis. Atlanta: CDC; n.d. Available from: https://www.cdc.gov/dialysis
4.Barraclough KA, et al. Carbon emissions from different dialysis modalities: A life cycle assessment. Am J Kidney Dis. 2025;86(4):465–474.e1. doi:10.1053/j.ajkd.2025.04.019
5.Chan CT, et al. Dialysis care in the era of climate change. J Am Soc Nephrol. 2021;32(9):2243–2251.
6.Rathore SS, Jindal K, Ghosh A, et al. Green dialysis from the Indian perspective: A systematic review. Cureus. 2024;16(2):e55623. doi:10.7759/cureus.55623
7. Soohoo M, Streja E, Obi Y, et al. Dialysate flow rates and dialysis adequacy: Balancing efficiency and resource use. Hemodial Int. 2022;26(1):34–42.
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