Eco-dialysis: the financial and ecological costs of dialysis waste products: is a 'cradle-to-cradle' model feasible for planet-friendly haemodialysis waste management?

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Nephrol Dial Transplant (2015) 30: 1018–1027 doi: 10.1093/ndt/gfv031

Advance Access publication 24 March 2015

Original Articles

Eco-dialysis: the

ﬁnancial and ecological costs of dialysis waste

products: is a

‘cradle-to-cradle’ model feasible for planet-friendly

haemodialysis waste management?

Giorgina Barbara Piccoli

1

*, Marta Nazha

2

, Martina Ferraresi

1

, Federica Neve Vigotti

3

, Amina Pereno

4

and

Silvia Barbero

4

1_{Nefrologia, Scienze Mediche e Biologiche, ASOU San Luigi Gonzaga, Orbassano, Torino, Italy,}2_{Scienze Mediche e Biologiche,ASOU San Luigi} Gonzaga, Orbassano, Torino, Italy,3Chair of Nephrology, University of Torino, Torino, Italy and4Architettura e Design, Politecnico di Torino, Torino, Italy

*Correspondence and offprint requests to: Piccoli Giorgina Barbara, E-mail: gbpiccoli@yahoo.it

A B S T R AC T

Background.Approximately 2 million chronic haemodialysis

patients produce over 2 000 000 tons of waste per year that in-cludes about 600 000 tons of potentially hazardous waste.

The aim of the present study was to analyse the characteris-tics of the waste that is produced through chronic haemodialy-sis in an effort to identify strategies to reduce its environmental

andﬁnancial impact.

Methods.The study included three dialysis machines and

dis-posables for bicarbonate dialysis, haemodiaﬁltration (HFR) and lactate dialysis. Hazardous waste is deﬁned as waste that comes

into contact with bodilyﬂuids. The weight and cost of waste

management was evaluated by various policies of differenti-ation, ranging from a careful-optimal differentiation to a care-less one. The amount of time needed for optimal management was recorded in 30 dialysis sessions. Non-hazardous materials were assessed for potential recycling.

Results.The amount of plastic waste that is produced per

dia-lysis session ranges from 1.5 to 8 kg (from 1.1 to 8 kg of poten-tially hazardous waste), depending upon the type of dialysis machine and supplies, differentiation and emptying policies.

Theﬁnancial cost of waste disposal is high, and is mainly

re-lated to hazardous waste disposal, with costs ranging from 2.2 to 16 Euro per session (2.7–21 USD) depending on the waste man-agement policy. The average amount of time needed for careful, optimal differentiation disposal is approximately 1 minute for a haemodialysis session and 2 minutes for HFR.

The ecological cost is likewise high: less than one-third of

non-hazardous waste (23–28%) is potentially recyclable,

while the use of different types of plastic, glues, inks and labels prevents the remaining materials from being recycled.

Conclusion.Acknowledging the problem of waste

manage-ment in dialysis could lead to savings of hundreds of millions of Dollars and to the reuse and recycling of hundreds of tons of plastic waste per year on a world-wide scale with considerable ﬁnancial and ecological savings.

Keywords: costs, disposables, ecology, haemodialysis, waste

I NT RO D U C T I O N

It is difﬁcult to determine exactly how many patients are on

haemodialysis world-wide. Estimates vary widely, and all of them are imprecise. However, if we take the gross estimate that about 2 million patients are currently being treated around the world, and if we multiply this number by the 156 average dialysis sessions per year (an average thrice weekly dialysis) we come up with about 300 million dialysis sessions per year

[1–2]. The estimate for 2025 is of about 4 million dialysis

pa-tients worldwide [3]. Such numbers represent highly relevant

challenges, not only to health-care budgets but also to the ecol-ogy of the planet due to the great need for water, power and, not

least, to the issue of waste production [4–14].

The problem of hospital waste is enormous in the developed world as well as in developing countries (which may have even

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more severe problems) and depends upon the health-care

estab-lishment, the level of instrumentation and the location [15–17].

In many developing countries, hospital waste management is a prevailing issue because the quantity of health-care waste (HCW) has risen sharply as a result of rapid population growth,

thus increasing the demand on health services [15–17]. The

production of waste is, however, still low as compared to

indus-trialized countries [15,18–19]. Two of the main problems are

the widespread lack of regulation of hazardous waste, as recom-mended by the general principles of the World Health Organ-ization (WHO), and the application of the rules in the few

places where the issue is regulated [18–22]. Overall, hospital

waste is divided into two main categories:‘hazardous’ (material

that has been in contact with blood or blood products) and

‘non-hazardous’ waste [23]. According to current regulations,

hazardous waste should be considered potentially harmful and should be disposed of differently. However, to date, the

po-tential for recycling these materials has not been studied [23].

On the contrary, non-hazardous waste could (and should)

be recycled. According to the WHO, HCW is deﬁned as the

total waste stream from a health-care facility and includes

po-tentially infectious and non-infectious waste [23]. Importantly,

if waste products are not separated, all HCW needs to be

con-sidered potentially infectious [23]. The amount of hazardous

waste is high: in our region (Piedmont, northern Italy), 10 000

000 of the 12 000 000 tons of hospital waste are classiﬁed as

haz-ardous; this striking amount reported by the authorities

indir-ectly underlines the need for more attention to this issue [24].

The composition of medical waste varies depending on the area, type and scale of the medical facility, as well as on the

clin-ical specialty and the procedures that are carried out [25]. The

production of waste ranges widely, as does the way it is

mea-sured: from 0.25–7.0 kg/bed/day in Europe and the USA to

0.4–5.5 kg/patient/day in 12 developing countries [26–29].

