Advancing Green Nephrology: A Scoping Review of Sustainability Interventions in Kidney Care

Advancing Green Nephrology: A Scoping Review of Sustainability Interventions in Kidney Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Advancing Green Nephrology: A Scoping Review of Sustainability Interventions in Kidney Care Aycan Yasar, James Larkin, Ingeborg Steinbach, Brett Duane, Harriet Atwell, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7620813/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Nov, 2025 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Abstract 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. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Chronic Kidney Disease (CKD) is a growing global health concern, affecting around 10% of the European population 1 . It is projected to increase to 18% of the population in some countries by 2040 and 28% by 2100 2,3 . Sustainability in nephrology matters not only due to the high environmental intensity of treatment modalities such as haemodialysis (HD), but also because kidney care is a growing global health burden. Green nephrology can reduce healthcare emissions, preserve resources, and improve health equity by ensuring resilient, low-carbon models of care 1 , 4 . As patients progress to End Stage Kidney Disease (ESKD), treatment options - primarily dialysis or transplantation become environmentally intensive. The annual carbon footprint for a patient receiving thrice-weekly HD is estimated at 3.8–10 tonnes of Carbon Dioxide Equivalent (CO₂e), which is substantially higher than the per capita healthcare emissions in many countries 5 , 6 . This is mostly due to high energy consumption and substantial waste generation. Studies have shown that patient and staff transportation also contribute significantly to the carbon footprint of dialysis units, adding up to 25–30% to the total carbon footprint of HD, particularly in in-centre models with long travel distances 5 , 7 . High volume of water use for dialysis presents an additional environmental impact. 8 With over 2.6 million people receiving dialysis globally as of 2020 and projections suggesting this may rise to 7 million by 2030, the environmental footprint of kidney care is expected to grow significantly 9 , 10 . As of December 2022, 56% of prevalent kidney replacement therapy patients in Europe were receiving HD and 5% peritoneal dialysis (PD), representing over 346,000 individuals on dialysis in total, a figure driven by ageing populations and rising rates of diabetes and hypertension 11 . Although technological advances have led to more efficient and home-based therapies, these have not consistently translated into lower environmental impact. The implementation of green nephrology initiatives remains limited, largely due to economic and regulatory barriers such as high upfront costs, lack of financial incentives, and the absence of specific guidelines or mandates for environmental performance 12 . With kidney care contributing a substantial amount of healthcare-based greenhouse gas (GHG) emissions, interventions reducing kidney care’s carbon footprint would positively impact overall healthcare emissions. For example, modelling from England estimates that if 60% of kidney centres adopted process based sustainable solutions, it could save the health service 11 tonnes of CO₂e 13 . While this analysis was specific to England, similar opportunities are likely across Europe: applying comparable process optimisations across EU kidney centres would be expected to yield substantially larger absolute carbon savings, given the higher number of patients treated and dialysis facilities in operation. In practice, sustainable kidney care interventions have already been documented in multiple European countries, targeting clinical transformation, procurement, waste management, water use and energy efficiency. This scoping review explores sustainable process optimisations and technological interventions implemented globally in kidney care to reduce its environmental impact alongside identifying key challenges and opportunities. Materials and Methods Search Strategy A scoping review was performed to identify literature exploring environmentally sustainable interventions in kidney care. This scoping review followed the PRISMA-ScR methodology that systematically searches and reports on scoping reviews 14 . The search was conducted in September 2024 using the databases of Embase, MEDLINE, Scopus, CINAHL alongside grey literature aligning with the search terms, such as case studies on sustainable kidney care interventions. Keywords and phrases that were used in the search included: chronic kidney disease, end stage kidney disease, renal care, kidney care, environmental impact, dialysis, carbon footprint, environmental sustainability, optimisations, systematic review, hospitals, dialysis units, greenhouse gas emissions, life cycle assessment. The exact search strategy can be found in Appendix 1 . This study is focused on the overall environmental impacts of kidney care and has reviewed initiatives that reduce the environmental impact of ESKD and its pathways, including HD, PD, transplant, and conservative care. The settings considered were hospitals, dialysis units or renal centres and home in case of home-based dialysis treatments. Study Selection The screening of all abstracts identified in the search was done independently by two reviewers (A.Y and J.L) from September to November 2024. Both reviewers met to resolve any discrepancies and confirmed the list of papers to be included in the full paper review stage. The same two reviewers then conducted full text screening of the papers that were included in this stage. A third reviewer (M.A) was asked to resolve any discrepancies. Data Extraction Covidence was used as the online software tool for managing the scoping review process. Data extraction was conducted by the same two reviewers. Reviewers used standardised questions to extract information from the papers. General information on the paper such as the title and authors were noted, alongside a description of the intervention, the sustainability category the intervention fit into and the modality of kidney disease it aligned with. Data on the environmental impact (e.g., CO₂e reductions) and reported outcomes was also extracted. Economic and social aspects were also considered. Two existing frameworks were used as a guide to shape the review questions: the Non-adoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework alongside The Centre for Sustainable Healthcare’s (CSH) Green Team Competition Success Factors criteria. The NASSS is a framework developed to systematically evaluate the outcomes of complex innovation projects in health and social care 15 . The framework specifically analyses non-adoption, abandonment, scale-up, spread, and sustainability. It includes seven domains: the technology, the adopters, the wider system, the condition, the value proposition, the organisation(s) embedding and adaption over time. The NASSS allows domains to be graded from complex to simple where more complex projects can be deemed as more likely to fail and provides a guide for implementing useful strategies. The CSH’s Green Team Competition Success Factors include 4 categories: people, process, resources and context. For people, it evaluates the involvement of patients, engagement of staff, cross-departmental communication, and support of senior leadership. For process, it analyses the level of guidance, strategy incentives, measurable targets, long term strategy and integrations into natural workflow. For resource, it evaluates the dedicated time, the degree of quality improvement training, infrastructure and equipment availability, evidence of implementation success elsewhere, and financial investment. Lastly for context, it looks at whether the aims align with the wider service, if it links to patient and staff benefits, and the organisational permissions, capacities and culture 16 . With the integration of the two frameworks, the reviewers came up with the following questions to assess the process optimisations and technological interventions: Does the paper discuss the optimisation/ technology and have information on the level of certainty by staff on what the optimisation is, where it comes from, its performance, usability, acceptability, any required adjustments to routine, and research evidence of change successfully implemented elsewhere? Does the paper discuss the organisation’s capacity and permissions, readiness for the change, ability to finance the investment, whether it is easy to embed the change to normal routine and workflow, the team functions, the IT and infrastructure to provide teams with data, equipment and dedicated time, the training and support process for the quality improvement, incentivisation of strategies, and clear guidance and evidence? Does the paper have information on the value proposition including its commercial value, the benefit to staff, patients and the healthcare system, whether there are any links to clinical outcomes, whether the aims aligned with wider service, organisational or system goals? Does the paper mention who the intended adopters are and the certainty level about how staff and patients will adopt the optimisation, any long-term strategies for embedding change at outset, measurable targets, systematic and coordinated approaches, support from senior leaders, team agreement on the changes being suitable, skills/capability of staff, MDT/cross-departmental communication, staff and patient engagement? Does the paper talk about the external context including adversity/conduciveness: political, professional bodies, patient groups, regulatory, commercial context, limited learning from others? Furthermore, the inclusion criteria followed in this review were: Studies assessing environmental interventions in kidney care around the world. Articles evaluating carbon footprint reduction strategies in kidney care and its pathways, including HD, PD, transplant, and conservative care. The settings considered were hospitals, dialysis units, renal centres or home settings for home based treatments. Papers addressing implementation challenges for sustainable kidney care practices. Papers published after the year 2005. This was decided as the number of papers published on the topic increased significantly from this point onwards, reflecting more focus on the area. The reviewers therefore thought that papers before this date may not align with contemporary perspectives. The exclusion criteria followed in this review were: Conference abstracts Opinion pieces or call for action papers