The Complex Relationship Between Kidney Health and Our Environment

The Complex Relationship Between Kidney Health and Our Environment

Nephrology Times

By Keightley Amen, BA, ELS 

The recycling symbol is an unmistakable icon that brings to mind environmental stewardship. The image consists of three arrows in a triangle formation inspired by a Mobius loop—a surface that has only one side and no end.

That continuous loop could also be used to illustrate the complex circle—or vicious cycle—of the environment and kidney care: Climate change impacts kidney health, increasing the number of people who ultimately need treatment. At the same time, kidney treatment takes a toll on the environment, further contributing to climate change. It is a loop that seemingly has no end.

Nephrologists are working to better understand and improve this complex relationship.

“This topic has not been deeply investigated, but there has been a lot more interest in the past 5 years. This is becoming more of an urgent issue, and the interest is palpable,” said Suzanne Watnick, MD, a professor of medicine at the University of Washington Division of Nephrology in Seattle and a practicing nephrologist at Puget Sound Veterans Administration. She has observed increasing interest and concern among patients, trainees, nephrologists, allied healthcare professionals, and staff.

Although she acknowledges that this is not an easy problem to address, she emphasizes its vital importance. “We need to establish sustainable practices that have long-term viability so we can continue to provide treatment to the patients who need it as life support.”

Environmental Effects on Kidney Health and Disease

The ways in which the environment can affect kidney health are multifactorial. One major consideration is heat stress and subsequent dehydration-related kidney injury.

“As we see global temperatures rise, which is a fact, we’re starting to see different effects on kidney health,” said Dr. Watnick, who is the inaugural Health Policy Scholar in Residence for the American Society of Nephrology (ASN) and has spoken and published extensively on the topic of nephrology and the environment. “This is especially true in places with decreasing capacity to provide and consume enough water, as well as lower-income countries where many people are doing hard labor in fields, in part due to heat.”

According to Fumihiko Sasai and colleagues,1 numerous epidemics of acute and chronic kidney conditions have been identified in hot, rural regions of the world. They predict that as higher temperatures and water shortages occur in more parts of the world, these conditions will lead to increased incidence of heat stroke, with its significant stress on the kidneys, as well as kidney stones and crystalluria. They predict that such conditions will also exacerbate chronic kidney disease, which makes people prone to heat-associated illnesses due to reduced thermoregulatory ability.

Particle pollution can also have serious effects on kidney health. “Short-term exposure to air pollution is linked with an increased risk of kidney disease-related events, including hospital admissions, and death,” according to Xiang Qian Lao and colleagues.2 “Long-term exposure, even at low to moderate levels, may lead to progressive pathophysiological changes, such as chronic systemic inflammation and oxidative stress, that contribute to the development of kidney disease. In addition, air pollution may exacerbate traditional kidney disease risk factors such as hypertension and diabetes, thereby accelerating disease progression,” they wrote.

A third major way the environment can affect renal health is through increasingly common extreme weather events, which cause care disruptions and interrupt the supply chain that is integral to kidney therapy and other medical treatments. A recent example is when Hurricane Helene caused major damage to a Baxter International manufacturing plant in North Cove, North Carolina, which led to a shortage of IV fluids that affected the entire country for months. Extreme weather events also cause flooding that may result in an increase in infectious diseases, which can lead to or exacerbate kidney conditions.

The Effects of Dialysis on Our Environment

Three million patients worldwide currently receive dialysis, and 5 million are expected to receive it by 2030.3 It is a lifesaving treatment, but it comes at a high cost to the environment.

• One dialysis treatment uses an average 490 L of water, which is 158% the average daily water use of a typical American household.4
• A single dialysis facility typically consumes enough electricity to power more than 100 homes, Dr. Watnick said.
• Hemodialysis creates more than 2,000,000 tons of waste per year, including 600,000 tons that are potentially hazardous.5
• Patient and staff travel to and from dialysis clinics also has an environmental impact.

Barriers to Change

Individuals and groups seeking to make improvements to mitigate the effects of kidney care on the environment face several barriers, including financial constraints, lack of data and literature on the subject, limited awareness among healthcare professionals and policymakers, resistance to change, and a paucity of incentives to create technologies that provide the same level of patient care but do not have such a significant impact on the environment.