Regardless of the amount, the clinical and ecological hazards can be reduced by proper handling, separation and recycling

[30–33].

Three hundred million dialysis sessions produce an

enor-mous amount of waste: a minimum of 2 kg of‘potentially

infec-tious’ material per dialysis session means that approximately

600 000 tons are produced worldwide every year [34–37].

These ﬁgures roughly double if all hazardous and

non-hazardous dialysis waste is considered together. The cost of waste disposal is extremely high: in Europe, the average cost of hazardous waste disposal is about 2 Euro (2.68 USD) per kg, although costs vary considerably [in our region, prices

range from 0.70 cents to 5 Euro (0.94–6.70 USD) per kg; the

median cost is 2 Euro, in keeping with the European standards]. This extremely broad range may be surprising and is certainly disturbing, and should prompt the medical authorities, who are often very keen on pursuing modest savings on drugs or med-ical supplies and on health-care personnel, to pay more

atten-tion to the ‘hidden costs’ of waste disposal that could be

re-invested in better patient care.

Hence, the cost of waste disposal for one dialysis session may

easily reach 10–25% of the initial cost of the disposables, and is

higher in the absence of careful differentiation of hazardous

materials [24,27,38].

Evaluating the life cycle of materials is an emerging method for analysing and improving waste disposal. The most recent approaches suggest that the life cycle of manufactured products

may shift from the classic‘from cradle-to-grave’ pathway, in

which the focus is on‘clean’ disposal (the grave), to true

recyc-ling, in which disposed products mayﬁnd a new life, as occurs

in nature, following a biomimetic or biomimicry approach,

called the‘from cradle-to-cradle’ pathway [38–40]. According

to the authors of the cradle-to-cradle model, this cyclical bio-logical model has nourished the planet for millions of years.

Technical products may be manufactured as‘nutrients’ for a

‘technosphere’ if they are produced keeping in mind the ﬁnal destiny of their components. In this regard, many of the tools that are used on a daily basis should be re-designed for almost

perpetual reuse, as is the case with the pages of the book‘Cradle

to Cradle’ in its North Point Press edition; it is printed on

syn-thetic paper made of plastic resin and inorganicﬁller, and it is

waterproof, resistant and recyclable without end [39].

Since there are currently no international guidelines or local laws regulating the responsibility of the dialysis wards with re-gard to differentiated waste management, we decided to analyse waste disposal in our dialysis ward in an effort to provide some

insight into theﬁnancial and ecological savings that may be had

from careful dialysis waste management. Theﬁrst step was to

quantify theﬁnancial differences between ‘careful’ and ‘careless’

waste disposal in a dialysis ward by following a classic‘from

cradle-to-grave’ life cycle analysis. The second step focussed

on the ecological potential of a‘from cradle-to-cradle’ pathway,

concentrating on the potentially recyclable, non-hazardous dia-lysis waste.

M AT E R I A L S A N D M E T H O D S

Study setting

The study was performed in a small dialysis unit that also serves as a training unit for home haemodialysis. Chronic treat-ments provided by the unit include in-centre bicarbonate dia-lysis (Bellco and Nikkiso); home diadia-lysis (Nikkiso and NxStage) and haemodiaﬁltration (HFR) (BELLCO). All types of dialysis, as well as the relative supplies were analysed.

Three dialysis sessions were analysed for each dialysis

ma-chine: two in vivo sessions (analysis of the‘cradle-to-grave’

life cycle), for which we analysed the various approaches to waste differentiation, followed by an assessment of the costs (ﬁ-nancial savings), and one in vitro session (‘cradle-to-cradle’)

aimed at assessing the potential for recycling‘non-hazardous’

waste (ecological savings).

Analysis of the life cycle from‘cradle-to-grave’: dialysis disposable waste management

Every step of the procedure was photographed and all the

materials were identiﬁed and weighed during and after two

regular dialysis sessions. We then simulated four different

pol-icies: a‘careful-optimal’ policy which involved separating

haz-ardous waste from non-hazhaz-ardous waste (taking special care

and carefully emptying all the residualﬂuids from the

disposa-bles); a‘careful-lazy’ policy, with correct differentiation, but

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without emptying the residualﬂuids; a ‘careless-lazy’ procedure

without differentiation, but emptying the residual ﬂuids, a

‘careless-maximal’ procedure without differentiation or emptying.

Consequently, two weights were assessed: a‘dry weight’ after

carefully draining the residualﬂuid, and a ‘wet’ weight,

consid-ering what was left at the end of the session.

The costs were calculated as min–max and median,

accord-ing to the cost of waste disposal available in our area (Piedmont, Italy) taken as representative of the range of costs reported in

Europe [24,41].

The amount of time that was needed for waste disposal at the end of the dialysis session was directly assessed in 30 non-consecutive sessions over a working week, and the amount of

time that was needed for‘ideal’ waste disposal as managed by

four different trained and skilled dialysis nurses was recorded.