with no actual intervention Studies not explicitly related to kidney care sustainability Studies before the year 2005 Results Study Selection A total of 2,512 records were identified through electronic databases including Embase (n=867), MEDLINE (n=847), Scopus (n=685), CINAHL (n=51), and grey literature (n=62). After removal of 12 duplicates, 2,500 records were screened by title and abstract. Based on the inclusion criteria, 221 studies were chosen to assess for eligibility, leading to the exclusion of 2,255 articles. Upon the full paper review of the 221 studies, 95 papers were deemed as suitable to include in the scoping review, further excluding 126 articles (Figure 1). Distribution by Modality Most studies focused on interventions in HD (n=58), followed by CKD (n=19), transplantation (n=6), PD (n=5), haemodiafiltration (HDF) (n=3), and very low kidney function care (VKD)/ conservative care (n=1) (Figure 4). This distribution reflects both the high environmental burden of HD and the relative availability of interventions documented in the literature. Nevertheless, several relevant initiatives were identified across all modalities. Sustainability Categories and Type of Interventions The 95 included studies were mapped into 16 sustainability categories, grouped by categories (Figure 3). The most frequently addressed categories were: Water use (n=18): including reverse osmosis (RO) water reuse for non-clinical purposes like cleaning and sanitation 8,17–33 . Waste management (n=17): such as improved clinical waste segregation, plastic reduction, and packaging redesign 34–50 . Procurement optimisation (n=11): including high-ratio concentrate solutions (e.g., 44:1, central acid delivery), reusable containers, and environmentally preferable materials 51–61 . Travel-related emissions (n=9): mainly tackled via telemedicine, home-based care, and virtual consultations 62–70 . Policy (n=8): targeting changes in institutional governance, reporting frameworks, and integrated sustainability planning 71–78 Energy efficiency (n=7): including dialysate flow reductions, LED lighting, solar energy installations, and heat exchangers 79–85 . Reuse (n=6): e.g. filters, or durable items 86–91 . Other less frequent categories included treatment pathway redesign and pharmaceutical waste reduction 92–109 . Haemodialysis HD related sustainability interventions were the most frequent and diverse, spanning all sustainability categories. Key strategies included: Clinical transformation through remote consultations (e.g., phone clinics, asynchronous platforms like Patients Know Best ), reducing unnecessary travel and facilitating patient-centred care. Supply chain optimisation, such as: Central Acid Delivery Systems to eliminate single-use containers 110 . High-concentration acid solutions (e.g., 44:1), reducing packaging and shipping needs 93 Packaging redesigns using low-density polyethylene (LDPE) to reduce plastic use 5 Water efficiency, primarily through reuse of RO reject water for non-clinical applications, avoiding potable water waste 23,25,35,111 . Energy savings, including: Dialysate flow reductions from 500 to 400 mL/min 95,96,107,112 Solar-assisted dialysis 30,81 . Heat recovery systems and efficient lighting 83 . Waste management, with interventions in material segregation, medication waste reduction, and infrastructure changes 34,40,108,109 . Chronic Kidney Disease In CKD settings, interventions targeted upstream practices, often involving paper use reduction, pharmaceutical waste management, and remote monitoring. Key findings include: Paperless systems and automation of lab results, reducing material use and clerical errors 47 Medication optimisation: better prescribing, stock management, and deprescription practices aimed at reducing unused drugs 108,109 Travel reduction strategies such as remote care pathways (e.g., home BP monitoring, digital records), virtual check-ins or community-based services were also observed in some nephrology clinics resulting in improved access while reducing emissions associated with it 68,69,113,114 Transplantation Few studies focused specifically on transplant settings, but those included: Digital tools to coordinate pre- and post-transplant care 62,64 Efforts to optimise medication use and delivery logistics 66 Education platforms and teleconsultation services that allowed stable patients to be managed closer to home 63,70 Besides transplant patients being fewer than those on dialysis, the interventions demonstrated potential in reducing medication-related waste and transport emissions. Peritoneal Dialysis PD was underrepresented despite being a home-based and potentially lower-impact modality. Notable examples included: Delivery optimisation to reduce packaging and shipment frequency 65 Local storage and reuse of packaging materials 43,44 Training adaptations to encourage environmentally conscious practices (e.g., appropriate disposal of dialysate bags and medication vials) 38 One study addressed energy savings in PD cyclers, although data were limited 42 Haemodiafiltration and Conservative Management Only a few studies were explicitly focused on HDF, with interventions similar to those in HD regarding flow rates, energy usage, and waste minimisation 105,115 . VKD patients (very low kidney function opting for conservative management) were the least represented, with only one mention related to telemedicine and home monitoring 69 . Distribution by Review Questions When analysed in light of the review questions derived from the integrated frameworks (NASSS and CSH’s Green Team Success Factors), a clear pattern emerges (Figure 5). Each study was assessed against five domains— Technology , Organisation , Value Proposition , Intended Adopters , and External Context . For each domain, we recorded a “yes” if the paper provided information relevant to that domain (e.g., describing a technological optimisation, organisational readiness, value for patients or health systems, intended adopters, or contextual enablers/barriers). Figure 5 therefore illustrates the number of studies that addressed each domain (“yes counts”) across different kidney care modalities, showing where evidence is more concentrated and where it is comparatively lacking. The majority of interventions were mapped under the Technology and Value Proposition domains, particularly in haemodialysis, reflecting the strong emphasis on equipment-level optimisations, process efficiencies, and demonstrable environmental and economic gains. Organisation and External Context followed a similar trend, again with haemodialysis predominating but also notable contributions from CKD-focused interventions, which often addressed broader systemic or upstream factors such as policy alignment, resource use, and digital care models. By contrast, Intended Adopters was consistently the least represented category across modalities, indicating that staff engagement, patient perspectives, and long-term embedding strategies were less frequently considered or reported. Taken together, this distribution highlights how most published interventions were designed and reported primarily through a technological and value-for-money lens, with relatively less explicit attention given to organisational readiness, contextual enablers, and especially adopter engagement - dimensions emphasised by the NASSS and Green Team Competition frameworks. This suggests that while many interventions demonstrate environmental and economic benefits, further research should more systematically assess how such initiatives perform in terms of stakeholder engagement, equity, and alignment with system-wide sustainability goals. Discussion This scoping review mapped 95 sustainability interventions across all major areas of kidney care. While HD dominated both the number and diversity of interventions - reflecting its resource-intensive nature - important and novel strategies were also identified in CKD, transplantation, PD, HDF, and conservative care/ VKD. The interventions covered a wide spectrum of sustainability categories, with water efficiency, waste reduction, procurement, and travel-related emissions emerging as the most common targets. Across modalities, the reviewed interventions included both structural and behavioural approaches, from telemedicine and digital health platforms to supply chain redesign, packaging improvements, and equipment-level optimisation. Haemodialysis: High Impact, High Innovation HD interventions were the most extensively documented, likely due to the modality’s disproportionate contribution to healthcare-related environmental impacts, particularly greenhouse gas emissions, water use, energy consumption, and plastic waste, as well as its higher global prevalence compared to PD, which positions it as a natural focal point for sustainability efforts. Studies targeting dialysate flow reductions, acid concentrate packaging, central acid delivery systems, and heat exchangers offer replicable solutions with demonstrable environmental and economic benefits. Clinical transformation initiatives - such as remote consultations and asynchronous care via platforms like Patients Know Best - reflect a growing move toward low-carbon models of care delivery that enhance patient autonomy while reducing emissions from patient and staff travel 116 . However, despite the maturity of this field in HD, interventions were highly variable in methodology, scope, and reporting standards. Many were pilot programs or quality improvement projects without long-term follow-up or consistent metrics, limiting comparability and scalability. Some clinical transformations focus on reducing travel to the hospital. For example, through setting up telephone clinics and virtual consultations, patients can access appointments without the need of going into hospital, hence reducing GHG emissions associated with travel and the outpatient appointment itself. Developing a system where the hospital schedules appointments over the phone, and blood tests, blood pressure and weight readings are taken prior to the phone appointment will facilitate virtual appointments 62 . Establishing phone tariffs to cover the calls might be required if not in place already 70 . Other methods to carry out virtual consultations include the use of software or apps which have two-way messaging features and accessible patient care plans 64 , 68 . Switching to central acid delivery is another optimisation where acid is delivered to dialysis units in bulk load, pumped into holding tanks and then distributed to dialysis machines via a piped loop system 110 . This initiative helps to make HD more sustainable as it reduces both acid waste