Objective To map and synthesise existing interventions aimed at improving environmental sustainability in kidney care and to identify challenges and opportunities for implementation across treatment modalities. Design Scoping review following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology. The study merged two existing frameworks to form appropriate review questions. Data sources Embase, MEDLINE, Scopus, and CINAHL alongside relevant grey literature, searched in September 2024. Eligibility criteria for selecting studies The review included studies from 1 January 2005 to 30 September 2024 that reported on environmental sustainability interventions in kidney care, including chronic kidney disease, haemodialysis, peritoneal dialysis, kidney transplantation, and conservative management and that provided measurable or descriptive information about the intervention. Conference abstracts and opinion pieces without intervention data were excluded. Results Out of 2,512 records screened, 95 studies were included. Environmental interventions were most commonly implemented in haemodialysis (n = 58), followed by chronic kidney disease (n = 19), transplantation (n = 6), peritoneal dialysis (n = 5), and conservative management (n = 1). Some studies addressed multiple modalities; therefore, categories are not mutually exclusive. The most frequent sustainability categories were water use, waste management, procurement optimisation, energy efficiency, and travel reduction. Interventions ranged from dialysate flow reduction and RO water reuse to telemedicine and supply chain redesign. While many demonstrated environmental and economic benefits, reporting was heterogeneous, and studies were concentrated in high-resource settings. Conclusions There is growing interest in sustainability within kidney care, particularly in haemodialysis. However, adoption across other modalities remains limited. Future work should prioritise underrepresented areas, standardise metrics, and ensure inclusion of low-resource contexts. Co-design of interventions with patients and staff, combined with consistent reporting using frameworks such as SQUIRE 2.0, is essential. Integration of sustainability into clinical practice and policy is urgently needed to align kidney care with global climate and health goals.

Background: Procurement activities in healthcare, especially within nephrology, contribute significantly to the environmental footprint. In peritoneal dialysis (PD), procurement of consumables such as dialysis bags, tubing, and machines plays a critical role in driving environmental impacts. Previous studies, including those by the National Health Service (NHS), have shown that procurement can account for up to 72% of the healthcare sector’s carbon emissions. Methods: A life cycle assessment (LCA) was conducted from April to July 2024 at the Nephrology Dialysis and Kidney Transplantation Unit of AOU Policlinico di Modena, Italy, in accordance with ISO 14040/14044 standards. The study focused on procurement-related environmental impacts in automated peritoneal dialysis (APD), based on a standard prescription of two 5L bags overnight and one 2L daytime dwell per day. Products were dismantled to assess materials and modelled using OpenLCA with the Ecoinvent v3.10 database. Transportation, manufacturing, and waste disposal were included within system boundaries. Results: The 5L Dialysate Bag (used twice daily) had the highest carbon footprint (1515 kg carbon dioxide equivalent [CO ₂ -eq/year]), followed by the 2L Bag (457 kg) and Automated Drainage System (286 kg). Primary drivers were long-distance transport, plastic production (especially polyethylene and PVC), and energy-intensive manufacturing. Although the 5L bags are used in greater quantities due to the APD prescription (typically two bags per night), it still showed a lower carbon footprint per litre of dialysate delivered (0.415 kg CO ₂ -eq/L) compared to the 2L bag (0.626 kg CO ₂ -eq/L). Smaller items like disinfectant sprays and medical kits contributed less individually but were used frequently. Across all categories, plastic production, packaging, electricity use, and incineration were key contributors. Conclusion: The environmental impact of PD procurement is concentrated in a few high-use, high-impact items. Reduction strategies should target material substitutions, modular product design, and lower-emission transport and energy use. Innovations such as local dialysate mixing, improved waste segregation, and increased recyclability could substantially reduce the environmental burden of PD. Graphical

Background: Peritoneal dialysis (PD) is a home-based treatment for kidney failure, offering significant social, economic and environmental advantages over haemodialysis (HD). It allows patients greater independence and flexibility, can reduce healthcare costs in some settings, and is reported to generate a smaller environmental footprint compared to HD. However, despite this, its environmental impact, particularly in terms of resource use and waste generation, is an area of growing concern. Evaluating PD through a sustainability lens, considering environmental, social, health and economic dimensions is crucial to improving its long-term viability and reducing the healthcare sector's environmental footprint. Methods: An LCA of the PD treatment pathway was conducted at the Nephrology Dialysis and Kidney Transplantation Unit, ‘Azienda Ospedaliero-Universitaria (AOU), Policlinico di Modena, Italy. Data were collected between April and July 2024 and was categorised into 17 PD-related procedures. Key activities assessed were electricity use, resource consumption (procurement), water consumption, patient and staff travel and waste disposal. Flow diagrams were created to model the PD pathway and product components were dismantled and weighed to determine material contributions. Environmental impacts were analysed using OpenLCA and the Ecoinvent database. Results: Automated peritoneal dialysis (APD) treatments produced greater emissions than continuous ambulatory peritoneal dialysis (CAPD), primarily due to higher electricity consumption and the use of polyvinylchloride. APD generated 3267 kg CO ₂ e annually compared to 2975 kg CO ₂ e for CAPD. Monthly patient examinations contributed 250 kg CO ₂ e per year, largely from travel. CAPD produced more healthcare waste (320 kg), leading to 810 kg CO ₂ e emissions, while APD waste emissions were lower at 374 kg CO ₂ e. Incremental dialysis approaches showed substantial reductions, with emissions falling to 1642 kg CO ₂ e (APD) and 1517 kg CO ₂ e (CAPD). The most impactful materials included polyethylene and PVC, with plastic components contributing significantly to overall emissions. Conclusion: This comprehensive life cycle assessment (LCA) highlights the environmental challenges associated with PD, particularly in waste generation and resource use. Key areas for improvement include reducing single-use plastic reliance, increasing recycling efforts and integrating energy-efficient solutions. This study provides a foundation for targeted sustainability interventions in PD and contributes to the broader goals of the KitNewCare project, which aims to optimise health outcomes while minimising environmental impacts in kidney care.

