eDIGEST: ISN Journals

October 2023 Edition

Impact Factor 2022


Kidney International®


Kidney International Supplements®


Kidney International Reports®

Kidney International® presents a selection of recently published articles on ecological issues covering green nephrology, sustainable kidney care, water implications in dialysis therapy, and urine for use as a fertilizer.


Green Nephrology: A Series of Mini Reviews on Minimizing the Environmental Impact of Kidney Health Care

This editorial highlights action taken by Kidney International® to launch a series of mini-reviews dedicated to the topic of Green Nephrology. The aim is to increase awareness of the climate and environmental impact of health care among members of the nephrology community, conduct a deep dive into the relationship between kidney care and the environment, and promote environmentally friendly practices in nephrology.

The importance of green nephrology lies at the intersection of healthcare and environmental sustainability, transcending the conventional boundaries of medical practice. Green nephrology represents a conscientious commitment to reducing the ecological footprint of kidney care while improving patient outcomes.

In a world grappling with climate change and resource scarcity challenges, this approach is commendable and imperative. With its substantial energy and water consumption, the kidney healthcare sector generates a significant environmental impact. Embracing green nephrology involves adopting eco-friendly practices in managing chronic kidney diseases, dialysis, and transplantation.

This not only conserves resources but also enhances patient care by promoting holistic well-being. By reducing waste, optimizing water and energy use, and minimizing carbon emissions, green nephrology contributes to a healthier planet and fosters a more sustainable healthcare system, ultimately benefiting both current and future generations.

These reviews highlight healthcare professionals’ crucial role in addressing the global environmental crisis and embody the philosophy that caring for the environment is inextricably linked to caring for our patients.

Read more

Our Shared Responsibility: The Urgent Necessity of Global Environmentally Sustainable Kidney Care

In this special report, this international group of nephrologists announces the “GREEN-K” initiative: Global Environmental Evolution in Nephrology and Kidney Care, with a vision of “sustainable kidney care for a healthy planet and healthy kidneys.”

They call for developing climate-resilient kidney care systems through accountable, sustainable, low-carbon health care. Their mission is to “promote and support environmentally sustainable and resilient kidney care through advocacy, education, and collaboration.”

They propose a pathway to achieve this goal through a global, collaborative, and inclusive multidisciplinary working group aligned with the United Nations 26th Conference of the Parties health sector principles.

A framework for providing environmentally sustainable quality kidney care across different stages of kidney disease is presented. The authors emphasize the need to prioritize health promotion, early detection and rigorous application of strategies to prevent disease progression, increased access to transplantation and low-carbon dialysis approaches. In addition, they outline a plan for the GREEN-K initiative, focusing on education, procurement, infrastructure and innovation, and sustainable clinical pathways in kidney care.

Read more

Water Implications in Dialysis Therapy, Threats and Opportunities to Reduce Water Consumption: A Call for the Planet

Water is a finite natural resource, and drinkable water is mistakenly regarded as being in infinite supply.

Hemodialysis therapy is a water-intensive, water-hungry treatment with potential environmental consequences.

The annual water consumption for hemodialysis is projected to be over 265 million m3 (resulting from 0.5 m3 each session for nearly 3.4 million patients, assuming they are treated for four hours, three times per week).

It is feasible to reshape hemodialysis from linear to circular by implementing the “3R” policy, which includes reducing or delaying the start of dialysis and incremental hemodialysis, and reusing and recycling reverse osmosis and wastewater.

To raise knowledge of the environmental impact of dialysis and facilitate targeted programs, healthcare employees and stakeholders must be educated. The systematic adoption of the “3R” strategy may result in environmental and economic savings, allowing the transition from a vicious to a virtuous circular water management.

Read more

Urine: From Waste to Fertilizer

The tremendous expansion in global population has boosted the need for mineral fertilizers to provide necessary food and shelter, which consumes 1.2% of global energy annually and increases man-made nitrogen load in the environment. The United Nations is at the forefront of efforts to reduce the nitrogen load in the environment.

The solution comes from our kidneys. Recycling urine or urine diversion (UD) to collect the key nutrients (Nitrogen, Phosphorus, and Potassium) for use as fertilizers saves water and reduces the burden on sewage systems and the environment.