Potential for recycling

The materials of the non-hazardous disposables were classi-ﬁed in cooperation with the Ecodesign team of the Politecnico di Torino, Italy. In particular, important information regarding the potential for recycling was collected for each non-hazardous

Table 1. Qualitative and quantitative analysis of single use Bellco Formula HD material

Material Composition Weight Differentiation

Set-up of the machine Dialyser pack PP 10.6 g Plastic

Pack of arterial bloodline Coating 1: paper 6 g Paper

Coating 2: PVC 4.8 g Plastic

Stoppers (×2) PP 1 g Plastic

Pack of venous bloodline Coating 1: paper 6 g Paper

Pack of Bicarbonate cartridge Nylon 1.7 g Plastic

Pack of saline solution 1000 mL PP 9.5 g Plastic

Stopper PP 0.3 g Plastic

Pack of wash solution 2000 mL PP 18.6 g Plastic

Pack of infusion tube Coating 1: paper 2.1 g Paper

Tot: 71.4 g (57.3 g of plastic material)

Material Composition Dry weight Wet weight Differentiation

Start of dialysis AVF connection kit:

Pack of AVF connection kit Coating 1: paper 3 g Paper

N°6 pre-cut patches cm 10×4 Coating: paper 1.2 g Paper

Pack of gauze pads TNT cm 5×5-8str Coating 1: paper 1.1 g Paper

Coating 2: plastic 1.7 g Plastic

Gauze pads Cotton 2.5 g Hazardous

Absorption crosspiece cm 60 × 40 Cellulose 30 g Hazardous

N°2 Pack of syringe Coating 1: paper 1.2 g Paper

Syringes (×2) PP 30 g Hazardous

Pack ofﬁstula needles (×2) Coating 1: paper 3.4 g Paper

Stoppers ofﬁstula needles (×2) PP 0.6 g Plastic

Wash solution 2000 mL bag Nylon. PP. PE. LATEX.PVC 30.1 g – Plastic Collection bag of wash solution PP. PE. PVC 34 g 1.8 kg Plastic

Tot: 149.3 g (dry)–1.915 kg (wet) (76.9 of plastic material)

End of dialysis AVF disconnection kit

Two packs of gauze pads TNT cm 5 × 5-8str Coating 1: paper 2.2 g Paper

Two packs of pre-cut patches forﬁstula cm 15 × 5 Coating 1: paper 2.2 g Paper

Pre-cut patches forﬁstula Coating 1: paper 0.7 g Paper

Coating 2: patch 1 g Hazardous

Acid concentrate bag Nylon. PP. PE. LATEX.PVC 43 g 1.7 kga _Plastic Saline solution 1000 mL bag Nylon. PP. PE. LATEX.PVC 22.5 g 0.9 kg Plastic

Bicarbonate cartridge PE. PVC. PP 0.55 kg 0.8 kga Non-differentiated

Dialyser/bloodlines/Infusion line Mix 1.05 kg 1.1 kg Hazardous

Fistula needles (×2) Silicon + metal 20 g

Tot: 1.711 kg (dry)– 4.545 kg (wet) (72.7 g of plastic material)

PVC: polyvinyl chloride, PP: polypropylene, PE: polyethylene; Dry, weight once the materials have been completely emptied; Wet, weight of materials before they have been emptied.

a_{Wet weight depends on the duration of dialysis session.}

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manufactured material: type of material(s); glues; inks and la-bels; other contaminants-constituents, weight, measurements

[42–45].

Statistical analysis

Descriptive analysis was performed as appropriate (mean and standard deviation, in case of parametric data; median

and min–max or range in case of non-parametric data). The

costs of dialysis were derived from ofﬁcial health ministry

sources, from the WHO and from regional data; Euro-USD

ex-change was established on 1st August 2014 (ofﬁcial rate:

$1.339 = 1 Euro).

R E S U LT S

Analysis of waste products in dialysis sessions

Tables1–4summarize the disposable waste that is produced

in the four main phases of the dialysis procedure, i.e. machine set-up, start of dialysis, end of dialysis and disposal of the dis-posables, for the dialysis machines we analysed.

In all cases, a small amount of non-hazardous paper and plastic is produced during the set-up phase, while the bulk of the waste is produced at the end of the session. The dialyser and the blood lines play a major role among the tested items,

followed, where needed, by the bicarbonate cart, while the pre-assembled dialyser-line-cart accounts for most of the hazardous waste that is produced in the NxStage machine.

There are some interesting differences among the machines that were used: for example, one bicarbonate dialysis session with the Bellco Formula HD produces about 207 g of non-hazardous plastic waste versus 200 g with the Nikkiso dialysis machine; HFR results in 223 g (not considering the Bicarbonate cartridge). Conversely, the NxStage dialysis machine produces 731 g of non-hazardous plastic waste per session. The differ-ence with regard to the Nxstage machine is mainly due to the bags of pureﬂow saline (on average 5 per session) that weighs

about 90 g without residualﬂuid; the ﬂuid warmer adds another

50 g (Figure1). Figure1depicts all the disposable waste that is

produced during a bicarbonate dialysis session performed using the Bellco and the Nikkiso dialysis machines.