Background: Environmental optimizations in kidney care have been analysed as part of the European Union co-funded KitNewCare project. Methods: Life Cycle Assessments (LCA) using Ecoinvent database and OpenLCA software quantified optimizing resource use (e.g. dialysis machines, reducing flow rates, incremental dialysis), energy-saving measures (e.g. solar energy, efficient lighting) and travel reduction (e.g. home dialysis, telemedicine). Efforts in waste management involve transitioning clinical waste to domestic waste streams, recycling and pyrolysis. Water-saving practices include reclaiming water for non-potable uses and efficient treatment systems. Results: LCA quantified these interventions, revealing significant environmental particularly in reducing travel and resource use. Travel optimizations yielded the most significant CO2 equivalent savings, while incremental dialysis also conserved water and reduced greenhouse gas emissions. Conclusion: The study underlines the importance of prioritizing impactful interventions to minimize the environmental footprint of chronic kidney disease care while maintaining clinical efficacy. Challenges include adapting strategies to local contexts, ensuring economic feasibility and integrating renewable energy sources based on regional energy mixes.

Background: Haemodialysis (HD) and online haemodiafiltration (OLHDF) are the main in-centre treatments for kidney failure. Both rely on high water and energy use and produce substantial greenhouse gas emissions. OLHDF provides superior solute clearance and improved survival compared with high-flux HD, but its environmental burden remains less defined. Clarifying these differences supports evidence-based and sustainable treatment decisions. Methods: A process-based life cycle assessment (LCA) was performed at the Nephrology, Dialysis and Kidney Transplant Unit, AOU Policlinico di Modena, Italy, in 2024, following ISO 14040 and 14,044 standards. The functional unit was one patient year of treatment, equal to 156 sessions. System boundaries included procurement, water treatment, session operations, travel and waste management. Modelling used OpenLCA with Ecoinvent 3.11 and the Italian electricity grid factor of 0.25 kg CO2 per kWh. Scenarios assessed HD-only, OLHDF-only and the real-world Modena treatment mix. Sensitivity analysis varied the share of OLHDF, session frequency, grid intensity and reverse-osmosis (RO) recovery rate and included a reduced-flow OLHDF prescription. Results: The annual footprint was 4469 kg CO2-eq, 60,290 MJ and 1364 m3 world-eq deprived water per patient year. HD generated 4427 kg CO2-eq and OLHDF 4548 kg CO2-eq, reflecting slightly higher electricity and water consumption and greater plastic use in OLHDF. Travel contributed 71% of total emissions and procurement 21%. Sensitivity analysis showed changes in RO efficiency and electricity mix had stronger effects than treatment type. Conclusions: HD and OLHDF have comparable environmental profiles. Clinical outcomes should drive modality choice, while sustainability gains depend on improving transport, water recovery, energy management and renewable integration.

Background: Haemodialysis (HD) has a significant environmental footprint due to its high resource consumption and waste generation. A key component is dialysate production, which typically involves mixing water, bicarbonate, and a single-use acid concentrate bag for each session. An alternative method is the central delivery of acid concentrate, prepared on-site using dry powder formulations. This study compares the environmental impact of these two delivery systems, focusing on waste reduction, elimination of single-use plastic, and decreased transport-related emissions. Methods: A detailed life cycle assessment (LCA) was carried out using OpenLCA and the Ecoinvent v3.1 database to compare the traditional acid concentrate bag system with the central delivery system (Granumix, Fresenius, Germany). Data on material inputs, energy use, waste generation, and transportation were collected. Flow diagrams captured the full life cycle of each method, and various environmental indicators were analysed, including climate change, acidification, and ecotoxicity. Results: The Granumix system demonstrated considerably lower environmental impact than traditional bag use. It reduced climate change potential by 30% (CO₂-equivalent) and freshwater ecotoxicity by 15%. Additional benefits were observed in acidification, resource use, and overall emissions, indicating the system’s broader environmental advantages. Conclusions: The central delivery of acid concentrate using the Granumix system is a more sustainable option for HD, significantly reducing environmental burdens across several categories. These findings underscore the value of adopting innovative delivery models to make essential healthcare treatments more environmentally sustainable. Graphical