Estimating the costs and amount of recyclable polyvinyl chloride plastic waste associated with discarded Icodextrin

Abstract

There is limited data characterizing healthcare waste associated with peritoneal dialysis (PD). In Canada, Icodextrin for continuous cycling PD (CCPD) is only available as 2.5L bags for one-time use, and any remaining volume that is not used for a dwell is discarded. The environmental impact of this practice has not been well characterized. As such, we sought to estimate the costs associated with discarded Icodextrin and associated polyvinyl chloride (PVC) plastic waste production within our renal program. We conducted a cross-sectional audit of all patients utilizing CCPD in the Alberta Kidney Care South program in Canada in 2022. Icodextrin fill volume data were captured and the costs associated with Icodextrin use were calculated. Among patients on CCPD, the average fill volume for Icodextrin was 1273 mL, suggesting that an average of 1227 mL was discarded. In fact, 88% of patients used dwell volumes ≤1.5L. In 2021, our program spent $1.27 million CAD on Icodextrin for CCPD. Given that an average of 49% of each 2.5L bag was discarded, we estimate that the annual value of wasted Icodextrin among patients being treated with CCPD in our program was $622,300 CAD, or $3036 CAD per patient. Annual PVC waste was calculated to be 25.9 kg per patient, and we estimate that PVC waste could be reduced by 35% if there was access to 1.5L Icodextrin solutions. Our work suggests that the availability of Icodextrin bags that are better aligned with volumes used by patients could reduce healthcare costs and PVC waste.

Background

There is emerging recognition of the importance of sustainable kidney care and reducing healthcare waste from dialysis.^1–4 Healthcare waste has been divided into hazardous (materials that have come into contact with bodily fluids) and nonhazardous (e.g. unused dialysate) waste by the World Health Organization. ⁵ The latter should be recycled and/or conserved when possible. Polyvinyl chloride (PVC) plastic is a recyclable material that can leach into groundwater supply and degrade into carcinogenic products.^6,7 It is used to make peritoneal dialysis (PD) dialysate solution bags and is an example of nonhazardous waste generated by PD.^4,8,9

Most of the published literature highlighting the environmental impacts of kidney programs has focused on hemodialysis, and less is known about healthcare waste associated with PD. Recent studies have shown that PD leads to large plastic waste production,^8,10 and that a substantial amount of recyclable PVC plastic ends up in the landfill. ⁹ Another potentially wasteful practice in PD is the discarding of unused PD dialysate solutions. Icodextrin is a commonly used solution for PD in Canada that can minimize exposure to hypertonic glucose solutions and better facilitate management of volume in long dwells.^11,12 Icodextrin comes in single-use 2.5L bags for continuous cycling PD (CCPD), and any remaining solution not used for the dwell is discarded. ¹³ Thus, for patients prescribed Icodextrin fill volumes smaller than 2L, a substantial amount of the solution may be wasted.

In this short report, we sought to calculate the cost associated with discarded Icodextrin and quantify the amount of recyclable PVC produced in a cohort of patients being treated with CCPD. Further, we estimated the potential reduction in PVC wastage if we had access to 1.5L Icodextrin solutions.

Methods and results

In the Alberta Kidney Care South (AKC-S) PD program, approximately 90% of patients are treated with CCPD (vs continuous ambulatory PD). There are no formal criteria for prescribing Icodextrin in our program, and the decision to utilize Icodextrin is left up to the prescribing nephrologist. We conducted a cross-sectional audit of patients being treated with CCPD in the AKC-S program in the province of Alberta, Canada on 16 February 2022 to collect data on prescribed Icodextrin fill volumes for CCPD. This was deemed a quality report that did not require accessing medical records or specific patient information, and patient-demographic information was not reported in this process. We calculated the total cost of Icodextrin for CCPD in our program to be $1.27 million in 2021. Icodextrin for CCPD is only available 2.5L in our program. Our report did not include patients using automated peritoneal dialysis without a long day dwell.

Cost of wasted Icodextrin and PVC production

In a cohort of 205 patients being treated with CCPD, the average prescribed fill volume was calculated to be 1273 mL. Given that each one-time use bag of Icodextrin is 2.5 L, the average amount of discarded Icodextrin was calculated to be 1227 mL, or 49% of the 2.5L bag. Thus, based on the current prescription data, we estimated that $622,300 CAD (49% of $1.27 million) was spent on discarded Icodextrin solution annually. In our cohort of 205 patients, this equates to $3036 CAD spent on discarded Icodextrin per patient annually (Figure 1).

Figure 1.

Calculations of the cost and amount of polyvinyl chloride waste associated with discarded Icodextrin among patients being treated with continious cycling peritoneal dialysis in our program.

A previous study has shown that each 2.5 L Icodextrin bag contains 70.98 g of recyclable PVC material (i.e. from part of the bags that had not came into contact with the dialysate effluent). ⁹ Assuming that each patient used one Icodextrin bag daily, the total annual recyclable PVC waste would equal 5311.1 kg, or 25.9 kg of PVC per patient per year (Figure 1).