Cost analysis according to the differentiation policy

Differentiation of the waste is the main determinant of the cost of waste management. The differences between a careful-optimal and a careful-lazy procedure are minor on a single dia-lysis scale [0.20 Euro (0.27 USD) on average], but may account for almost 1 million Euro (more than 1 300 000 USD) per year

in Italy (considering 156 dialysis sessions per year and 30 000–

35 000 prevalent dialysis patients), or about 60 million Euro

Table 2. Qualitative and quantitative analysis of single use Nikkiso material

Pack of arterial-venous bloodline Coating 1: paper 6 g Paper

Stoppers (×4) PP 2.1 g Plastic

Pack of bicarbonate cartridge Nylon 1.7 g Plastic

Stopper (×1) PP 0.3 g Plastic

Start of dialysis The items are the same as in Table1(Bellco HD) Tot: 149.3 g (dry)–1.915 kg (wet) (76.9 g plastic)

End of dialysis AVF disconnection kit:

Two packs of gauze pads TNT cm 5 × 5–8str Coating 1: paper 1.1 g Paper

Acid concentrate bag 5000 mL Nylon. PP. PE. LATEX.PVC 43 g 3.3 kga Plastic Saline solution 1000 mL bag Nylon. PP. PE. LATEX.PVC 22.5 g 0.9 kg Plastic

Bicarbonate cartridge PE. PVC. PP 0.6 kg 0.8 kga Non-differentiated

Dialyser/bloodlines/Infusion line Mix 1 kg 1.05 kg Hazardous

Fistula needles (×2) Silicon + metal 20 g Hazardous

Tot: 1.728 kg (dry)–6.113 kg (wet) (71 g of plastic material)

PVC, polyvinyl chloride; PP, polypropylene; PE, polyethylene; Dry, weight once the materials have been completely emptied; Wet, weight of materials before they have been emptied.

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(about 80 million USD) worldwide (156 sessions per year, 2 million patients).

Theseﬁgures become striking when we consider the

differ-ence between a careful-optimal and a careless-maximal proced-ure: if we consider a gross average difference of 10 Euro (13.39

USD) calculated on the three‘conventional’ dialysis procedures,

theﬁgure rises to 45–52.5 million Euro (60–70.30 million USD)

in Italy and to 3 billion Euro (4 billion USD) world-wide.

Furthermore, considering a rounded average of 30–35 Euro

(40–47 USD) for the ‘new’ disposables that are needed for a

bi-carbonate dialysis session in Italy, the cost of managing the haz-ardous waste products accounts for between 10 and 50% of the

initial cost of the‘new’ disposable materials (Table5).

The median time needed for the‘careful-optimal’

manage-ment of the waste disposables at the end of the dialysis session was assessed during 30 sessions, and was 57 and 70 s (45

min-imum–103 maximum) with the Nikkiso and Bellco bicarbonate

dialysis, respectively, and 96 s (min 65–max 140) for HFR.

Characterization of‘non-hazardous’ disposables with respect to the potential for recycling

Overall, the potentially recyclable waste material from each of the dialysis sessions consists of paper and cardboard

(Ta-bles1–4), accounting for 223–736 g per dialysis session (not

considering the packaging, which is, at least in our setting, dis-posed of separately directly into the paper recycling bin) and of

Table 3. Qualitative and quantitative analysis of single use NxStage material

Set-up of the machine Pre-assembled pack (dialyser/bloodline) PP 26.7 g Plastic

Connector tabs I Recyclable plastic 2.7 g Plastic

Connector tabs II ×2 Recyclable plastic 1.1 g Plastic

Paper tape (×4) Paper and glue 0.9 g Paper

Pack of saline solution 1000 mL (×2) PP 19 g Plastic

Pack of all acid solution 5000 mL PP 21.6 g Plastic

Pack of one acid solution 5000 mL (×5) PP 29 g Plastic

Pack ofﬂuid warmer disposable set PP 16 g Plastic

Start of dialysis AVF connection kit:

Pack of AVF connection kit Coating 1: paper 3 g Paper

N°6 pre-cut patches cm 10 × 4 Coating: paper 1.2 g Paper

Pack of gauze pads TNT cm 5 × 5–8str Coating 1: paper 1.1 g Paper

Coating 2: plastic 1.7 g Plastic

N°2 Pack of syringe Coating 1: paper 1.2 g Paper

Syringes (×2) PP 30 g Hazardous

Pack ofﬁstula needles (×2) Coating 1: paper 3.4 g Paper

Stoppers ofﬁstula needles (×2) PP 0.6 g Plastic

Wash solution 2000 mL bag Nylon. PP. PE. LATEX.PVC 30.1 g 1.8 kga Plastic

Tot: 115.3 g (dry)–1.885 g (wet) (42.9 g of plastic material)

End of dialysis AVF disconnection kit:

Two packs of gauze pads TNT cm 5 × 5–8str Coating 1: paper 1.1 g Paper

Coating 2: patch 1.0 g Hazardous

NxStage pureﬂow solution 5000 mL (×5) Nylon. PP. PE. LATEX.PVC 90 g (450 g)

450 g + 300 ga Plastic

Expressﬂuid warmer disposable set PHT 50 g 70 g Plastic

Saline solution 1000 mL bag (×2) Nylon. PP. PE. LATEX.PVC 22.5 g (45 g) 45 g + 0.7 kga Plastic Pre-assembled kit (dialyser/bloodline) Mix 0.7 kg 1.2 kg Hazardous

Fistula needles Silicon + metal 20 g Hazardous

Tot: 1.308 g (dry)–2.828 g (wet) (550.5 g of plastic material)

PVC, polyvinyl chloride; PP, polypropylene; PE, polyethylene; PHT, polyhexahydrotriazine; Dry, weight once the materials have been completely emptied; Wet, weight of materials before they have been emptied.

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different types of plastic. Figure2reports the per cent distribu-tion of the potentially recyclable or reusable plastic materials derived from the non-hazardous dialysis waste. The main re-cyclable plastic waste includes polyvinyl chloride (PVC) and polypropylene (PP); the minimal amount of polyethylene that was present was calculated together with PP.

Overall, the recyclable plastic materials account for about

one-fourth of all the plastic materials that are used (Figure2).