However, several national organizations have launched initiatives to address the impact of nephrology on the environment. The International Society of Nephrology’s Global Environmental Evolution in Nephrology and Kidney Care (GREEN-K) initiative6 has a vision of “sustainable kidney care for a healthy planet and healthy kidneys” and a mission to “promote and support environmentally sustainable and resilient kidney care through advocacy, education, and collaboration.” The actions it is taking include:

• Creating a dedicated “green nephrology” field
• Funding and promoting research and presentations
• Establishing best practices in sustainable kidney care
• Promoting an industry-aided transition to low-carbon and zero-waste dialysis therapies
• Establishing metrics that facilities can use to understand how their environmental impact compares with that of others and how it changes over time
• Developing and promoting competencies, processes, and incentives

The ASN’s Statement on Climate Change7 declared that “climate health is kidney health.” The organization started an emergency preparedness group and a sustainability subgroup. Among their priorities are:

• Advocating with policymakers
• Broadening access to lower-impact therapy options, such as home dialysis
• Encouraging the development of new treatment options, such as wearable or implantable artificial kidneys
• Preventing kidney diseases by addressing risk factors such as nutrition, access to care, chronic stress, and comorbid conditions such as hypertension and diabetes

The ASN has partnered with the US Department of Health and Human Services on the KidneyX project, which aims to accelerate innovation in this space. The initiative recently awarded a Sustainability Prize totaling $7.25 million for innovations that reduce water or power used during dialysis.8

Jeff Wilzbacher, senior director of sustainability and energy for DaVita, a major provider of dialysis services, said the company is working toward “achieving 100% renewable energy in North America, cutting our carbon footprint by over 70%, and saving hundreds of millions of gallons of water—helping to offset the environmental impact of delivering life-sustaining care to our patients.”

He echoed Dr. Watnick’s emphasis on the importance of data, which will help clinics set evidence-based emissions targets and participate in greenhouse gas accounting.

 Take Local Action to Make Global Change

 Wilzbacher and Dr. Watnick encourage healthcare professionals and staff members to get involved at the clinic level.

“Clinicians can lead the way by modeling sustainable practices in their centers and communities,” Wilzbacher said.

Dr. Watnick said clinics can take many steps to reduce the specialty’s impact, including:

• Identifying green nephrology champions
• Instituting regular environmental rounds to look for areas for improvement (eg, water leaks, improper disposal)
• Purchasing equipment that uses less electricity and water (for example, new energy-efficient reverse osmosis machines can reduce water usage, saving money and lessening environmental impact)
• Implementing water-saving technology and reuse systems
• Minimizing single-use items
• Buying in bulk to reduce deliveries’ impact on the environment
• Reducing prescriptions for unnecessary medications
• Promoting recycling programs for packaging and other noncontaminated materials
• Helping patients find environmentally friendly transportation to the clinic, such as public transportation and carpools

At Montreal Children’s Hospital Dialysis Centre, nephrologist Marie-Michèle Gaudreault-Tremblay, MD, and medical student Leina Kingdom sought ways to reduce their clinic’s footprint. They discovered existing features on their dialysis machine that could reduce water usage without compromising treatment quality. By adjusting the amount of water used to the patient’s blood flow, they were able to reduce dialysate flow to 300 mL of water per minute and save 98 L of water per patient per treatment.9

When added together, local efforts can have a global impact.

Link to Article

References

1. Sasai F, et al. Nephrol Dial Transplant. 2023;38(1):41-48. doi:10.1093/ndt/gfab258
2. Lao XQ, et al. Kidney Int. 2024;106(2):214-225. doi:10.1016/j.kint.2024.04.021
3. Kolbrink B, et al. Nephrol Dial Transplant. 2023;38(11):2528-2536. doi:10.1093/ndt/gfad099
4. Haddad S, et al. 2024;5(11):1747-1749. doi:10.34067/KID.0000000590
5. Piccoli GB, et al. Nephrol Dial Transplant. 2015;30(6):1018-1027. doi:10.1093/ndt/gfv031
6. Stigant CE, et al. Kidney Int. 2023;104(1):12-15. doi:10.1016/j.kint.2022.12.015
7. American Society of Nephrology. Statement on Climate Change. Accessed August 4, 2025. https://www.asn-online.org/policy/webdocs/22.4.22StatementOnClimateChange.pdf
8. American Society of Nephrology. ASN Society News. Accessed August 6, 2025. https://www.asn-online.org/news/item.aspx?ID=397
9. McGill University Health Centre. Saving lives while helping the planet. Accessed August 6, 2025. https://muhc.ca/news-and-patient-stories/news/saving-lives-while-saving-planet