Green dialysis: A sustainable model from Sur hospital’s new renal dialysis unit, Oman

Water consumption

A single conventional hemodialysis session requires approximately 400–500 L of water, with only about 40% directly used for dialysate production. When extrapolated to the global dialysis population of nearly 3 million patients, annual water consumption reaches an estimated 156 billion liters. This massive water footprint is particularly concerning given that many regions with growing dialysis needs face water scarcity challenges.^[6]

Energy consumption

A typical dialysis session consumes between 15 and 20 kWh of electricity, resulting in approximately 3,000–4,000 kWh annually per patient. Globally, this amounts to approximately 62 billion kWh of power consumption by dialysis services each year. This energy demand has significant implications for both operational costs and carbon emissions (especially in areas that depend on fossil fuels for electricity generation). In addition, the need for uninterrupted power supply systems to prevent treatment disruptions during outages further increases energy requirements and infrastructure costs.^[6,7]

Waste generation

Each hemodialysis session generates approximately 2 kg of clinical waste, mainly plastic-based. For a patient receiving thrice-weekly treatments, this amounts to over 300 kg of waste annually. The global dialysis population generates an estimated 625,000 tons of plastic waste each year, which presents particular challenges for disposal due to its classification as biohazardous material, often preventing recycling and necessitating incineration or specialized landfill disposal. The environmental impact extends beyond the waste itself to include the carbon emissions associated with its production, transportation, and disposal.^[8]

Carbon footprint

The healthcare sector accounts for approximately 4.4% of global greenhouse gas emissions, with nephrology services representing a disproportionate share due to their resource-intensive nature. Recent life-cycle assessments estimate that a single in-center hemodialysis session produces approximately 7–10 kg of carbon dioxide equivalent (CO_2e) emissions. For a patient receiving thrice-weekly treatments, this translates to 1.1–1.5 tons of CO₂e annually.^[9]

Economic implications

High water and energy consumption during conventional dialysis translate directly to operational costs, which are projected to increase as resource scarcity intensifies. Waste management costs are similarly substantial, particularly for biohazardous materials requiring specialized disposal.

The National Health Service (NHS) analysis determined that by implementing sustainable practices, potential savings of £7 million in costs, 11,000 tons of CO₂e, and 470 million liters of water could be achieved. This suggests that environmental sustainability in dialysis is not only an ethical but also a financial necessity.^[10]

Water conservation strategies

Water conservation in dialysis begins with recognizing that reverse osmosis (RO) rejects water – typically discarded as waste – that meets all World Health Organization criteria for potable water. Innovative facilities have implemented systems to capture and repurpose this resource, significantly reducing water consumption [Figure 1].

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Figure 1:

Uses of water excreted in dialysis.

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Some facilities have implemented more advanced water reclamation systems that recycle dialysis effluent water through additional purification processes, further reducing freshwater requirements. These systems can achieve water savings of up to 80% compared to conventional dialysis setups.^[6]

For home-based dialysis patients, simple collection systems allow reject water to be repurposed for domestic utilities, gardens, and animal watering. This not only reduces environmental impact but also mitigates the financial burden of increased water bills associated with home dialysis.^[12]

Energy efficiency approaches

Energy efficiency in dialysis encompasses both technological innovations and operational strategies. Solar power integration represents a promising approach so that in regions with abundant sunlight, such as Oman, solar power can significantly offset the energy demands of dialysis facilities. Hence, some centers have established grid-share arrangements that not only reduce operational costs but can potentially generate revenue by feeding excess electricity back to the national grid during periods of low dialysis activity.^[13]

Additional energy efficiency measures include:

• Heat recovery systems that capture and repurpose waste heat from dialysis machines

• Light-emitting diodes (LED) lighting and motion sensors to reduce unnecessary electricity consumption

• Energy-efficient heating, ventilation, and air conditioning systems with intelligent controls to optimize climate conditions

• Scheduling dialysis sessions to align with periods of lower electricity costs or higher renewable energy availability.

These approaches can collectively reduce energy consumption by up to 30%.^[14]

Waste reduction and management

Waste reduction strategies in green nephrology focus on minimizing waste generation and improving the management of unavoidable waste streams [Table 1].