DISCUS SION

The problem of waste management is emblematic of the rapidly

changing challenges in the medical world due to theﬁnancial

crisis that is profoundly modifying lifestyles in several

indus-trialized countries and is placing tremendousﬁnancial pressure

on health-care systems that have fewer and fewer resources with which to meet the ever growing needs of an aging population

[46–48].

The even faster spread of medical technologies almost unex-pectedly poses new challenges, including an ecological one, due

to the enormous quantity of waste produced by hospitals and by

the overall use of health-care supplies [2–10,49–50]. While all

waste products are a challenge for the ecosystem, the so-called hazardous waste, which is potentially contaminated by human

pathogens, also represents a tremendous, albeit still hidden,

ﬁ-nancial challenge. In the absence of standardized rules and guidelines on differentiation, the cost of hazardous waste

dis-posal may account for 10–50% of the cost of the disposables

for a dialysis session (Tables1–5).

Hence, theﬁrst major achievement of this analysis is to

high-light the importance of careful differentiation and management of dialysis waste, since the difference between a careful approach and a careless one may remarkably increase the costs of dialysis, a crucial issue in times of economic constraints. Due to the enor-mous number of dialysis patients, simply emptying the residual ﬂuids may lead to savings of several million Dollars per year

[33]. While we chose to refer to average costs, it has to be

under-lined that the cost of waste disposal varies greatly among coun-tries as well as within the same region, and therefore, at least in some settings, the cost of careless waste disposal may be equal to

the cost of the original supplies (Table5).

Table 4. Qualitative and quantitative analysis of single use Bellco Formula HFR material

Pack of arterial bloodline Coating 1: paper 6 g Paper

Pack of venous bloodline Coating 1: paper 6 g Paper

Pack of bicarbonate cartridge Nylon 1.7 g Plastic

Pack of saline solution 1000 ml PP 9.5 g Plastic

Stopper (×1) PP 0.5 g Plastic

Pack of adsorbing dialyser PP 9.9 g Plastic

Pack of bloodline for adsorbent dialyser Coating 1: paper 6.9 g Paper

Material Composition Dry Wet Differentiation

Start of dialysis The items are the same as in Table1(Bellco HD) Tot: 149.3 g (dry)–1.915 kg (wet) (76.9 g plastic)

End of dialysis AVF disconnection kit

Two packs of gauze pads TNT Gauze pads Coating 1: paper 1.1 g Paper

Two packs of pre-cut patches forﬁstula cm 15 × 5 Cotton 2.5 g Hazardous

Coating 1: paper 2.2 g Paper

Pre-cutﬁstula patches Coating 1: paper 0.7 g Paper

Acid concentrate bag 3800 mL Nylon. PP. PE. LATEX.PVC 42.9 g 2.1 kga Plastic Saline solution 1000 mL bag Nylon. PP. PE. LATEX.PVC 22.5 g 0.65 kg Plastic

Bicarbonate cartridge PE. PVC. PP 0.55 kg 1 kga Non-differentiated

Dialyser/bloodlines/infusion line Mix 1.75 kg 1.85 kg Hazardous

Fistula needles (×2) Silicon + metal 20 g Hazardous

Tot: 2.408 kg (dry)–5.643 kg (wet) (70.9 g of plastic material)

PVC, polyvinyl chloride; PP, polypropylene; PE, polyethylene; HFR, haemodiaﬁltration reinfusion.

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Differentiation is not a matter of time, but of attention: the average time needed at the end of the dialysis session (i.e. in the

phase that‘produces’ most of the waste) for careful

differenti-ation between hazardous and non-hazardous waste, and for separation of plastic and paper from among the non-hazardous waste, is around 1 minute per session, with minimal differences among the nurses in the same unit.

Our data on hazardous waste are in line with other assess-ments performed in the UK. However, the novelty of our ana-lysis is the focus on different types of waste management and on their implications since, in the absence of shared guidelines on this issue, each dialysis centre develops its own policy. There may be less attention to this issue in some settings, such as in Italy and other European countries where waste disposal falls into the category of general hospital expenses and is not

per-ceived as an integral part of the cost of dialysis [30,36,51–

55]. Some experts,ﬁrst and foremost the master of this new

out-look, Agar in Australia, followed by the Green Nephrology net-work in the UK, are actively proposing innovative and creative responses to these issues, highlighting how attention to these

hidden costs may allow signiﬁcant savings (several million

Euro or Dollars per year) at‘zero cost’ with respect to the quality

of care [2,4–7,55].

Theﬁnancial costs are but a part of the ecological costs of

dialysis: whatever their destiny, i.e. incineration, landﬁll or

reuse, the 600 000 tons of dialysis waste products pose tremen-dous ecological problems. The scale of interventions suggested by the European Commission in its report on the Thematic

Strategy on the Prevention and Recycling of Waste in a chapter

entitled‘Introducing life cycle thinking in waste policy’ starts

with the prevention of waste, followed by reuse, recycling,

re-covery, with disposal of waste being the last resort [56].

While all these steps require a closer relationship with the in-dustry in order to develop an eco-friendly design, starting

from the packaging—which is often oversized—to the general

idea of replacing pre-assembled structures (which often require large plastic frames) with smaller single-component packages thus favouring ecology with respect to a supposedly friendlier machine set-up, we instead focussed the second part of our

ana-lysis on the potential for recycling (Figure2).