Hypothetical reduction in recyclable PVC production

In our cohort, 180 patients (88%) were prescribed fill volumes ≤1500 mL. If we assumed that (1) there was access to 1.5L Icodextrin solution bags, (2) all 180 patients with fill volumes ≤1500 mL used 1.5L Icodextrin solution bags, and (3) the amount of recyclable PVC in 1.5 L bags was proportionally smaller compared to the 2.5 L bags (i.e. if 70.98 g of PVC for every 2.5 L bag, then there was 42.59 g of PVC for every 1.5 L bag), then the total PVC waste would equal to 3445.7 kg, or 16.8 kg of recyclable PVC per patient per year (Figure 1), equating to 35% less PVC waste per year.

Discussion

The need for upfront costs to change infrastructure and abandon established practice patterns may partially explain why sustainable kidney care is not commonly prioritized in dialysis programs. ¹⁰ We show that conservation of Icodextrin could reduce healthcare costs and PVC plastic waste. Although we presented the costs as per patient values to increase generalizability across programs, it is worth noting that the aggregate cost of discarded Icodextrin at a national level is likely quite high. This cost will continue to grow as the prevalence of kidney failure increases globally.^14,15

Reducing plastic waste supports the broader goals of the global community as outlined in the Global Plastic Treaty, ¹⁶ an UN-led international agreement to end plastic pollution. This has led to emerging interest in finding ways to recycle PD plastic and reduce the volume of PVC in landfills. ⁷ Despite the known toxicities of PVC breakdown products, ⁶ only 5 countries globally have begun to establish recycling programs for PD-associated PVC, ¹⁷ and this service is not yet available in Canada. Use of incremental PD is another strategy that may reduce PVC waste. Prescribing lower doses of PD (including using Icodextrin as needed for fluid retention) among patients with adequate residual kidney function would lower the amount of PVC waste generated. We highlight that, in addition to recycling and strategic use of incremental PD prescriptions, using smaller Icodextrin bags may further reduce PVC waste. Our audit revealed that a large majority of patients on CCPD use Icodextrins fill volumes ≤ 1500 mL, and that the use of hypothetical 1.5 L bags could reduce PVC waste by 35%.

It is worth noting that smaller format Icodextrin solutions exist in certain countries and for specific purposes. As an example, 2L Icodextrin solutions are available for CCPD in Australia. ⁸ Further, Icodextrin 4% solutions are available in 1.5L bags to be used as intraperitoneal irrigate for surgery. ¹⁸ This highlights the potential for suppliers to provide Icodextrin solutions in a variety of sizes. Further work is needed to understand the reasons for regional variations in the availability of smaller-format Icodextrin solutions, and to understand why Icodextrin for CCPD is only available in 2.5L solution bags in Canada.

There is no safety data to promote the use of unspent Icodextrin solutions (that would otherwise be discarded). Therefore, having access to smaller format Icodextrin solutions bags for smaller fill volumes may be the most pragmatic way to reduce discarded Icodextrin. Unfortunately, providing smaller solution bags may not be profitable for private dialysis vendors, despite the large cost and PVC reduction potential for healthcare programs. Thus, implementing this change may depend on advocacy efforts from nephrology and environmental organizations to work with vendors to produce more practically sized PD solutions. We plan to work with other Canadian dialysis programs to quantify costs on a national scale and to disseminate this information to the larger nephrology community. Ultimately, we hope to partner with policymakers and nephrology organizations to develop advocacy strategies that will promote sensible changes from dialysis vendors and suppliers. As an example, these efforts may consider contractual obligations from dialysis vendors that include certain financial and environmental targets, and lead to sustainable and financially sensible practices in PD programs. Further, having access to smaller and cheaper PD solutions may promote uptake of PD in lower income countries, where the availability of PD services is limited and cost-saving strategies are needed.^19,20

To the best of our knowledge, our report is the first to explore the economic and environmental impacts of oversized Icodextrin solutions. Our intention was to highlight this under-recognized problem and provide basis for future quality-improvement work. There are however several limitations of this report worth noting. First, our estimates of costs and PVC do not account for temporal changes in prescribed fill volume and number of patients being treated with CCPD. Second, we estimate the weight of PVC in a hypothetical sized solution bag (1.5L) which will not be completely accurate (if ever such a product was created). Future work looking at designing smaller-format Icodextrin bags may consider comparing the empty weight of different sized glucose PVC bags in order to determine whether weight of PVC is proportional to the volume of bags. Finally, we did not include patients on continuous ambulatory peritoneal dialysis which may have underestimated total costs and PVC waste.

In summary, we present the costs and PVC waste associated with discarded Icodextrin and highlight how the use of smaller Icodextrin solutions may lead to substantial reductions in PVC-containing plastic waste production. Further work is needed to reduce the environmental impact of PD.