and packaging waste. Other options for more sustainable acid solutions include working with manufacturers to change acid concentration levels. For example, the development of 44:1 concentrate solutions has reduced container size and helped lower transport-related emissions by decreasing road freight volume 93 , 117 . Additionally, manufacturers using low density polyethylene (LDPE) lightweight packaging to replace the rigid high density polyethylene plastic packaging also helps to significantly reduce the plastic waste of a kidney unit 94 . Other changes implemented to reduce the carbon footprint of ESKD can involve infrastructure- and estates-level changes. Installing solar panels to dialysis units can allow dialysis sessions to be powered with renewable energy 30 , 79 . This could help to reduce the environmental burden of dialysis sessions and lead to energy cost savings. Water use is one of the most wasteful components of dialysis with around 500l used per treatment 118 . This is assuming that the dialysate flow is 500 ml per minute requiring 125l of water for a patient where two thirds of the water is rejected in reverse osmosis 94 . Therefore, initiatives to reduce water use and reuse reject water are also impactful in reducing the environmental impact of dialysis. Reducing water use could be done through initiatives such as reducing dialysis fluid flow rate to 400 ml per minute where water will be saved without compromising clinical outcomes 96 , 119 . Also, as the rejected water does not encounter the patient and does not carry any infection risks, it could be reused in activities such as toilet flushing or laundry, through the installation of a reverse osmosis plant 23 , 26 , 33 . Other hotspots that could be targeted to reduce the environmental impact of ESKD are reducing paper use in clinical practices, for example by automating blood test results 47 , and introducing waste segregation systems to improve waste management at the hospital. 50 , 108 , 109 . CKD, PD, and Transplantation: Emerging Opportunities CKD-focused interventions were generally broader in scope and upstream in nature, addressing prescription practices, paperless administration, and patient self-monitoring 74 . These efforts align well with planetary health principles by preventing disease progression and reducing dependence on high-resource interventions 120 . PD despite its theoretical advantage as a home-based therapy with fewer infrastructural demands, was underrepresented. A handful of studies addressed waste reduction in supply deliveries, local material reuse, and training for sustainable practices, but further research is needed - especially regarding environmental trade-offs between CAPD and APD modalities 121 , 122 . Transplantation-related sustainability remains a research gap. While studies highlighted remote follow-up and medication logistics, more comprehensive evaluations are needed to understand the full environmental and economic implications of transplantation compared to dialysis, particularly over the long term 123 . Underexplored Areas: Pharmaceuticals, Reuse and Conservative Care/ VKD and Co-Benefits Pharmaceutical waste, though a recognised issue in nephrology (particularly in CKD and post-transplant patients) 124 , was infrequently addressed. Optimising medication stocks and prescribing behaviours can reduce both waste and costs, yet this area remains underdeveloped compared to others such as water or energy efficiency. The reprocessing of single-use medical devices is increasingly being reconsidered in response to pressing global challenges such as supply shortages, resource scarcity, and the prohibitive carbon cost of manufacturing and transporting medical products. Dialyser reuse, historically associated with cost-containment in low- and middle-income countries, is now being reconsidered in high-income settings as a sustainability strategy in response to the ecological emergency 125 . When conducted under validated protocols, dialyser reprocessing has been shown to preserve clinical adequacy and safety while significantly reducing plastic and packaging waste. Nonetheless, adoption remains limited due to persistent cultural concerns, regulatory restrictions, and the absence of updated guidelines 126 . Reintroducing dialyser reuse into routine practice would require a multipronged effort: further research into safety and cost-effectiveness, regulatory reform (e.g., enabling Article 17 in EU countries), engagement of industry stakeholders in viable economic models, and a gradual shift of healthcare systems towards circular resource use. These developments reflect growing consensus that circularity principles, long underutilized in nephrology, offer promising co-benefits for both environmental sustainability and system resilience. The complete lack of sustainability research in patients with very low kidney function opting for conservative care is striking. As the population ages and more patients opt for conservative care, it is essential to develop low-impact, supportive models that prioritise quality of life and avoid unnecessary interventions 127 – 129 . Finally, the adoption of sustainable interventions such as remote consultations, home-based dialysis modalities, incremental haemodialysis, and conservative kidney management offers not only environmental benefits but also recognised health co-benefits. Remote care pathways have been associated with improved patient experience, engagement, and treatment adherence, while reducing the burden of travel without compromising care quality 130 , 131 . Home-based therapies, particularly peritoneal dialysis with remote monitoring, have demonstrated improvements in quality of life, autonomy, and patient-reported outcomes 132 . Incremental haemodialysis, which individualises treatment frequency according to residual kidney function, has been associated with better preservation of residual function, fewer hospitalisations, lower symptom burden, and non-inferior survival compared to conventional thrice-weekly schedules. 133 When aligned with patient values and preferences, conservative management may further reduce unnecessary interventions and hospital admissions, facilitating more holistic, low-impact models of care that support both planetary and patient wellbeing 134 . This review highlights a need for standardised metrics to assess environmental performance in kidney care. Only a small number of interventions reported quantitative outcomes in terms of kg CO₂ equivalence, kWh, litres of water saved, or waste volumes. Adoption of LCA methodologies or alignment with ISO 14040/44 standards would significantly improve comparability and validity 135 . Additionally, the heterogeneity in study design - ranging from audits and case reports to full implementation projects - limits generalisability. 5 Many reports lacked economic evaluation or stakeholder feedback, and few addressed unintended consequences (e.g., workload shifts, digital exclusion, or rebound effects) 15 . The analysis of the review categories, based on the NASSS framework and the CSH’s Green Team Competition Success Factors (Fig. 5 ), reveals that sustainability interventions in kidney care are unevenly distributed across modalities and categories. Haemodialysis showed the highest number of optimisations in all domains, particularly in the Technology and Value Proposition categories, reflecting the high material and energy intensity of HD and the focus of innovation efforts on equipment, consumables, and process efficiency. Chronic kidney disease interventions, while fewer overall, were more evenly spread across categories, suggesting a broader range of intervention types at earlier stages of the patient pathway. In contrast, peritoneal dialysis, haemodiafiltration, and transplantation had fewer documented optimisations, indicating potential gaps or under-reporting of sustainability initiatives in these areas. This imbalance highlights an opportunity for future research and intervention design to extend beyond HD, ensuring that sustainability strategies are applied comprehensively across all kidney care modalities. Beyond this descriptive mapping, triangulation of the CSH’s Green Team success factors with frameworks like the Sustainable Value framework 136 will provide further insights. While many interventions quantified environmental and economic benefits, relatively few addressed cross-disciplinary teamwork, staff engagement, or long-term integration into clinical workflow - dimensions emphasised by the Green Team framework 16 . Indeed, an integrative review of healthcare "Green Team" initiatives found that staff engagement, alongside policy support, external collaboration and organisational structure, was one of the four main facilitators of success in environmentally sustainable initiatives. 137 Likewise, applying the Sustainable Value lens shows that social dimensions such as patient experience, equity of access, and staff wellbeing were rarely considered. Recent evidence shows that organisational culture and job satisfaction are central to sustainable healthcare quality: by optimising processes and reducing waste, healthcare services can enhance staff wellbeing and ultimately improve patient care - underscoring the importance of embedding social value criteria into sustainability interventions. 