Interestingly, at least with the sample dialysis machines we analysed, only a minor amount of the plastic waste products could be recycled. Recycling is a very complex and delicate

pro-cess by which only few‘plastic’ elements may be processed

to-gether, and the presence of even small amounts of glues, inks or other materials (such as plastic tags) impairs entry into the

re-cycling process [30,57]. Hence, industry should search for new

materials or new designs, such as plastic bags that can be as-sembled without glues or that are made up of several layers of the same polymers in order to achieve varying thickness. Sim-ply avoiding the use of plastic tags, inks and glues could almost reverse the prevalence of recyclable versus non-recyclable disposables.

Greater attention to these issues by the medical community should represent a driving force for a paradigm shift in the in-dustrial design of dialysis disposables.

F I G U R E 1 :Differnt disposables needed for a dialysis session with various dialysis machines.

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Table 5. Financial effect of the different policies of waste management (costs of hazardous waste management) Bellco Formula HD

Policy ‘Careful-optimal’ Hazardous waste totally emptied and separated

‘Careful-lazy’ Without emptying the dialyser

‘Careless-lazy’ Hazardous waste not emptied, non-hazardous emptied, not differentiated

‘Careless Max’ Without differentiation and emptying

Weight 1.22 kg 1.27 kg 1.59 kg 6.55 kg

Cost per dialysis session

Median 2.44€ Median 2.54€ Median 3,18€ Median 13.10€

Min 0.80–max 6.83 € Min 0.83–max 7.11 € Min 1.05–max 8.90 € Min 4.32–max 36.68 €

Median 3.25 $ Median 3.40 $ Median 4.26 $ Median 17.54 $

Min 1.07–max 9.14 $ Min 1.11–max 9.52 $ Min 1.40–max 11.92 $ Min 5.79–max 49.10 $

Nikkiso HD

Policy ‘Careful-optimal’ ‘Careful-lazy’ ‘Careless-lazy’ ‘Careless Max’

Weight 1.11 kg 1.16 kg 1.47 kg 8.09 kg

Median 2.22€ Median 2.32€ Median 2.94€ Median 16.18€

Min 0.73–max 6.22 € Min 0.76–max 6.50 € Min 0.97–max 8.23 € Min 5.34–max 45.30 €

Min 0.98–max 8.33 $ Min 1.02–max 8.70 $ Min 1.30–max 11.02 $ Min 7.15–max 60.64 $

NxStage

Policy ‘Careful’ ‘Careless-lazy’ ‘Careless Max’

Weight 1.3 kg 2.07 kg 3.08 kg

Median 2.60€ Median 2.14€ Median 6.16€

Min 0.86–max 7.28 € Min 1.37–max 11.59 € Min 2.03–max 17.25 €

Median 3.48 $ Median 2.86 $ Median 8.25 $

Min 1.15–max 9.75 $ Min 1.83–max 15.52 $ Min 2.72–max 23.09 $

Bellco Formula HFR

Policy ‘Careful-optimal’ ‘Careful-lazy’ ‘Careless-lazy’ ‘Careless Max’

Weight 1.87 kg 1.97 kg 2.30 kg 7.67 kg

Median 3.74€ Median 3.94€ Median 2.60€ Median 15.34€

Min 1.23–max 10.41 € Min 1.30–max 11.03 € Min 1.52–max12. 88 € Min 5.06–max 42.95 €

Min 1.65–max 13.93 $ Min 1.74–max 15.13$ Min 2.03–max 17.24 $ Min 6.78–max 57.50 $ HD, bicarbonate haemodialysis; HFR, haemodiaﬁltration with reinfusion.

The range of costs is calculated taking into account the median, minimum and maximum cost of hazardous waste disposal in our region (Piedmont, northern Italy). Conversion Euro-USD: 1.339 at 1 August 2014.

F I G U R E 2 : The per cent distribution of the potentially recyclable or reusable plastic material derived from non-hazardous dialysis waste.

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Indeed, recycling and reducing waste production follows a cradle-to-grave process that limits the amount of waste pro-ducts on the basis of the analysis of a linear production (from cradle-to-grave): a well-designed product will produce less waste (for example by optimizing packaging) or be recyclable (for example by avoiding the use of different types of plastic in the same device). While great advances could be attained relatively easily through more careful attention by manufac-turers, the result is quantitative (reducing the waste), but the basic problem remains unsolved.

Conversely, the cradle-to-cradle model presents a more

chal-lenging, but also potentially deﬁnitive solution, for which each

product is designed to be reused for endless cycles (such as the paper in the Cradle to Cradle North Point Press edition), to be upgraded by replacing part of the hardware (an idea applicable to cars, as well as to dialysis machines) and to be re-divided into the original materials that can enter the production process

again and again [39]. An analysis of the employed materials

is aﬁrst step for both processes; however, the main message

of the cradle-to-cradle model is that reducing waste, albeit use-ful, will never be a solution, and that a completely new way of

‘rethinking things’ is urgently needed [39].

The main novelty of our study is that it combines aﬁnancial

analysis and an ecologic assessment of the potential for recyc-ling dialysis supplies.

The main limitation is that it only includes few dialysis ma-chines, hence somehow limiting the generalization of the re-sults. This is, however, to the best of our knowledge, the only study considering and comparing several types of dialysis

ma-chines [30]. In this regard, the present study may offer an

ana-lytical frame, following the various phases of dialysis, to be implemented with other machines or disposables, thus increas-ing our knowledge on this issue. Furthermore, calculatincreas-ing the potential savings must be carried out using the local data of the cost of waste disposal that, as we have discussed, may vary greatly even within the same region; once more, our study may provide a model for further analyses.

Greater attention to these‘hidden’ dialysis costs may become

an important tool for balancing and limiting theﬁnancial

dif-ferences in aﬁeld that has tremendous political implications

which are largely beyond the scope of this paper [58–60].

