Water is a dwindling natural resource and potable water is wrongly considered an unlimited resource. Dialysis, particularly hemodialysis, is a water-hungry treatment that impacts the environment. The global annual water use of hemodialysis is ∼265 million m³/year. In this reference estimate, two-thirds of this water is represented by reverse-osmosis reject water, discharged into the drain. In this review, we would like to draw attention to the complexity and importance of water-saving in hemodialysis. We propose that circular water management may comply with the "3R" concept: Reduce (reduce dialysis need, reduce dialysate flow, and optimize reverse osmosis performance), Reuse (reuse wastewater as potable water), and Recycle (dialysis effluents for agriculture and aquaponic use). Awareness and sustainability should be integrated to create positive behaviors. Effective communication is crucial for water savings since local perspectives may lead to global opportunities. Besides the positive environmental impacts, planet-friendly alternatives may have significant financial returns. Innovative policies based on the transition from linear to circular water management may lead to a paradigm shift and establish a sustainable water management model. This review seeks to support policymakers in making informed decisions about water use, avoiding wasting, and finding solutions that may be planet-friendly and patient-friendly in dialysis, especially in hemodialysis treatments.

Green nephrology, also often called sustainable nephrology, has become a field of interest in our discipline in recent years. Although several reviews have been published, comparatively few original articles have appeared, witnessing interest but also lack of original data. Greater awareness of the effect nephrology has on the planet, including, but not limited to its carbon footprint, is needed to promote education and research on these issues. Increasing awareness entails increasing knowledge at various levels, and it is for this reason that we are presenting this review focusing on educational activities that have been and could further be undertaken to spread knowledge of these topics. We start from a description of the various approaches to green nephrology: technical, mainly focused on dialysis, clinical, encompassing medical and nonmedical treatments in all CKD phases, and comprehensive, embedding kidney care in the society. We further summarize what is known and the fundamental needs and problems we presently face in reducing dialysis carbon-print, optimizing the pathways of care, avoiding futility in clinical work and research, and implementing lifestyle interventions and education. We further acknowledge the lack of data on lifecycle of items and procedures, including commonly used drugs, and identify research needs at various levels. We finally discuss some examples of educational programs on green nephrology that are already available at various levels, from medical schools (an educational game), to medical meetings (healthy eating and reduction of plastic and paper waste), and daily clinical practice, in which teaching passes also through examples (personalizing dialysis and adapting schedules to each patient). Finally, we identify some barriers that educational approaches may offer ways to overcome, to promote effective, targeted interventions that will make us advance on the road to reduce nephrology's carbon footprint.

Reusing hemodialysis wastewater (HWW) is more difficult due to its higher conductivity (salinity) and the need for an iterative RO or adsorption process. It can therefore be challenging and technologically laborious. In this context, this study aimed to investigate the possibility of treating HWW by combining electro-coagulation (EC) and electro-oxidation (EO) processes and adsorption as the best technologies to achieve efficient removal of dissolved micropollutants. In this work, the application of electro-coagulation/electro-oxidation processes using, respectively, aluminum and platinum electrodes combined with adsorption onto active carbon to treat HWW was studied. In the EC process, high removal of phosphate ions and chemical oxygen demand (COD) was observed. In the EO process, the COD removal performance, total nitrogen, and Mg were significant and reached 100, 83, and 89%, respectively, after 100 min of treatment. The estimated energies required to treat HWW by EC and/or EO were approximately 0.7 kWh/m³ and 0.05 kWh/m³, respectively. While the EO and EC processes used for COD removal from HWW showed almost similar performances, the EO process seems to consume less energy. Therefore, electrochemical removal of HWW can be successfully performed using the EO process and activated carbon (AC) for the complete removal of COD and the mineralization of pharmaceutical residues. The experimental results showed that the coupling of the three processes (EC–EO–AC) provides treated water that can be reused in agriculture due to its less sodium absorption ratio (SAR) value and might be an alternative method of wastewater treatment responding to the concept of green dialysis.

Background: This study aimed to investigate the effects of intradialytic concurrent (resistance–endurance) training combined with melatonin (MEL) supplementation on oxidative stress, inflammation, and cellular damage in hemodialysis (HD) patients. Methods: Thirty-two HD patients were randomly assigned to three groups: Exercise (EX)-MEL, EX-Placebo (PLA), and Control (C)-PLA. Participants in the EX-MEL and EX-PLA groups underwent 12 weeks of concurrent training. Before nocturnal sleep, they ingested either 3 mg of MEL (EX-MEL) or a placebo (EX-PLA and C-PLA). Blood samples were collected at baseline and after 12 weeks of intervention to assess lipid peroxidation [malondialdehyde (MDA)], antioxidant biomarkers [ferric-reducing antioxidant power (FRAP), reduced glutathione (GSH), total thiol (THIOL)], total bilirubin (TBIL), uric acid (UA), biomarkers of muscle and liver damage [aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), creatine kinase (CK), lactate dehydrogenase (LDH), and Gamma-glutamyltransferase (Gamma-GT)], and inflammation [C-reactive protein (CRP)]. Results: EX-MEL demonstrated a decrease in MDA (p < 0.05) and CRP (p < 0.05), and an increase in FRAP (p < 0.05) pre- and post-training. Both EX-MEL and EX-PLA showed an increase in GSH (p < 0.001, and p < 0.05, respectively) and THIOL (p < 0.01, and p < 0.05, respectively) pre- and post-training. No significant changes were observed in TBIL, UA, ASAT, ALAT, CK, LDH, or Gamma-GT pre- and post-training across all groups. Conclusion: Concurrent training combined with MEL supplementation enhances oxidant–antioxidant balance and reduces inflammation in HD patients more effectively than intradialytic concurrent training alone.

In this study, biofilm formation and the production of key virulence factors were systematically evaluated across 33 strains of Pseudomonas aeruginosa isolated from diverse hospital environments in Tunisia. Among these, 13 strains demonstrated strong biofilm-forming capacities. Adding glucose (9%, w/v) to the culture medium generally enhanced biofilm development, indicating that glucose supplementation may promote biofilm formation in clinical isolates. The 13 selected biofilm-forming strains exhibited a consistent production of critical virulence factors, including pyocyanin, rhamnolipid, and LasA protease, known for its staphylolytic activity. However, profiles of extracellular polysaccharide (EPS) production and motility showed considerable heterogeneity among the strains, suggesting a strain-specific regulation of these traits. Based on a comprehensive analysis of biofilm formation and virulence expression, strain 2629 was chosen as a model organism due to its robust biofilm-producing ability and high virulence factor output. This strain was used in subsequent in vitro assays to evaluate the anti-biofilm potential of a commercial disinfectant containing peracetic acid and other active agents. Results indicated that a 3% (v/v) concentration of the disinfectant, applied for 5 min, was nearly sufficient to eradicate the biofilm formed by the model strain. These findings underscore the importance of selecting a representative biofilm-forming strain for accurate in vitro assessments of disinfectant activity.