138 Taken together, these findings suggest that the current literature has largely prioritised measurable technical and economic outcomes, while underreporting organisational, contextual, and social aspects that are equally important for long-term adoption and system-wide sustainability. Embedding Green Team and Sustainable Value criteria more explicitly in future studies would strengthen the evidence base, ensuring that sustainability interventions in kidney care are not only environmentally and economically effective but also feasible, acceptable, and equitable across diverse contexts. While the search was comprehensive, potential limitations include publication bias toward positive or innovative results, and underrepresentation of grey literature and non-English sources 14 . Moreover, most interventions originated from high-income countries, highlighting the need for context-specific solutions in low- and middle-income settings 139 . Also, as is consistent with scoping review methodology, no formal risk of bias or certainty assessment was performed, and no meta-analysis or synthesis of effect measures was conducted. This approach is appropriate given the exploratory nature of the review and the heterogeneity of study designs, but it should be noted as a limitation in the interpretation of results. Our findings support the integration of sustainability principles into routine nephrology care, aligning clinical outcomes with respect for planetary boundaries. This shift can be facilitated by professional societies, regulators, and procurement agencies through the incentivisation of low-impact practices such as low-flow HD and the use of reusable consumables, the incorporation of environmental criteria into procurement tenders and clinical guidelines, and the promotion of staff education and sustainability literacy across kidney care services. Healthcare organisations can also implement multimodal interventions that address travel, procurement, and waste simultaneously, maximising co-benefits for patients, providers, and the environment 140 , 141 . Crucially, many sustainability interventions identified in this review were cost-saving or cost-neutral, offering a strong economic case for action even in resource-constrained systems. Future research should prioritise longitudinal studies that include robust environmental and economic impact assessments 13 , 51 , while also ensuring the inclusion of diverse patient populations and treatment modalities such as PD, conservative kidney management, and transplantation. Co-design with patients and healthcare staff is essential to enhance the acceptability, feasibility, and equity of interventions, and consistent reporting using tools like the SQUIRE 2.0 checklist or a dedicated environmental quality framework will be key to improving transparency and comparability across studies 142 . Conclusion This scoping review reveals a growing landscape of innovation in sustainable kidney care, yet underscores the urgent need for coordination, standardisation, and system-level thinking. Nephrology faces a pivotal moment: rising environmental challenges and growing inequities make sustainable transformation both urgent and achievable. By advancing interventions that are evidence-based, environmentally sound, and designed with attention to equity and access, the kidney community can lead by example toward a greener, healthier future. Declarations Ethical Approval Ethical approval was not required for this study as it did not involve human participants or animal research. The study focused solely on the analysis of papers related to kidney care sustainability. Informed Consent to Participate Informed consent was not applicable to this study, as it did not involve any individual participants, patients, or human data. Competing Interests The authors declare that they have no competing interests. Funding This work was supported by EU Horizon [Grant No. 101137054] and UK Research and Innovation (UKRI) [Grant No. 10110449] as part of the KitNewCare project. Author Contribution Aycan, James and Marta assisted in the screening and writing of the review. Brett and Inge assisted in the creation of the concept and reviewing. 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Available from: https://pubmed.ncbi.nlm.nih.gov/26369893/ Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in International Urology and Nephrology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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16:40:07","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":260106,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/1dc88c3e882f48e3ec7af25c.html"},{"id":92531237,"identity":"f741ba38-52a1-4ef5-84bc-6a0d1d6895b5","added_by":"auto","created_at":"2025-09-30 16:40:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":435903,"visible":true,"origin":"","legend":"\u003cp\u003eNASSS Framework, from Greenhalgh T, How to improve success of technology projects in health and social care\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/3bd5aebe619317c467bff314.png"},{"id":92532981,"identity":"8e10d2e4-f588-41bf-9c3e-d59c21a6a839","added_by":"auto","created_at":"2025-09-30 16:56:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":126297,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/8ab52d75240cac2205ed3a5b.png"},{"id":92531235,"identity":"33868eed-f50b-4fac-8c7a-2c4b54c2f202","added_by":"auto","created_at":"2025-09-30 16:40:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":64775,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of optimisations by sustainability category\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/90d7e290bc0304813b8afc92.png"},{"id":92532982,"identity":"0f13ce48-6133-47ac-a3ea-40d12c4e354b","added_by":"auto","created_at":"2025-09-30 16:56:07","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21444,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of optimisations by modality\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/ddd7bfe37097a7a35e5dadfa.png"},{"id":92532180,"identity":"d5de934b-142d-4b5b-b854-5e66a0502a3d","added_by":"auto","created_at":"2025-09-30 16:48:07","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":69134,"visible":true,"origin":"","legend":"\u003cp\u003eHeatmap of 'Yes' counts by kidney care modality and the review questions based on the NASSS and CSH’s Green Team Competition Success Factors (Categorised by: Technology, Organisation, Value Proposition, Intended Adopters, External Context).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/bc5bc94d8e15fde89b03c5e6.png"},{"id":97178684,"identity":"3790cc97-c332-47fe-959b-2c66db7733dc","added_by":"auto","created_at":"2025-12-01 16:12:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1487467,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/57a0050a-aba7-4947-8991-3cefbdd900c6.pdf"},{"id":92532179,"identity":"8253b4b0-50a5-49cc-85d9-ed75b7d63a75","added_by":"auto","created_at":"2025-09-30 16:48:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14786,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7620813/v1/7fe09299ef8bdcd2913e64c7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Advancing Green Nephrology: A Scoping Review of Sustainability Interventions in Kidney Care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic Kidney Disease (CKD) is a growing global health concern, affecting around 10% of the European population\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It is projected to increase to 18% of the population in some countries by 2040 and 28% by 2100\u003csup\u003e2,3\u003c/sup\u003e. Sustainability in nephrology matters not only due to the high environmental intensity of treatment modalities such as haemodialysis (HD), but also because kidney care is a growing global health burden. Green nephrology can reduce healthcare emissions, preserve resources, and improve health equity by ensuring resilient, low-carbon models of care\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. As patients progress to End Stage Kidney Disease (ESKD), treatment options - primarily dialysis or transplantation become environmentally intensive. The annual carbon footprint for a patient receiving thrice-weekly HD is estimated at 3.8\u0026ndash;10 tonnes of Carbon Dioxide Equivalent (CO₂e), which is substantially higher than the per capita healthcare emissions in many countries\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This is mostly due to high energy consumption and substantial waste generation. Studies have shown that patient and staff transportation also contribute significantly to the carbon footprint of dialysis units, adding up to 25\u0026ndash;30% to the total carbon footprint of HD, particularly in in-centre models with long travel distances\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. High volume of water use for dialysis presents an additional environmental impact.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWith over 2.6\u0026nbsp;million people receiving dialysis globally as of 2020 and projections suggesting this may rise to 7\u0026nbsp;million by 2030, the environmental footprint of kidney care is expected to grow significantly\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. As of December 2022, 56% of prevalent kidney replacement therapy patients in Europe were receiving HD and 5% peritoneal dialysis (PD), representing over 346,000 individuals on dialysis in total, a figure driven by ageing populations and rising rates of diabetes and hypertension\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Although technological advances have led to more efficient and home-based therapies, these have not consistently translated into lower environmental impact. The implementation of green nephrology initiatives remains limited, largely due to economic and regulatory barriers such as high upfront costs, lack of financial incentives, and the absence of specific guidelines or mandates for environmental performance\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWith kidney care contributing a substantial amount of healthcare-based greenhouse gas (GHG) emissions, interventions reducing kidney care\u0026rsquo;s carbon footprint would positively impact overall healthcare emissions. For example, modelling from England estimates that if 60% of kidney centres adopted process based sustainable solutions, it could save the health service 11 tonnes of CO₂e \u003csup\u003e13\u003c/sup\u003e. While this analysis was specific to England, similar opportunities are likely across Europe: applying comparable process optimisations across EU kidney centres would be expected to yield substantially larger absolute carbon savings, given the higher number of patients treated and dialysis facilities in operation. In practice, sustainable kidney care interventions have already been documented in multiple European countries, targeting clinical transformation, procurement, waste management, water use and energy efficiency. This scoping review explores sustainable process optimisations and technological interventions implemented globally in kidney care to reduce its environmental impact alongside identifying key challenges and opportunities.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSearch Strategy\u003c/h2\u003e\u003cp\u003eA scoping review was performed to identify literature exploring environmentally sustainable interventions in kidney care. This scoping review followed the PRISMA-ScR methodology that systematically searches and reports on scoping reviews\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. The search was conducted in September 2024 using the databases of Embase, MEDLINE, Scopus, CINAHL alongside grey literature aligning with the search terms, such as case studies on sustainable kidney care interventions. Keywords and phrases that were used in the search included: chronic kidney disease, end stage kidney disease, renal care, kidney care, environmental impact, dialysis, carbon footprint, environmental sustainability, optimisations, systematic review, hospitals, dialysis units, greenhouse gas emissions, life cycle assessment. The exact search strategy can be found in \u003cspan refid=\"Sec21\" class=\"InternalRef\"\u003eAppendix 1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eThis study is focused on the overall environmental impacts of kidney care and has reviewed initiatives that reduce the environmental impact of ESKD and its pathways, including HD, PD, transplant, and conservative care. The settings considered were hospitals, dialysis units or renal centres and home in case of home-based dialysis treatments.