CON C LU SI ON S

Waste disposal is a crucial issue in dialysis. Theﬁnancial

impli-cations are enormous and acknowledging them may result in

important savings at‘zero cost’ in terms of quality of care, a

cru-cial issue in these times of economic crisis in which we must face the growing needs of an aging population.

The ecological implications, which require closer

cooper-ation with experts in manyﬁelds and with the manufacturers,

are likewise remarkable: less than 30% of the plastic disposables are recyclable and, to date, none is reusable. Greater attention to, and better cooperation with, the industry on these rather ne-glected aspects of dialysis treatment may increase the sustain-ability of renal replacement therapy on our endangered planet.

AC KN OW L E DG E ME NTS

Preliminary data in abstract form were presented at the 51st ERA.EDTA Congress in Amsterdam 2014. It received a young investigator award (to M.F.). We thank Valerie Perricone for her precious language editing.

CO NF LI CT OF I NTE R E S T

The results presented in this paper have not been published pre-viously in whole or part, except in abstract format. None of the authors has any conﬂict of interest.

R E F E R E N C E S

1. American Society of Nephrology (ASN).‘Prevalence of kidney failure treat-ment is skyrocketing worldwide’. ScienceDaily. 7 November 2013.www. sciencedaily.com

2. Agar JW. Personal viewpoint: hemodialysis—water, power, and waste dis-posal: rethinking our environmental responsibilities. Hemodial Int 2012; 16: 6–10

3. Tarrass F, Benjelloun M, Benjelloun O. Water Conservation: an emerging but vital issue in hemodialysis therapy. Blood Purif 2010; 30: 181–185 4. Agar JW. Conserving water in and applying solar power to haemodialysis:

‘green dialysis’ through wiser resource utilization. Nephrology (Carlton) 2010; 15: 448–453

5. Agar JW. It is time for‘green dialysis’. Hemodial Int 2013; 17: 474–478 6. Agar JW, Perkins A, Tjipto A. Solar-Assisted Hemodialysis. Clin J Am Soc

Nephrol 2012; 7: 310–314

7. Agar JW, Simmonds RE, Knight R. Using water wisely: new, affordable, and essential water conservation practices for facility and home hemodialysis. Hemodial Int 2009; 13: 32–37

8. Agar JW. Reusing dialysis wastewater: the elephant in the room. Am J Kid-ney Dis 2008; 52: 10–12

9. Burnier M, Martin PY. Nephrology between economy and ecology. Rev Med Suisse 2013; 9: 443–444

10. Connor A, Milne S, Owen A. Toward greener dialysis: a case study to illus-trate and encourage the salvage of reject water. J Ren Car. 2010; 36: 68–72 11. Ponson L, Arkouche W, Laville M. Toward green dialysis: focus on water

savings. Hemodial Int 2014; 18: 7–14

12. Tarrass F, Benjelloun M. The effects of water shortages on health and human development. Perspect Public Health 2012; 132: 240–244 13. Tarrass F. Research needs: treatment of hemodialysis wastewater for

agricul-tural reuse. Water Environ Res 2010; 82: 291–293

14. Tarrass F, Benjelloun M, Benjelloun O. Recycling wastewater after hemodi-alysis: an environmental analysis for alternative water sources in arid re-gions. Am J Kidney Dis 2008; 52: 154–158

15. Kastl J, Himstedt T, Boccato C et al. Water saving in dialysis care through the consequent use of an environmental management system. Blood Purif 2011; 32: 143

16. Eleyan D, Al-Khatib IA, Garﬁeld J. System dynamics model for hospital waste characterization and generation in developing countries. Waste Manag Res 2013; 31: 986–995

17. Guerrero LA, Maas G, Hogland W. Solid waste management challenges for cities in developing countries. Waste Manag 2013; 33: 220–232

18. McGain F, Naylor C. Environmental sustainability in hospitals - a system-atic review and research agenda. J Health Serv Res Policy 2014; 19: 245–252 19. Diaz LF, Eggerth LL, Enkhtsetseg SH et al. Characteristics of healthcare

wastes. Waste Manag 2008; 28: 1219–1226

20. Johnson SS. Medical waste disposal rules expected in 1989. JAMA 1988; 260: 2784

21. Walkinshaw E. Medical waste-management practices vary across Canada. CMAJ 2011; 183: E1307–E1308

ORIGINAL

ARTICLE

(10)

22. Walkinshaw E. Too much of a good thing? CMAJ 2011; 183: E1309–E1310 23. Kühling JG, Pieper U. Management of healthcare waste: developments in Southeast Asia in the twenty-ﬁrst century. Waste Manag Res 2012; 30(9 Suppl): 100–104

24. www.who.int(1 July 2014, date last accessed)

25. www.regionepiemonte.it(1 July 2014, date last accessed)

26. Cheng YW, Li KC, Sung FC. Medical waste generation in selected clinical facilities in Taiwan. Waste Manag 2010; 30: 1690–1695

27. Cheng YW, Sung FC, Yang Y et al. Medical waste production at hospitals and associated factors. Waste Manag 2009; 29: 440–444

28. Lee BK, MJ Ellenbecker MJ, Moure-Ersaso R. Alternatives for treatment and disposal cost reduction of regulated medical wastes. Waste Manag 2004; 24: 143–151

