Environmentally sustainable design guide for haemodialysis facilities: An Australian and New Zealand society of Nephrology initiative.

Haemodialysis facilities have a large environmental impact due to high energy, water and consumable usage by haemodialysis equipment. As climate change and natural resource scarcity escalate, all the while the number of people requiring dialysis increases, there is an urgent need for dialysis facilities that meet care needs while minimising environmental impact. To address this, the Australian and New Zealand Society of Nephrology engaged an environmental sustainability consulting practise to develop a best practise guide for the environmentally sustainable design and operation of haemodialysis facilities. Four opportunity areas were considered, namely energy, water, waste and resource recovery, and additional sustainability. A total of 28 environmental improvement initiatives were identified. The majority (n = 23) were general measures that could be applied across all healthcare settings, while five were specific to haemodialysis facilities. Recommendations were made regarding specific measures that should be undertaken and/or standards that must be met to achieve the intent of each initiative. These were stratified to enable their application to both existing dialysis facilities and new builds. The lifecycle stage of a haemodialysis facility to which each initiative applied was highlighted, as was its potential impact. This guide provides a tailored and comprehensive resource for the kidney care community to enable the integration of best practise sustainability considerations into both existing and new facilities. If broadly implemented, it has the potential to markedly improve the environmental impact of haemodialysis provision.

The Carbon Footprint of Peritoneal Dialysis in Australia.

BACKGROUND: As climate change escalates with increasing health impacts, healthcare must address its carbon footprint. A critical first step is understanding the sources and extent of emissions from commonly utilised clinical care pathways. METHODS: We used attributional process-based life cycle analysis to quantify CO2 equivalent emissions associated with the delivery of Baxter home automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) in Australia. RESULTS: Annual per patient carbon emissions attributable to the manufacture and disposal of PD fluids and consumables were 1,992 kg CO2equivalent emissions for APD and 1,245 kg CO2equivalent emissions for CAPD. Transport impacts varied depending on the distance between site of manufacture of PD fluids and consumables and the home state of the patient. As a result, the total impact of providing PD also differed by Australian state, ranging from 2,350-4,503 kg CO2 equivalent emissions for APD and from 1,455-2,716 kg CO2 equivalent emissions for CAPD. Recycling of polyvinyl chloride (PVC) could reduce emissions by up to 14 per cent for APD and 30 per cent for CAPD, depending on the distance between the site of PVC waste generation and the recycling centre. CONCLUSIONS: This study demonstrated higher per patient carbon emissions from APD compared to CAPD, due to both higher fluid and consumable requirements, and the consequent higher transport impacts. PVC recycling can partially mitigate PD associated carbon emissions.

Our shared responsibility: the urgent necessity of global environmentally sustainable kidney care.

In response to Earth's accelerating climate crisis, we, an international group of nephrologists, call on our global community to unite and align kidney care in accordance with United Nation's 26th Conference of the Parties health sector principles. We announce a global and inclusive initiative, "GREEN-K": Global Environmental Evolution in Nephrology and Kidney Care, with a vision of "sustainable kidney care for a healthy planet and healthy kidneys" and mission to "promote and support environmentally sustainable and resilient kidney care globally through advocacy, education, and collaboration." A patient-centric approach that permits climate change mitigation and adaptation is proposed. Multi-stakeholder GREEN-K action and focus areas will include education, sustainable clinical care, and advances toward environmentally sustainable innovations, procurement, and infrastructure. Mindful of the disproportionately high climate impact of kidney therapies, we welcome the opportunity to work together in shared accountability to patients and Earth's natural systems.

Important lack of difference in tacrolimus and mycophenolic acid pharmacokinetics between Aboriginal and Caucasian kidney transplant recipients.