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Selection\u003c/h3\u003e\n\u003cp\u003eThe screening of all abstracts identified in the search was done independently by two reviewers (A.Y and J.L) from September to November 2024. Both reviewers met to resolve any discrepancies and confirmed the list of papers to be included in the full paper review stage. The same two reviewers then conducted full text screening of the papers that were included in this stage. A third reviewer (M.A) was asked to resolve any discrepancies.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eCovidence was used as the online software tool for managing the scoping review process. Data extraction was conducted by the same two reviewers. Reviewers used standardised questions to extract information from the papers. General information on the paper such as the title and authors were noted, alongside a description of the intervention, the sustainability category the intervention fit into and the modality of kidney disease it aligned with. Data on the environmental impact (e.g., CO₂e reductions) and reported outcomes was also extracted. Economic and social aspects were also considered.\u003c/p\u003e\u003cp\u003eTwo existing frameworks were used as a guide to shape the review questions: the Non-adoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework alongside The Centre for Sustainable Healthcare\u0026rsquo;s (CSH) Green Team Competition Success Factors criteria.\u003c/p\u003e\u003cp\u003eThe NASSS is a framework developed to systematically evaluate the outcomes of complex innovation projects in health and social care\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The framework specifically analyses non-adoption, abandonment, scale-up, spread, and sustainability. It includes seven domains: the technology, the adopters, the wider system, the condition, the value proposition, the organisation(s) embedding and adaption over time. The NASSS allows domains to be graded from complex to simple where more complex projects can be deemed as more likely to fail and provides a guide for implementing useful strategies.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe CSH\u0026rsquo;s Green Team Competition Success Factors include 4 categories: people, process, resources and context. For people, it evaluates the involvement of patients, engagement of staff, cross-departmental communication, and support of senior leadership. For process, it analyses the level of guidance, strategy incentives, measurable targets, long term strategy and integrations into natural workflow. For resource, it evaluates the dedicated time, the degree of quality improvement training, infrastructure and equipment availability, evidence of implementation success elsewhere, and financial investment. Lastly for context, it looks at whether the aims align with the wider service, if it links to patient and staff benefits, and the organisational permissions, capacities and culture\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWith the integration of the two frameworks, the reviewers came up with the following questions to assess the process optimisations and technological interventions:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eDoes the paper discuss the optimisation/ technology and have information on the level of certainty by staff on what the optimisation is, where it comes from, its performance, usability, acceptability, any required adjustments to routine, and research evidence of change successfully implemented elsewhere?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDoes the paper discuss the organisation\u0026rsquo;s capacity and permissions, readiness for the change, ability to finance the investment, whether it is easy to embed the change to normal routine and workflow, the team functions, the IT and infrastructure to provide teams with data, equipment and dedicated time, the training and support process for the quality improvement, incentivisation of strategies, and clear guidance and evidence?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDoes the paper have information on the value proposition including its commercial value, the benefit to staff, patients and the healthcare system, whether there are any links to clinical outcomes, whether the aims aligned with wider service, organisational or system goals?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDoes the paper mention who the intended adopters are and the certainty level about how staff and patients will adopt the optimisation, any long-term strategies for embedding change at outset, measurable targets, systematic and coordinated approaches, support from senior leaders, team agreement on the changes being suitable, skills/capability of staff, MDT/cross-departmental communication, staff and patient engagement?\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDoes the paper talk about the external context including adversity/conduciveness: political, professional bodies, patient groups, regulatory, commercial context, limited learning from others?\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFurthermore, the inclusion criteria followed in this review were:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStudies assessing environmental interventions in kidney care around the world.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eArticles evaluating carbon footprint reduction strategies in kidney care and its pathways, including HD, PD, transplant, and conservative care.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe settings considered were hospitals, dialysis units, renal centres or home settings for home based treatments.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePapers addressing implementation challenges for sustainable kidney care practices.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePapers published after the year 2005. This was decided as the number of papers published on the topic increased significantly from this point onwards, reflecting more focus on the area. The reviewers therefore thought that papers before this date may not align with contemporary perspectives.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe exclusion criteria followed in this review were:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eConference abstracts\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOpinion pieces or call for action papers with no actual intervention\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies not explicitly related to kidney care sustainability\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudies before the year 2005\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003e\u003cstrong\u003eStudy Selection\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA total of 2,512 records were identified through electronic databases including Embase (n=867), MEDLINE (n=847), Scopus (n=685), CINAHL (n=51), and grey literature (n=62). After removal of 12 duplicates, 2,500 records were screened by title and abstract. Based on the inclusion criteria, 221 studies were chosen to assess for eligibility, leading to the exclusion of 2,255 articles. Upon the full paper review of the 221 studies, 95 papers were deemed as suitable to include in the scoping review, further excluding 126 articles (Figure 1).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDistribution by Modality\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost studies focused on interventions in HD (n=58), followed by CKD (n=19), transplantation (n=6), PD (n=5), \u0026nbsp;haemodiafiltration (HDF) (n=3), and very low kidney function care (VKD)/ conservative care (n=1) (Figure 4). This distribution reflects both the high environmental burden of HD and the relative availability of interventions documented in the literature. Nevertheless, several relevant initiatives were identified across all modalities.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSustainability Categories and Type of Interventions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe 95 included studies were mapped into 16 sustainability categories, grouped by categories (Figure 3). The most frequently addressed categories were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWater use (n=18): including reverse osmosis (RO) water reuse for non-clinical purposes like cleaning and sanitation\u003csup\u003e8,17\u0026ndash;33\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eWaste management (n=17): such as improved clinical waste segregation, plastic reduction, and packaging redesign\u003csup\u003e34\u0026ndash;50\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eProcurement optimisation (n=11): including high-ratio concentrate solutions (e.g., 44:1, central acid delivery), reusable containers, and environmentally preferable materials\u003csup\u003e51\u0026ndash;61\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eTravel-related emissions (n=9): mainly tackled via telemedicine, home-based care, and virtual consultations\u003csup\u003e62\u0026ndash;70\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003ePolicy (n=8): targeting changes in institutional governance, reporting frameworks, and integrated sustainability planning\u003csup\u003e71\u0026ndash;78\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eEnergy efficiency (n=7): including dialysate flow reductions, LED lighting, solar energy installations, and heat exchangers\u003csup\u003e79\u0026ndash;85\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eReuse (n=6): e.g. filters, or durable items\u003csup\u003e86\u0026ndash;91\u003c/sup\u003e.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOther less frequent categories included treatment pathway redesign and pharmaceutical waste reduction\u003csup\u003e92\u0026ndash;109\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eHaemodialysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eHD related sustainability interventions were the most frequent and diverse, spanning all sustainability categories. Key strategies included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eClinical transformation through remote consultations (e.g., phone clinics, asynchronous platforms like \u003cem\u003ePatients Know Best\u003c/em\u003e), reducing unnecessary travel and facilitating patient-centred care.