Some facilities have reduced plastic waste by up to 65% through comprehensive waste management programs.^[14] These initiatives not only reduce environmental harm but also reduce medical waste disposal costs and save money.

The concept of “circular economy” is increasingly applied to dialysis; this approach shifts the paradigm from a linear “take-make-dispose” model to a circular system where materials are recovered and repurposed.^[15]

Metrics for measuring environmental impact in healthcare

Standardized metrics are essential for assessing environmental performance and tracking improvements over time. Regular monitoring and reporting of these indicators enable facilities to track progress, set targets, and demonstrate commitment to environmental stewardship [Table 3].^[18]

Application of standards to dialysis facilities

Integrating sustainability standards into dialysis facility design, construction, and operation represents a significant opportunity to reduce environmental impact while potentially enhancing care quality and operational efficiency. As these standards evolve, they will increasingly incorporate dialysis-specific considerations, providing clearer pathways for renal care providers to advance environmental sustainability.^[19]

Background and context

The South Ash Sharqiyah Governorate of Oman has witnessed a steady increase in ESKD patients, reflecting global trends in the rising prevalence of CKD. Sur hospital’s original dialysis unit, initially equipped with 8 dialysis beds, expanded to 14 beds due to growing demand but continued to face capacity constraints [Tables 4 and 5].

This situation prompted healthcare planners to conceptualize a future-ready, sustainable dialysis facility to meet current needs while accommodating projected growth. The planning process incorporated clinical and environmental requirements, recognizing the relevance of sustainability in a region facing water scarcity and high energy demands.

The project received funding from the Al Jisr Foundation, demonstrating the role of public-private partnerships in advancing sustainable healthcare infrastructure in Oman. By serving local dialysis patients of the South Ash Sharqiyah Governorate, the facility also reduces the environmental impact associated with patient travel to distant treatment centers. This localization of care represents an often-overlooked aspect of healthcare sustainability, reducing transportation emissions while improving patient quality of life.

Innovative technologies and approaches at Sur hospital’s RDU

Waste reduction strategies

Sur hospital’s green RDU implements comprehensive waste reduction strategies addressing the substantial waste generation associated with conventional dialysis [Figure 3].

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Figure 3:

Waste reduction strategies. PVC: Polyvinyl chloride.

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These strategies aim to reduce waste generation by up to 65%, which aligns with results achieved at other environmentally optimized dialysis centers. The approach recognizes that waste reduction must be addressed throughout the product life-cycle, from procurement to disposal.

Building design innovations

The physical design of Sur hospital’s green RDU incorporates numerous innovations that enhance environmental performance while creating a healing environment for patients and staff [Figure 4]:

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Figure 4:

Building design innovations.

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Thermal efficiency is divided into two categories:

• Sustainable materials

  • Locally sourced stone and other building materials

  • Low volatile organic compounds finishes throughout to maintain indoor air quality

  • Durable flooring and surface materials to reduce replacement frequency

  • Recyclable and renewable materials where possible.

• Biophilic design elements:

  • Integration of natural elements and materials

  • Views of exterior green spaces from treatment areas

  • Indoor plants to improve air quality and create a calming environment

  • Water features utilizing recycled water to create a soothing soundscape.

These design innovations collectively create a facility that minimizes environmental impact and provides a more pleasant and therapeutic environment for patients undergoing dialysis treatments, which typically require several hours per session, multiple times per week.

Patient care quality metrics

The primary concern in any healthcare innovation is maintaining or enhancing the quality of patient care. Evidence from existing green dialysis implementations suggests that sustainable practices can be integrated without compromising clinical outcomes. Key quality metrics expected to be monitored at Sur hospital’s RDU include:

• Dialysis adequacy (Kt/V values)

• Infection rates

• Patient satisfaction scores

• Quality of life measures

• Hospitalization rates

• Mortality rates.

Preliminary data from other green dialysis facilities suggest that patients often report improved satisfaction with treatment environments that incorporate natural lighting, views of nature, and other sustainable design elements. The psychological benefits of receiving treatment in a facility visibly committed to environmental stewardship may also contribute to overall patient well-being .^[21]

Staff satisfaction and engagement

Healthcare worker satisfaction and engagement represent important indicators of facility success. Green healthcare facilities have demonstrated several benefits in this area:^[22]

• Reduced staff turnover rates

• Improved recruitment success

• Higher reported job satisfaction

• Greater engagement in quality improvement initiatives

• Reduced absenteeism.

