Impact of the Type of Dialysate Acid Concentrate Container on the Environmental Footprint of Hemodialysis Centers

Rationale & Objective: Hemodialysis is the most common form of kidney replacement therapy and has a significant environmental footprint, raising sustainability concerns as demand increases. This study aimed to assess the environmental impact of one aspect of the hemodialysis procedure, the type of container used to hold the acid concentrate that is used to prepare dialysate.

Study Design: A retrospective cross-sectional life cycle assessment (LCA) of acid concentrate containers used in hemodialysis was conducted.

Setting & Participants: 15 hemodialysis centers in 3 Spanish regions participated, representing approximately 5% of the national hemodialysis population.

Exposure: 4 acid concentrate container types from 2 manufacturers were assessed: canisters (3.9 L), flexible bags (4.2 L), and centralized storage tanks (300 L and 600 L).

Outcomes: The primary outcome was the environmental impact of each container measured by carbon footprint (measured in kilograms of CO2 equivalent [CO2eq]) and 16 additional environmental impact categories.

Analytical Approach: LCA was performed using openLCA software and the ecoinvent v3.10 database, considering the full life cycle of the containers, including production, transport, and waste disposal.

Results: The 3.9-L canister had a CO2eq 1.63 times higher than the 4.2-L flexible bag and 2.63 times higher than the storage tanks (P <0.001). The main contributors to the carbon footprint were container production and waste disposal, particularly plastic use and canister production and disposal. Storage tanks had the lowest CO2eq (P < 0.001), with no difference between the 300-L and 600-L storage tanks. There were also significant differences in the environmental impact of different containers across 16 impact categories, with the greatest differences observed for freshwater ecotoxicity, nonrenewable energy use, and freshwater eutrophication.

Limitations: Assumptions regarding transport and disposal processes may introduce some variability. Additionally, financial costs were not assessed, which could influence container selection.

Conclusions: The choice of dialysate acid concentrate container is associated with a differential environmental impact. Thus, this study has identified a key potential approach to decrease the environmental impact of kidney replacement therapy.