\u003c/li\u003e\n \u003cli\u003eSupply chain optimisation, such as:\u003cul\u003e\n \u003cli\u003eCentral Acid Delivery Systems to eliminate single-use containers\u003csup\u003e110\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eHigh-concentration acid solutions (e.g., 44:1), reducing packaging and shipping needs\u003csup\u003e93\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003ePackaging redesigns using low-density polyethylene (LDPE) to reduce plastic use\u003csup\u003e5\u003c/sup\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eWater efficiency, primarily through reuse of RO reject water for non-clinical applications, avoiding potable water waste\u003csup\u003e23,25,35,111\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eEnergy savings, including:\u003cul\u003e\n \u003cli\u003eDialysate flow reductions from 500 to 400 mL/min\u003csup\u003e95,96,107,112\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eSolar-assisted dialysis\u003csup\u003e30,81\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003eHeat recovery systems and efficient lighting\u003csup\u003e83\u003c/sup\u003e.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eWaste management, with interventions in material segregation, medication waste reduction, and infrastructure changes\u003csup\u003e34,40,108,109\u003c/sup\u003e.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e\u003cstrong\u003eChronic Kidney Disease\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eIn CKD settings, interventions targeted upstream practices, often involving paper use reduction, pharmaceutical waste management, and remote monitoring. Key findings include:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePaperless systems and automation of lab results, reducing material use and clerical errors\u003csup\u003e47\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eMedication optimisation: better prescribing, stock management, and deprescription practices aimed at reducing unused drugs\u003csup\u003e108,109\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eTravel reduction strategies such as remote care pathways (e.g., home BP monitoring, digital records), virtual check-ins or community-based services were also observed in some nephrology clinics \u0026nbsp;resulting in improved access while reducing emissions associated with it\u003csup\u003e68,69,113,114\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e\u003cstrong\u003e\u0026nbsp;Transplantation\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eFew studies focused specifically on transplant settings, but those included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDigital tools to coordinate pre- and post-transplant care\u003csup\u003e62,64\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eEfforts to optimise medication use and delivery logistics\u003csup\u003e66\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eEducation platforms and teleconsultation services that allowed stable patients to be managed closer to home\u003csup\u003e63,70\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBesides transplant patients being fewer than those on dialysis, the interventions demonstrated potential in reducing medication-related waste and transport emissions.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePeritoneal Dialysis\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003ePD was underrepresented despite being a home-based and potentially lower-impact modality. Notable examples included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDelivery optimisation to reduce packaging and shipment frequency\u003csup\u003e65\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eLocal storage and reuse of packaging materials\u003csup\u003e43,44\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eTraining adaptations to encourage environmentally conscious practices (e.g., appropriate disposal of dialysate bags and medication vials)\u003csup\u003e38\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOne study addressed energy savings in PD cyclers, although data were limited\u003csup\u003e42\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eHaemodiafiltration and Conservative Management\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eOnly a few studies were explicitly focused on HDF, with interventions similar to those in HD regarding flow rates, energy usage, and waste minimisation\u003csup\u003e105,115\u003c/sup\u003e. VKD patients (very low kidney function opting for conservative management) were the least represented, with only one mention related to telemedicine and home monitoring\u003csup\u003e69\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDistribution by Review Questions \u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWhen analysed in light of the review questions derived from the integrated frameworks (NASSS and CSH\u0026rsquo;s Green Team Success Factors), a clear pattern emerges (Figure 5). Each study was assessed against five domains\u0026mdash;\u003cem\u003eTechnology\u003c/em\u003e, \u003cem\u003eOrganisation\u003c/em\u003e, \u003cem\u003eValue Proposition\u003c/em\u003e, \u003cem\u003eIntended Adopters\u003c/em\u003e, and \u003cem\u003eExternal Context\u003c/em\u003e. For each domain, we recorded a \u0026ldquo;yes\u0026rdquo; if the paper provided information relevant to that domain (e.g., describing a technological optimisation, organisational readiness, value for patients or health systems, intended adopters, or contextual enablers/barriers). Figure 5 therefore illustrates the number of studies that addressed each domain (\u0026ldquo;yes counts\u0026rdquo;) across different kidney care modalities, showing where evidence is more concentrated and where it is comparatively lacking.\u0026nbsp;The majority of interventions were mapped under the Technology and Value Proposition domains, particularly in haemodialysis, reflecting the strong emphasis on equipment-level optimisations, process efficiencies, and demonstrable environmental and economic gains. Organisation and External Context followed a similar trend, again with haemodialysis predominating but also notable contributions from CKD-focused interventions, which often addressed broader systemic or upstream factors such as policy alignment, resource use, and digital care models. By contrast, Intended Adopters was consistently the least represented category across modalities, indicating that staff engagement, patient perspectives, and long-term embedding strategies were less frequently considered or reported.\u003c/p\u003e\n\u003cp\u003eTaken together, this distribution highlights how most published interventions were designed and reported primarily through a technological and value-for-money lens, with relatively less explicit attention given to organisational readiness, contextual enablers, and especially adopter engagement - dimensions emphasised by the NASSS and Green Team Competition frameworks. This suggests that while many interventions demonstrate environmental and economic benefits, further research should more systematically assess how such initiatives perform in terms of stakeholder engagement, equity, and alignment with system-wide sustainability goals.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review mapped 95 sustainability interventions across all major areas of kidney care. While HD dominated both the number and diversity of interventions - reflecting its resource-intensive nature - important and novel strategies were also identified in CKD, transplantation, PD, HDF, and conservative care/ VKD.\u003c/p\u003e\u003cp\u003eThe interventions covered a wide spectrum of sustainability categories, with water efficiency, waste reduction, procurement, and travel-related emissions emerging as the most common targets. Across modalities, the reviewed interventions included both structural and behavioural approaches, from telemedicine and digital health platforms to supply chain redesign, packaging improvements, and equipment-level optimisation.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eHaemodialysis: High Impact, High Innovation\u003c/h2\u003e\u003cp\u003eHD interventions were the most extensively documented, likely due to the modality\u0026rsquo;s disproportionate contribution to healthcare-related environmental impacts, particularly greenhouse gas emissions, water use, energy consumption, and plastic waste, as well as its higher global prevalence compared to PD, which positions it as a natural focal point for sustainability efforts. Studies targeting dialysate flow reductions, acid concentrate packaging, central acid delivery systems, and heat exchangers offer replicable solutions with demonstrable environmental and economic benefits.\u003c/p\u003e\u003cp\u003eClinical transformation initiatives - such as remote consultations and asynchronous care via platforms like \u003cem\u003ePatients Know Best\u003c/em\u003e - reflect a growing move toward low-carbon models of care delivery that enhance patient autonomy while reducing emissions from patient and staff travel\u003csup\u003e\u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e116\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, despite the maturity of this field in HD, interventions were highly variable in methodology, scope, and reporting standards. Many were pilot programs or quality improvement projects without long-term follow-up or consistent metrics, limiting comparability and scalability.