At Sur hospital’s RDU, staff engagement in sustainability initiatives is being built into the operational model from the outset. Staff members receive training in the technical aspects of green dialysis systems and the environmental and health rationale behind these approaches. This comprehensive education aims to create a workforce that serves as sustainability ambassadors within the facility and the broader community.

Water usage reductions

• 70–80% reduction in net water consumption through RO reject water reuse

• Approximately 25 million liters of water are saved annually at full capacity

• Additional savings through water-efficient fixtures in non-clinical areas.

Energy savings

• 30–40% reduction in grid electricity consumption through solar power integration

• Estimated 500,000 kWh of clean energy is generated annually

• Additional savings through energy-efficient equipment and building systems.

Waste reduction measurements

• 60–65% reduction in plastic waste through recycling and material optimization

• 50–60% reduction in hazardous waste through improved segregation and handling

• Overall waste volume reduction of approximately 40 tons annually at full capacity.

  • These projections will be validated through comprehensive monitoring systems integrated into the facility’s operations. Regular reporting and analysis of resource consumption data will enable continuous improvement and optimization of sustainable practices.

Cost-benefit analysis

The economic dimensions of green dialysis are critical for demonstrating the viability and scalability of this approach. The cost-benefit analysis for Sur hospital’s RDU considers:

• Initial investment versus long-term savings:

  • Higher upfront capital costs for sustainable technologies and systems

  • Operational savings through reduced resource consumption

  • Maintenance considerations for specialized systems

  • Potential revenue from grid-share arrangements for solar electricity.

• Operational cost comparisons:

  • Utility cost reductions (water, electricity, waste disposal)

  • Potential staff productivity benefits

  • Reduced transportation costs through localized care

  • Potential lowering of inpatient hospitalization costs through improved care environment

Return on investment timeline

• Projected payback period of 7–10 years for significant sustainability investments

• Faster returns for certain elements (e.g., LED lighting, water conservation)

• Non-financial returns, including reputation enhancement and environmental benefits.

While the initial investment in sustainable technologies and systems exceeds that of conventional dialysis facilities, the projected operational savings and potential revenue streams create a compelling economic case for green dialysis. This financial viability is essential for demonstrating that environmental responsibility and economic goals can be complementary rather than competing priorities in healthcare delivery.

International Society of Nephrology’s GREEN-K initiative

The International Society of Nephrology (ISN) has taken a leadership role in advancing sustainable kidney care through its GREEN-K initiative. This program calls for developing climate-resilient kidney care systems that function through accountable, sustainable, low-carbon healthcare delivery.^[23]

Sorbent dialysis systems:

• Regenerate dialysate during treatment

• Reduce water consumption by up to 90%

• Particularly valuable for home dialysis and water-scarce regions^[19]

Biodegradable dialysis consumables:

• Development of bio-based polymers for dialysis tubing and components

• Reduced environmental impact at end-of-life

• Potential for composting rather than landfill or incineration^[26]

Wearable artificial kidneys:

• Miniaturized, portable dialysis systems

• Significantly reduced resource requirements

• Potential for improved patient quality of life and reduced environmental impact^[27]

Telehealth Integration:

• Remote monitoring to reduce unnecessary clinic visits

• Optimization of treatment parameters to improve efficiency

• Reduced transportation-related emissions

Sur hospital’s green RDU has been designed with the flexibility to incorporate these emerging technologies as they mature, ensuring that the facility remains at the forefront of sustainable kidney care throughout its operational life.^[28]

Research priorities in sustainable kidney care

The advancement of sustainable kidney care depends on robust research addressing key knowledge gaps. Priority research areas identified by the nephrology community include:

• Life-cycle assessments of dialysis technologies and consumables

• Clinical outcomes in green dialysis implementations

• Economic analyses of sustainable kidney care models

• Patient and provider perspectives on environmental sustainability in dialysis

• Adaptation strategies for different geographic and economic contexts.

Sur hospital’s green RDU presents an opportunity to contribute to this research agenda through systematic data collection and analysis. Collaboration with academic institutions and international organizations can facilitate the dissemination of findings and integration into the growing body of knowledge on sustainable kidney care.^[29]