29. Hamoda M, El-Tomi N, Bahman QY. Variations in hospital waste quan-tities and generation rates. J Environ Sci Health 2005; A40: 467–476 30. Eker HH, Bilgili MS. Statistical analysis of waste generation in healthcare

services: a case study. Waste Manag Res 2011; 29: 791–796

31. James R. Incineration: why this may be the most environmentally sound method of renal health care waste disposal. J Ren Car. 2010; 36: 161–169

32. Connor A, Mortimer F, Tomson C. Clinical transformation: the key to green nephrology. Nephron Clin Pract 2010; 116: c200–c205

33. Connor A, Mortimer F. The green nephrology survey of sustainability in renal units in England, Scotland and Wales. J Ren Care 2010; 36: 153–160 34. Piccoli GB. Spending review, personal view, water and waste in (home)

hemodialysis. G Ital Nefrol 2014; 31. pii: gin/31.1.3

35. Lim AE, Perkins A, Agar JW. The carbon footprint of an Australian satellite haemodialysis unit. Aust Health Rev 2013; 37: 369–374

36. Hoenich NA, Pearce C. Medical waste production and disposal arising from renal replacement therapy. Adv Ren Replace Ther 2002; 9: 57–62 37. Hoenich NA, Levin R, Pearce C. Clinical waste generation from renal units:

implications and solutions. Semin Dial 2005;18: 396–400

38. Jabrane M, Fadili W, Kennou B et al. Evaluation of the impact of a hemo-dialysis center on environment and local ecology. Nephrol Ther 2013; 9: 481–485

39. Directive 2008/98/EC of The European Parliament and of The Council of 19 November 2008 on waste and repealing certain Directives. Available at

www.eur-lex.europa.eu( page:http://eur-lex.europa.eu/legal-content/EN/ TXT/?uri=CELEX:32008L0098) (30 December 2014, date last accessed) 40. McDonough W. Cradle to Cradle: Remarking the Way We Make Things.

New York, USA: North Point Press, 2002

41. Forbes P. The Gecko’s Foot: how Scientists are Taking Leaf From Nature’s Book. London: Harper Collins, 2005

42. A guide to the Hazardous Waste Regulations and the List of Waste Regula-tions in England and Wales (Environmental Agency). available at.www. hazwasteonline.com(30 December 2014, date last accessed)

43. Hatti-Kaul R, Törnvall U, Gustafsson L et al. Industrial biotechnology for the production of bio-based chemicals—a cradle-to-grave perspective. Trends Biotechnol 2007; 25: 119–124

44. Ignatyev IA, Thielemans W, Vander Beke B. Recycling of polymers: a re-view. Chem Sus Chem 2014; 7: 1579–1593

45. Al-Salem SM, Lettieri P, Baeyens J. Recycling and recovery routes of plastic solid waste (PSW): a review. Waste Manag 2009; 29: 2625–2643 46. Hopewell J, Dvorak R, Kosior E. Plastics recycling: challenges and

oppor-tunities. Philos Trans R Soc Lond B Biol Sci 2009; 364: 2115–2126 47. Hutchinson TA. The price and challenges of extraordinary success: treating

end-stage renal failure in the next millennium. CMAJ 1999; 160: 1589–1590 48. Andersen MJ, Friedman AN. The comingﬁscal crisis: nephrology in the

line ofﬁre. Clin J Am Soc Nephrol 2013; 8: 1252–1257

49. Rubin RJ. Understanding Washington: a nephrologist’s perspective from inside the Beltway. Am J Kidney Dis 2013; 62: 1042–1045

50. James R. Dialysis and the environment: comparing home and unit based haemodialysis. J Ren Care 2007; 33: 119–123

51. Machado CK, Pinto LH, Del Ciampo LF et al. Potential environmental tox-icity from hemodialysis efﬂuent. Ecotoxicol Environ Saf 2014; 102: 42–47 52. Park LK. Guidelines on disposing of medical waste in the dialysis clinic.

Ne-phrol News Issues 2002; 16: 16–17

53. Vanholder R, Davenport A, Hannedouche T et al. Dialysis Advisory Group of American Society of Nephrology. Reimbursement of dialysis: a compari-son of seven countries. J Am Soc Nephrol 2012; 23: 1291–1298

54. Berger A, Edelsberg J, Inglese GW et al. Cost comparison of peritoneal dia-lysis versus hemodiadia-lysis in end-stage renal disease. Am J Manag Care 2009; 15: 509–518

55. Icks A, Haastert B, Gandjour A et al. Costs of dialysis—a regional population-based analysis. Nephrol Dial Transplant 2010; 25: 1647–1652 56. www.greendialysis.org. ofﬁcial site of Green dialysis (lead Authors: John

Agar and Antony Perkins) (30 December 2014, date last accessed) 57. European Topic Centre on Sustainable Consumption and Production.

De-cember 2009 EEA Project Manager: Lars Mortensen (Prepared by: Mont O, Power K). available at.www.scp.eionet.europa.eu(30 December 2014, date last accessed)

58. Miranda ML, Hale B. Waste not, want not: the private and social costs of waste-to-energy production. Energy Policy 1997; 25: 587–600

59. Barba M, Mazza A, Guerriero C et al. Wasting lives: the effects of toxic waste exposure on health. The case of Campania, Southern Italy. Cancer Biol Ther 2011; 12: 106–111

60. Europol Agency (European Union’s law enforcement agency) on illegal waste: available at. www.europol.europa.eu/content/simplenews/ europol-warns-increase-illegal-waste-dumping-1057(30 December 2014, date last accessed)

Received for publication: 2.11.2014; Accepted in revised form: 16.1.2015

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