\u003c/p\u003e\u003cp\u003eSome clinical transformations focus on reducing travel to the hospital. For example, through setting up telephone clinics and virtual consultations, patients can access appointments without the need of going into hospital, hence reducing GHG emissions associated with travel and the outpatient appointment itself. Developing a system where the hospital schedules appointments over the phone, and blood tests, blood pressure and weight readings are taken prior to the phone appointment will facilitate virtual appointments\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. Establishing phone tariffs to cover the calls might be required if not in place already\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. Other methods to carry out virtual consultations include the use of software or apps which have two-way messaging features and accessible patient care plans\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSwitching to central acid delivery is another optimisation where acid is delivered to dialysis units in bulk load, pumped into holding tanks and then distributed to dialysis machines via a piped loop system\u003csup\u003e\u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e110\u003c/span\u003e\u003c/sup\u003e. This initiative helps to make HD more sustainable as it reduces both acid waste and packaging waste. Other options for more sustainable acid solutions include working with manufacturers to change acid concentration levels. For example, the development of 44:1 concentrate solutions has reduced container size and helped lower transport-related emissions by decreasing road freight volume \u003csup\u003e\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e,\u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e\u003c/sup\u003e. Additionally, manufacturers using low density polyethylene (LDPE) lightweight packaging to replace the rigid high density polyethylene plastic packaging also helps to significantly reduce the plastic waste of a kidney unit\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOther changes implemented to reduce the carbon footprint of ESKD can involve infrastructure- and estates-level changes. Installing solar panels to dialysis units can allow dialysis sessions to be powered with renewable energy\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u003c/sup\u003e. This could help to reduce the environmental burden of dialysis sessions and lead to energy cost savings.\u003c/p\u003e\u003cp\u003eWater use is one of the most wasteful components of dialysis with around 500l used per treatment\u003csup\u003e\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e118\u003c/span\u003e\u003c/sup\u003e. This is assuming that the dialysate flow is 500 ml per minute requiring 125l of water for a patient where two thirds of the water is rejected in reverse osmosis\u003csup\u003e\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e. Therefore, initiatives to reduce water use and reuse reject water are also impactful in reducing the environmental impact of dialysis. Reducing water use could be done through initiatives such as reducing dialysis fluid flow rate to 400 ml per minute where water will be saved without compromising clinical outcomes\u003csup\u003e\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e,\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e\u003c/sup\u003e. Also, as the rejected water does not encounter the patient and does not carry any infection risks, it could be reused in activities such as toilet flushing or laundry, through the installation of a reverse osmosis plant\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOther hotspots that could be targeted to reduce the environmental impact of ESKD are reducing paper use in clinical practices, for example by automating blood test results\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e, and introducing waste segregation systems to improve waste management at the hospital.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e108\u003c/span\u003e,\u003cspan citationid=\"CR109\" class=\"CitationRef\"\u003e109\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCKD, PD, and Transplantation: Emerging Opportunities\u003c/h2\u003e\u003cp\u003eCKD-focused interventions were generally broader in scope and upstream in nature, addressing prescription practices, paperless administration, and patient self-monitoring\u003csup\u003e\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e. These efforts align well with planetary health principles by preventing disease progression and reducing dependence on high-resource interventions\u003csup\u003e\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePD despite its theoretical advantage as a home-based therapy with fewer infrastructural demands, was underrepresented. A handful of studies addressed waste reduction in supply deliveries, local material reuse, and training for sustainable practices, but further research is needed - especially regarding environmental trade-offs between CAPD and APD modalities\u003csup\u003e\u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e,\u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTransplantation-related sustainability remains a research gap. While studies highlighted remote follow-up and medication logistics, more comprehensive evaluations are needed to understand the full environmental and economic implications of transplantation compared to dialysis, particularly over the long term\u003csup\u003e\u003cspan citationid=\"CR123\" class=\"CitationRef\"\u003e123\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eUnderexplored Areas: Pharmaceuticals, Reuse and Conservative Care/ VKD and Co-Benefits\u003c/h2\u003e\u003cp\u003ePharmaceutical waste, though a recognised issue in nephrology (particularly in CKD and post-transplant patients)\u003csup\u003e\u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e124\u003c/span\u003e\u003c/sup\u003e, was infrequently addressed. Optimising medication stocks and prescribing behaviours can reduce both waste and costs, yet this area remains underdeveloped compared to others such as water or energy efficiency.\u003c/p\u003e\u003cp\u003eThe reprocessing of single-use medical devices is increasingly being reconsidered in response to pressing global challenges such as supply shortages, resource scarcity, and the prohibitive carbon cost of manufacturing and transporting medical products. Dialyser reuse, historically associated with cost-containment in low- and middle-income countries, is now being reconsidered in high-income settings as a sustainability strategy in response to the ecological emergency\u003csup\u003e\u003cspan citationid=\"CR125\" class=\"CitationRef\"\u003e125\u003c/span\u003e\u003c/sup\u003e. When conducted under validated protocols, dialyser reprocessing has been shown to preserve clinical adequacy and safety while significantly reducing plastic and packaging waste. Nonetheless, adoption remains limited due to persistent cultural concerns, regulatory restrictions, and the absence of updated guidelines\u003csup\u003e\u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e126\u003c/span\u003e\u003c/sup\u003e. Reintroducing dialyser reuse into routine practice would require a multipronged effort: further research into safety and cost-effectiveness, regulatory reform (e.g., enabling Article 17 in EU countries), engagement of industry stakeholders in viable economic models, and a gradual shift of healthcare systems towards circular resource use. These developments reflect growing consensus that circularity principles, long underutilized in nephrology, offer promising co-benefits for both environmental sustainability and system resilience.\u003c/p\u003e\u003cp\u003eThe complete lack of sustainability research in patients with very low kidney function opting for conservative care is striking. As the population ages and more patients opt for conservative care, it is essential to develop low-impact, supportive models that prioritise quality of life and avoid unnecessary interventions\u003csup\u003e\u003cspan additionalcitationids=\"CR128\" citationid=\"CR127\" class=\"CitationRef\"\u003e127\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFinally, the adoption of sustainable interventions such as remote consultations, home-based dialysis modalities, incremental haemodialysis, and conservative kidney management offers not only environmental benefits but also recognised health co-benefits. Remote care pathways have been associated with improved patient experience, engagement, and treatment adherence, while reducing the burden of travel without compromising care quality\u003csup\u003e\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e,\u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e\u003c/sup\u003e. Home-based therapies, particularly peritoneal dialysis with remote monitoring, have demonstrated improvements in quality of life, autonomy, and patient-reported outcomes\u003csup\u003e\u003cspan citationid=\"CR132\" class=\"CitationRef\"\u003e132\u003c/span\u003e\u003c/sup\u003e. Incremental haemodialysis, which individualises treatment frequency according to residual kidney function, has been associated with better preservation of residual function, fewer hospitalisations, lower symptom burden, and non-inferior survival compared to conventional thrice-weekly schedules.\u003csup\u003e\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e\u003c/sup\u003e When aligned with patient values and preferences, conservative management may further reduce unnecessary interventions and hospital admissions, facilitating more holistic, low-impact models of care that support both planetary and patient wellbeing\u003csup\u003e\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis review highlights a need for standardised metrics to assess environmental performance in kidney care. Only a small number of interventions reported quantitative outcomes in terms of kg CO₂ equivalence, kWh, litres of water saved, or waste volumes. Adoption of LCA methodologies or alignment with ISO 14040/44 standards would significantly improve comparability and validity\u003csup\u003e\u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAdditionally, the heterogeneity in study design - ranging from audits and case reports to full implementation projects - limits generalisability.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Many reports lacked economic evaluation or stakeholder feedback, and few addressed unintended consequences (e.g., workload shifts, digital exclusion, or rebound effects)\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe analysis of the review categories, based on the NASSS framework and the CSH\u0026rsquo;s Green Team Competition Success Factors (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), reveals that sustainability interventions in kidney care are unevenly distributed across modalities and categories. Haemodialysis showed the highest number of optimisations in all domains, particularly in the \u003cem\u003eTechnology\u003c/em\u003e and \u003cem\u003eValue Proposition\u003c/em\u003e categories, reflecting the high material and energy intensity of HD and the focus of innovation efforts on equipment, consumables, and process efficiency. Chronic kidney disease interventions, while fewer overall, were more evenly spread across categories, suggesting a broader range of intervention types at earlier stages of the patient pathway. In contrast, peritoneal dialysis, haemodiafiltration, and transplantation had fewer documented optimisations, indicating potential gaps or under-reporting of sustainability initiatives in these areas. This imbalance highlights an opportunity for future research and intervention design to extend beyond HD, ensuring that sustainability strategies are applied comprehensively across all kidney care modalities.