AIM: To examine whether differences in tacrolimus and mycophenolic acid (MPA) pharmacokinetics contribute to the poorer kidney transplant outcomes experienced by Aboriginal Australians. METHODS: Concentration-time profiles for tacrolimus and MPA were prospectively collected from 43 kidney transplant recipients: 27 Aboriginal and 16 Caucasian. Apparent clearance (CL/F) and distribution volume (V/F) for each individual were derived from concentration-time profiles combined with population pharmacokinetic priors, with subsequent assessment for between-group difference in pharmacokinetics. In addition, population pharmacokinetic models were developed using the prospective dataset supplemented by previously developed structural models for tacrolimus and MPA. The change in NONMEM objective function was used to assess improvement in goodness of model fit. RESULTS: No differences were found between Aboriginal and Caucasian groups or empirical Bayes estimates, for CL/F or V/F of MPA or tacrolimus. However, a higher prevalence of CYP3A5 expressers (26% compared with 0%) and wider between-subject variability in tacrolimus CL/F (SD = 5.00 compared with 3.25 L/h/70 kg) were observed in the Aboriginal group, though these differences failed to reach statistical significance (p = .07 and p = .08). CONCLUSION: There were no differences in typical tacrolimus or MPA pharmacokinetics between Aboriginal and Caucasian kidney transplant recipients. This means that Bayesian dosing tools developed to optimise tacrolimus and MPA dosing in Caucasian recipients may be applied to Aboriginal recipients. In turn, this may improve drug exposure and thereby transplant outcomes in this group. Aboriginal recipients appeared to have greater between-subject variability in tacrolimus CL/F and a higher prevalence of CYP3A5 expressers, attributes that have been linked with inferior outcomes.

Comparison of free plasma versus saliva mycophenolic acid exposure following mycophenolate mofetil administration in adult kidney transplant recipients.

Therapeutic monitoring (TDM) of mycophenolic acid (MPA) has the potential to improve drug inefficacy and toxicities in kidney transplantation. However, measurement of plasma MPA concentrations is laborious and invasive. This study examined the utility of saliva compared with plasma based TDM of MPA. Paired blood and saliva samples were collected from 47 adult kidney transplant recipients pre- and at 1-, 2-, and 4-hours post mycophenolate mofetil administration. No relationship was observed between saliva MPA concentrations and either total or free plasma MPA concentrations (p > 0.05). This suggests that saliva is a poor direct marker of plasma MPA concentrations and therefore should not be used for MPA TDM.

Prolonged immunosuppression does not improve risk of sensitization or likelihood of retransplantation after kidney transplant graft failure.

The optimum approach towards immunosuppression withdrawal following kidney transplant failure is unclear. Prolonged weaning may be associated with reduced sensitization, less graft nephrectomy and greater likelihood of retransplantation, but conversely increased risk of infection, malignancy and death. We conducted a single-centre retrospective analysis of patients experiencing graft failure between 2007 and 2017, comparing rates of sensitization, retransplantation, nephrectomy, infection, malignancy and death between patients who had immunosuppression weaned over <90 vs. 90-180 vs. >180 days. Patient survival after immunosuppression withdrawal over <90 vs. 90-180 vs. >180 days was 73.3%, 72.1% and 80.4%, respectively (P = 0.35), with no differences in cPRA (80.06 vs. 81.21 vs. 85.42, P = 0.66) or retransplantation rate [24/31 (77.4%) vs. 21/35 (60.0%) vs. 22/36 (61.1%), P = 0.13]. There was significantly less nephrectomy after late immunosuppression cessation [10/42 (23.8%) vs. 7/42 (16.7%) vs. 3/43 (7.0%), P = 0.01] but no differences in infections or malignancy. On competing risk regression (death as competing risk) controlling for cofactors including age, nephrectomy and rejection, prolonged immunosuppression did not predict likelihood of retransplantation (SHR 1.000, P = 0.88). Prolonged immunosuppression withdrawal does not reduce sensitization or improve retransplantation rates but is associated with less nephrectomy. Immunosuppression withdrawal should be tailored to individual circumstances after graft failure.

Kidney transplant recipient perspectives on telehealth during the COVID-19 pandemic.

