Abstract
The health consequences of accelerating climate instability are now widely recognized. What is only beginning to receive comparable attention is the environmental footprint of healthcare itself1–3 Globally, healthcare contributes approximately 5% of annual greenhouse gas emissions—nearly three times that of the aviation industry.3,4 Climate change is not only an environmental crisis, but a health emergency, particularly in kidney disease, where a bidirectional relationship exists between planetary health and patient outcomes2,3,5–8 Climate change may significantly influence the incidence and geographic distribution of chronic kidney disease (CKD). Rising temperatures, shifting rainfall patterns, and more frequent extreme weather events can increase the risk of kidney stone formation, acute kidney injury, and overall CKD prevalence. In addition, climate-related disasters can disrupt healthcare systems, making it more difficult for patients with kidney disease to access essential, life-sustaining treatments. 3
Chronic kidney disease and kidney failure impact an estimated 30 million people worldwide, a figure projected to double by 2030 in part due to climate-related factors. 2 At the same time, access to kidney replacement therapy remains profoundly unequal across low- and middle-income countries. 9 The combination of rising disease burden and high-resource therapies places a unique ethical responsibility on nephrology to embed sustainability into clinical practice and advocacy. Kidney replacement therapies are among the most resource-intensive treatments in medicine, generating substantial waste and emissions. Sustainability can no longer be peripheral—it must be integral to kidney care delivery.2,3,9,10
The growing mobilization around climate responsibility has led to the development of the GREEN-K initiative (Global Environmental Evolution in Nephrology and Kidney Care) under the International Society of Nephrology, promoting environmentally sustainable kidney care (ESKC).2,11 Furthermore, conclusions from the Kidney Disease: Improving Global Outcomes (KDIGO) Green Nephrology Controversies Conference highlights that “green dialysis” initiatives have been adopted in certain regions. However, broader implementation remains necessary, along with the development of innovative technologies and care models to further reduce the environmental footprint of dialysis. 10 Within this framework, peritoneal dialysis (PD) occupies a critical space. Life-cycle analyses consistently demonstrate that PD carries a lower carbon footprint than in-center hemodialysis (ICHD).3,12 Recent comprehensive Australian analyses further demonstrate that continuous ambulatory PD (CAPD) represents the lowest impact modality compared with automated PD (APD).3,12 These findings reinforce the environmental rationale for home-based therapies.
Yet even PD is not without environmental cost. Across modalities, the dominant contributor to emissions remains the manufacture, packaging, and transport of consumables—particularly plastic-based materials—with limited and inconsistent recycling infrastructure.12,13
In this “Green” Issue of Peritoneal Dialysis International, contributors outline practical and innovative pathways to reduce the environmental footprint of PD worldwide.
In this issue's review Sustainable PD – Your Questions Answered, Choo et al. present a structured framework for embedding sustainability into PD practice, drawing on the Centre for Sustainable Healthcare's five domains: health promotion, patient empowerment, lean resource management, low-carbon alternatives, and operational efficiency. Patients receiving PD are uniquely positioned to observe the material footprint of their therapy—accumulating cardboard, plastic bags, and tubing in their homes. Disposal often falls to patients themselves, further complicated by municipal recycling variability and rural–urban disparities. The authors emphasize patient empowerment as a sustainability strategy, which is highlighted in Images in PD by Pronça de Morae and Batista, who show an ingenious way a patient reuses the plastics amassed from empty PD bags to form a fence.
The Short Report by Ghimire et al. examines lean resource use through the lens of icodextrin packaging in Canada. In their APD cohort, only 2.5L icodextrin bags are commercially available, despite a mean prescribed fill volume of 1.2L. This mismatch results in approximately 50% dialysate waste, generating both unnecessary PVC plastic disposal and significant annual financial waste per patient. Their analysis highlights how seemingly minor industry decisions in packaging can carry meaningful environmental and economic consequences.
The Original Article by Nicdao et al. extends the sustainability discussion by quantifying the environmental impact of incremental PD compared to full-dose therapy. Using retrospective data and upstream life-cycle modeling, they demonstrate reductions in carbon emissions, water consumption, and waste generation with incremental approaches. Incremental PD emerges not only as a patient-centered clinical approach but also as a lower-carbon alternative consistent with sustainable practice.
Finally, the Original Article by Cruz-Cruz et al. explores one of the most forward-thinking concepts in PD sustainability: effluent reuse. While biochemical and microbiological analyses suggest potential feasibility as a non-potable water source, logistical and purification challenges remain. Nonetheless, initiating scientific discourse on effluent reuse represents an important step toward circular resource models in kidney care.
Collectively, these contributions underscore that environmentally sustainable kidney care is not aspirational—it is imperative. Peritoneal dialysis already offers a lower-carbon alternative within kidney replacement therapy.10,12,13 However, meaningful environmental progress requires coordinated action across clinicians, patients, industry partners, policymakers, and health systems. 10
As the burden of kidney disease rises alongside climate volatility, nephrology must lead rather than follow. Embedding sustainability into PD care is not only environmentally responsible—it is ethically aligned with our mission to protect health. The resilience of kidney care for future generations will depend on how deliberately we act today. As we rethink the environmental footprint of PD, even the way we share this science deserves reflection. While not yet realized, we aspire for this journal to one day become fully paperless—aligning our words on sustainability with meaningful action.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: JP serves on a speaker's bureau for Baxter Healthcare and Fresenius Medical Care and has received speaker fees from ARA, US Renal Care, and Davita Healthcare. He has served as a consultant for Bayer, Baxter Healthcare, GSK, Otsuka, AstraZeneca, Amgen, and Outset Medical, and holds stock/stock options in iREN Medical. He has received salary support from Arbor Research Collaborative for Health, the International Society for Peritoneal Dialysis, and the American Society of Nephrology. He currently serves as Editor-in-Chief of Peritoneal Dialysis International.