\u003c/p\u003e\u003cp\u003eBeyond this descriptive mapping, triangulation of the CSH\u0026rsquo;s Green Team success factors with frameworks like the Sustainable Value framework\u003csup\u003e\u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u003c/sup\u003e will provide further insights. While many interventions quantified environmental and economic benefits, relatively few addressed cross-disciplinary teamwork, staff engagement, or long-term integration into clinical workflow - dimensions emphasised by the Green Team framework\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Indeed, an integrative review of healthcare \"Green Team\" initiatives found that staff engagement, alongside policy support, external collaboration and organisational structure, was one of the four main facilitators of success in environmentally sustainable initiatives. \u003csup\u003e137\u003c/sup\u003eLikewise, applying the Sustainable Value lens shows that social dimensions such as patient experience, equity of access, and staff wellbeing were rarely considered. Recent evidence shows that organisational culture and job satisfaction are central to sustainable healthcare quality: by optimising processes and reducing waste, healthcare services can enhance staff wellbeing and ultimately improve patient care - underscoring the importance of embedding social value criteria into sustainability interventions.\u003csup\u003e\u003cspan citationid=\"CR138\" class=\"CitationRef\"\u003e138\u003c/span\u003e\u003c/sup\u003e Taken together, these findings suggest that the current literature has largely prioritised measurable technical and economic outcomes, while underreporting organisational, contextual, and social aspects that are equally important for long-term adoption and system-wide sustainability. Embedding Green Team and Sustainable Value criteria more explicitly in future studies would strengthen the evidence base, ensuring that sustainability interventions in kidney care are not only environmentally and economically effective but also feasible, acceptable, and equitable across diverse contexts.\u003c/p\u003e\u003cp\u003eWhile the search was comprehensive, potential limitations include publication bias toward positive or innovative results, and underrepresentation of grey literature and non-English sources\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Moreover, most interventions originated from high-income countries, highlighting the need for context-specific solutions in low- and middle-income settings\u003csup\u003e\u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e139\u003c/span\u003e\u003c/sup\u003e. Also, as is consistent with scoping review methodology, no formal risk of bias or certainty assessment was performed, and no meta-analysis or synthesis of effect measures was conducted. This approach is appropriate given the exploratory nature of the review and the heterogeneity of study designs, but it should be noted as a limitation in the interpretation of results.\u003c/p\u003e\u003cp\u003eOur findings support the integration of sustainability principles into routine nephrology care, aligning clinical outcomes with respect for planetary boundaries. This shift can be facilitated by professional societies, regulators, and procurement agencies through the incentivisation of low-impact practices such as low-flow HD and the use of reusable consumables, the incorporation of environmental criteria into procurement tenders and clinical guidelines, and the promotion of staff education and sustainability literacy across kidney care services.\u003c/p\u003e\u003cp\u003eHealthcare organisations can also implement multimodal interventions that address travel, procurement, and waste simultaneously, maximising co-benefits for patients, providers, and the environment\u003csup\u003e\u003cspan citationid=\"CR140\" class=\"CitationRef\"\u003e140\u003c/span\u003e,\u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e141\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCrucially, many sustainability interventions identified in this review were cost-saving or cost-neutral, offering a strong economic case for action even in resource-constrained systems.\u003c/p\u003e\u003cp\u003eFuture research should prioritise longitudinal studies that include robust environmental and economic impact assessments\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e, while also ensuring the inclusion of diverse patient populations and treatment modalities such as PD, conservative kidney management, and transplantation. Co-design with patients and healthcare staff is essential to enhance the acceptability, feasibility, and equity of interventions, and consistent reporting using tools like the SQUIRE 2.0 checklist or a dedicated environmental quality framework will be key to improving transparency and comparability across studies\u003csup\u003e\u003cspan citationid=\"CR142\" class=\"CitationRef\"\u003e142\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review reveals a growing landscape of innovation in sustainable kidney care, yet underscores the urgent need for coordination, standardisation, and system-level thinking. Nephrology faces a pivotal moment: rising environmental challenges and growing inequities make sustainable transformation both urgent and achievable. By advancing interventions that are evidence-based, environmentally sound, and designed with attention to equity and access, the kidney community can lead by example toward a greener, healthier future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical approval was not required for this study as it did not involve human participants or animal research. The study focused solely on the analysis of papers related to kidney care sustainability.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eInformed Consent to Participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eInformed consent was not applicable to this study, as it did not involve any individual participants, patients, or human data.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis work was supported by EU Horizon [Grant No. 101137054] and UK Research and Innovation (UKRI) [Grant No. 10110449] as part of the KitNewCare project.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAycan, James and Marta assisted in the screening and writing of the review. Brett and Inge assisted in the creation of the concept and reviewing. 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Available from: https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-021-02516-6\u003c/li\u003e\n\u003cli\u003eZoccali C, Barraclough K, Eckelman M, Amenos AC, Germond-Duret C, Pecoits-Filho R, et al. #2695 THE ENVIRONMENTAL IMPACT OF CHRONIC KIDNEY DISEASE INTERNATIONALLY: RESULTS OF A LIFE CYCLE ASSESSMENT. Nephrology Dialysis Transplantation [Internet]. 2023 Jun 14 [cited 2025 Jun 24];38(Supplement_1). Available from: https://dx.doi.org/10.1093/ndt/gfad063c_2695\u003c/li\u003e\n\u003cli\u003eMortimer F, Isherwood J, Wilkinson A, Vaux E. Sustainability in quality improvement: redefining value. Future Healthc J [Internet]. 2018 Jun [cited 2025 May 21];5(2):88\u0026ndash;93. Available from: https://pubmed.ncbi.nlm.nih.gov/31098540/\u003c/li\u003e\n\u003cli\u003eLaw A, Dahlke J, Kalogirou SR. Facilitating Green Teams in Health Care International Journal of Nursing Student Scholarship (IJNSS) [Internet]. 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Available from: https://pubmed.ncbi.nlm.nih.gov/38008159/\u003c/li\u003e\n\u003cli\u003eBadanta B, Sierra AP, Fern\u0026aacute;ndez ST, Mu\u0026ntilde;oz FJR, P\u0026eacute;rez-Jim\u0026eacute;nez JM, Gonzalez-Cano-Caballero M, et al. Advancing Environmental Sustainability in Healthcare: Review on Perspectives from Health Institutions. Environments 2025, Vol 12, Page 9 [Internet]. 2025 Jan 3 [cited 2025 Jun 24];12(1):9. Available from: https://www.mdpi.com/2076-3298/12/1/9/htm\u003c/li\u003e\n\u003cli\u003eZurynski Y, Herkes-Deane J, Holt J, McPherson E, Lamprell G, Dammery G, et al. How can the healthcare system deliver sustainable performance? A scoping review. BMJ Open [Internet]. 2022 May 24 [cited 2025 Jun 24];12(5):e059207. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9125771/\u003c/li\u003e\n\u003cli\u003eOgrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. 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Available from: https://pubmed.ncbi.nlm.nih.gov/26369893/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7620813/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7620813/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003cbr\u003e\nTo map and synthesise existing interventions aimed at improving environmental sustainability in kidney care, and to identify challenges and opportunities for implementation across treatment modalities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e\u003cbr\u003e\nScoping 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sources:\u003c/strong\u003e\u003cbr\u003e\nEmbase, MEDLINE, Scopus, and CINAHL alongside relevant grey literature, searched in September 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria for selecting studies:\u003c/strong\u003e\u003cbr\u003e\nThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nOut 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nThere 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.\u003c/p\u003e","manuscriptTitle":"Advancing Green Nephrology: A Scoping Review of Sustainability Interventions in Kidney Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 16:40:02","doi":"10.21203/rs.3.rs-7620813/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe82bcfb-ee4d-48e9-8a11-6b6023dd9048","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:06:14+00:00","versionOfRecord":{"articleIdentity":"rs-7620813","link":"https://doi.org/10.1007/s11255-025-04904-5","journal":{"identity":"international-urology-and-nephrology","isVorOnly":false,"title":"International Urology and Nephrology"},"publishedOn":"2025-11-29 15:56:57","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-09-30 16:40:02","video":"","vorDoi":"10.1007/s11255-025-04904-5","vorDoiUrl":"https://doi.org/10.1007/s11255-025-04904-5","workflowStages":[]},"version":"v1","identity":"rs-7620813","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7620813","identity":"rs-7620813","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}