The COVID-19 pandemic has challenged the delivery of health services. Telehealth allows delivery of care without in-person contacts and minimizes the risk of vial transmission. We aimed to describe the perspectives of kidney transplant recipients on the benefits, challenges, and risks of telehealth. We conducted five online focus groups with 34 kidney transplant recipients who had experienced a telehealth appointment. Transcripts were thematically analyzed. We identified five themes: minimizing burden (convenient and easy, efficiency of appointments, reducing exposure to risk, limiting work disruptions, and alleviating financial burden); attuning to individual context (depending on stability of health, respect patient choice of care, and ensuring a conducive environment); protecting personal connection and trust (requires established rapport with clinicians, hampering honest conversations, diminished attentiveness without incidental interactions, reassurance of follow-up, and missed opportunity to share lived experience); empowerment and readiness (increased responsibility for self-management, confidence in physical assessment, mental preparedness, and forced independence); navigating technical challenges (interrupted communication, new and daunting technologies, and cognizant of patient digital literacy). Telehealth is convenient and minimizes time, financial, and overall treatment burden. Telehealth should ideally be available after the pandemic, be provided by a trusted nephrologist and supported with resources to help patients prepare for appointments.

Green nephrology.

Clear evidence indicates that the health of the natural world is declining globally at rates that are unprecedented in human history. This decline represents a major threat to the health and wellbeing of human populations worldwide. Environmental change, particularly climate change, is already having and will increasingly have an impact on the incidence and distribution of kidney diseases. Increases in extreme weather events owing to climate change are likely to have a destabilizing effect on the provision of care to patients with kidney disease. Ironically, health care is part of the problem, contributing substantially to resource depletion and greenhouse gas emissions. Among medical therapies, the environmental impact of dialysis seems to be particularly high, suggesting that the nephrology community has an important role to play in exploring environmentally responsible health-care practices. There is a need for increased monitoring of resource usage and waste generation by kidney care facilities. Opportunities to reduce the environmental impact of haemodialysis include capturing and reusing reverse osmosis reject water, utilizing renewable energy, improving waste management and potentially reducing dialysate flow rates. In peritoneal dialysis, consideration should be given to improving packaging materials and point-of-care dialysate generation.

Telehealth model of care for routine follow up of renal transplant recipients in a tertiary centre: A case study.

Royal Melbourne Hospital (RMH) performs over 140 kidney transplant operations annually. Kidney transplant recipients require regular medical review, which results in loss of time and costs from travel, particularly for regional patients, and places high demand on the hospital outpatient service. The RMH renal transplant unit initiated a telehealth service in 2016 to provide cost effective, patient-centred clinical care for regional patients. To date, 263 clinical reviews have been conducted via telehealth, potentially saving 203,202 kilometres in travel distance; 2771 hours in car travel time; an estimated AUD $31,048 in petrol savings and 51 tonnes CO2 equivalents of greenhouse gas emissions. Lessons learnt have included the importance of using technology that allows patients to access telehealth from their place of choice. The option of a joint consultation with local healthcare providers has facilitated the development of extended care networks for our patients. Incorporation of telehealth into our outpatient system has been achieved with the existing nephrology workforce, making it a sustainable long-term review option. Our renal transplant telehealth outpatient clinic has been a successful change in the way we provide care to regional patients. Formal comparison of clinical outcomes and the patient experience of telehealth versus in person reviews are underway.

Optimizing Mycophenolic Acid Exposure in Kidney Transplant Recipients: Time for Target Concentration Intervention.

The immunosuppressive agent mycophenolate is used extensively in kidney transplantation, yet dosing strategy applied varies markedly from fixed dosing ("one-dose-fits-all"), to mycophenolic acid (MPA) trough concentration monitoring, to dose optimization to an MPA exposure target (as area under the concentration-time curve [MPA AUC0-12]). This relates in part to inconsistent results in prospective trials of concentration-controlled dosing (CCD). In this review, the totality of evidence supporting mycophenolate CCD is examined: pharmacological characteristics, observational data linking exposure to efficacy and toxicities, and randomized controlled trials of CCD, with attention to dose optimization method and exposure achieved. Fixed dosing of mycophenolate consistently leads to underexposure associated with rejection, as well as overexposure associated with toxicities. When CCD is driven by pharmacokinetic calculation to a target concentration (target concentration intervention), MPA exposure is successfully controlled and clinical benefits are seen. There remains a need for consensus on practical aspects of mycophenolate target concentration intervention in contemporary tacrolimus-containing regimens and future research to define maintenance phase exposure targets. However, given ongoing consequences of both overimmunosuppression and underimmunosuppression in kidney transplantation, impacting short- and long-term outcomes, these should be a priority. The imprecise "one-dose-fits-all" approach should be replaced by the clinically proven MPA target concentration strategy.