Compared to conventional wastewater treatment systems, UD technologies are predicted to reduce greenhouse gas emissions by 29% to 47%, energy use by 26% to 41%, and freshwater use by almost half. Acceptance of urine-fertilized food is based mainly on rising knowledge of the worldwide challenge and social norms.

Read more

Recent publications in Kidney International Reports® discuss environmental changes, the effects of occupational heat stress on kidney health, and the relationship between seasons and kidney function in CKDu.


This review summarizes climate change’s known and anticipated effects on the environment, patterns of infectious diseases, and their impact on kidney health. These include gradual effects from increasing ambient temperatures and the results of sudden catastrophic weather events.

The authors describe how climate change and the accelerated loss of biodiversity, primarily due to human activities, disturb the balance of ecosystems on large and individual scales, leading to increased rates of infectious disease and shifts in their spectrum.

Conditions such as leptospirosis, mosquito-borne disease, Hantavirus renal syndrome, scrub typhus, schistosomiasis, and water-borne diseases with their implications on kidney health are discussed in more detail.

The review highlights the vulnerability of populations in low and lower-middle-income countries and the downward spiral perpetuated by ongoing environmental changes brought on by climate change in these regions.

The authors emphasize the need for a consistent and coordinated global effort to combat climate change and minimize and adapt to biodiversity loss.

Read more

Occupational heat stress has recently been linked to the development of chronic kidney disease (CKD). Many factors, such as exposure to high temperatures (outdoors and indoors), insufficient rehydration, strenuous work, and impaired heat dissipation, are associated with repeated acute kidney injury episodes. These episodes can result in abnormal repair mechanisms and lead to kidney fibrosis, vascular rarefaction, and glomerulosclerosis, and can eventually cause CKD.

Read more 

Could seasons influence kidney function? In this observational study by Arora et al., summers were associated with more acidosis, higher uric acid levels, low urine ammonium excretion, and increased angiotensinogen levels in patients with CKDu.

This is one of the very few studies to evaluate the relationship between season and kidney function in CKDu patients. Findings must be further studied in other populations and compared with healthy controls.

Read more

Heat stress is a hazardous occupational risk that demands our attention within kidney care. This editorial outlines the effect of heat stress on workers in a non-agricultural environment from India and discusses strategies for the future.

Vulnerable workers, such as those with pre-existing kidney conditions or undergoing kidney treatments, are particularly at risk due to their compromised ability to regulate body temperature and maintain hydration.

Heat stress occurs when the body’s internal cooling mechanisms, such as sweating and blood vessel dilation, become overwhelmed by prolonged exposure to high temperatures and humidity. This can lead to a dangerous rise in core body temperature.

For individuals with compromised kidney function, the consequences can be dire. When exposed to excessive heat, these individuals face an increased burden on their already weakened renal system. Heat stress can lead to dehydration, electrolyte imbalances, and reduced blood flow to the kidneys, exacerbating their conditions and potentially causing acute kidney injury.

Kidney healthcare professionals must be aware of their patients’ heightened heat stress risk. They should encourage preventive measures like hydration, cooling strategies, and work-rest schedules tailored to kidney health status to ensure their safety in the workplace.

Moreover, educating both workers and employers to recognize and mitigate these risks is paramount to preserving the well-being of vulnerable workers in industries with high heat exposure.

Read more

More evidence is available to support the detrimental effects of heat stress on renal function. A study including salt pan workers identified heat strain as a main agrochemical exposure leading to renal insufficiencies.

Workers exposed to increased workloads at high temperatures were more likely to develop low glomerular filtration rate and a lack of proteinuria. High rates of dehydration and possible dyselectrolytemia-related symptoms were also associated with heat stress exposure, affecting heart rates, urine specific gravity, serum creatinine and uric acid levels.

These findings raise concerns about the conditions of workers in high-temperature settings. They require frequent breaks, availability of clean drinking water, and safe and adequate sewage disposal.

The authors call for action for a sustainable work environment for the most vulnerable populations around the globe by providing essential basic human needs.

Read more View visual abstract