Sustainable peritoneal dialysis: Your questions answered

Welcome to AudioScholar. Today we're covering Sustainable peritoneal dialysis: Your questions answered, by Choo S and colleagues, published in Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis.

Healthcare contributes about five percent of global greenhouse gas emissions, a footprint larger than the entire aviation industry. Within medicine, nephrology is particularly resource-intensive. Peritoneal dialysis, despite being a home therapy, generates a surprising amount of waste—from plastic bags and tubing to cardboard packaging and the energy used for transport and cyclers. Clinicians and patients alike are increasingly asking: can we provide high-quality care without costing the Earth? This paper addresses that question directly, arguing that our duty of care must expand to include environmental stewardship, especially as climate change itself poses direct threats to our patients through heat-related kidney injury and disruptions to care from extreme weather.

This article is an invited review, structured as a practical guide for clinicians. It's not a systematic review or a new clinical trial, but rather a synthesis of current evidence and expert recommendations. The authors frame their advice around five core principles of sustainable healthcare: promoting health and preventing disease, empowering patients, creating lean and efficient care pathways, using low-carbon alternatives, and optimizing the use of resources. They start with a case vignette of a patient overwhelmed by the waste from his new automated peritoneal dialysis prescription, a scenario many of us will recognize.

The review first quantifies the environmental impact of peritoneal dialysis. The carbon footprint varies by modality and location, but the numbers are significant. Continuous ambulatory peritoneal dialysis, or CAPD, generates about 1.3 to 1.8 tonnes of carbon dioxide equivalents per patient per year. For automated peritoneal dialysis, or APD, that number jumps to between 4.3 and 5.4 tonnes per year. To put that in perspective, the global average carbon footprint per person is about 4.7 tonnes. So, a single patient on APD can have a carbon footprint equivalent to that of an average global citizen, driven by the manufacturing of plastics and dialysate, transportation, and the electricity needed to run the cycler.

So, what can be done? The authors lay out a comprehensive, multi-pronged strategy. The most impactful interventions, they argue, are often the best clinical ones. Preventing or slowing the progression of chronic kidney disease is the most sustainable action of all, as it avoids the resource use of any renal replacement therapy. Similarly, promoting kidney transplantation is a key goal, as it offers better quality of life and has a much lower long-term environmental impact than dialysis.

For patients who do require peritoneal dialysis, the authors recommend "prescribing wisely." This includes using incremental PD—starting patients on a lower dose of dialysis and increasing it only as their residual kidney function declines. This approach uses less dialysate and fewer supplies, reduces treatment burden, and aligns with international guidelines without compromising clinical outcomes.

Next is optimizing logistics and supplies. This means moving away from a "one size fits all" monthly order. Clinicians should implement inventory management systems and work with patients to ensure they only order what they need, preventing the accumulation and waste of expired supplies. The review also highlights the role of virtual care. Using telehealth for routine check-ups can significantly cut down on travel-related emissions for both patients and providers, which is especially beneficial for those in rural areas.

A major focus of the paper is on tackling the mountain of plastic waste. One practical solution discussed is the use of alternative drainage systems. Instead of a new single-use plastic bag for every exchange, options like a U-drain, which connects directly to household plumbing, can eliminate this waste stream entirely. Reusable collection reservoirs are another option. While recycling PD plastics is challenging due to their classification as medical waste in many regions, the authors point to successful pilot programs that show it is possible with patient education, industry collaboration, and proper waste segregation.

The authors also touch on patient empowerment through diet. Encouraging a plant-based or plant-forward diet can be a win-win. It has potential health benefits for PD patients—like reduced constipation and volume overload—and carries a significantly lower environmental footprint than diets high in animal protein. Of course, this requires careful collaboration with renal dietitians to ensure nutritional adequacy.

Finally, the review looks to the future. Emerging technologies like sorbent-based systems, which regenerate and reuse a small volume of dialysate, could dramatically reduce the need for water, plastic bags, and shipping. Another innovation is point-of-care dialysate generation, where patients could use a small home device to create sterile fluid from concentrate, reducing annual supply shipments from three tonnes down to just a couple hundred kilograms.

A key strength of this review is its practical, actionable focus. It moves beyond simply describing the problem and provides a clear roadmap for clinicians, departments, and health systems. By grounding its recommendations in the established principles of sustainable healthcare, it offers a robust framework for quality improvement projects. However, the authors acknowledge the limitations. As a narrative review, it doesn't systematically assess the quality of all available evidence. Furthermore, the feasibility of many of the proposed solutions—like recycling programs or U-drains—is highly dependent on local infrastructure, regulations, and cost, meaning they won't be immediately available to everyone. Many of the emerging technologies are also still in early phases of development and are not yet in widespread clinical use.

So, what does this mean for your practice? The first step is to start the conversation—with your patients, your colleagues, and your hospital administration. On a practical level, you can immediately begin to "prescribe PD wisely" by considering incremental starts for appropriate patients. Make reviewing supply orders a routine part of patient follow-up to minimize waste. Educate your patients on what can and cannot be recycled in your area. At a system level, you can advocate for your unit to appoint a "Green Champion," conduct a waste audit to identify hotspots, and explore the feasibility and cost-effectiveness of introducing reusable drainage systems. Ultimately, the paper’s core message is that sustainable kidney care is not separate from high-quality care; it is an essential component of it.

That's your AudioScholar summary. The full transcript and reference are on the episode page. Until next time.

This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.