The healthcare sector contributes significantly to global emissions, accounting for more than 4% worldwide and up to 10% in some high-income countries. Hemodialysis (HD), a life-sustaining treatment for kidney failure, is among the most resource-intensive therapies due to its heavy use of energy, water, and single-use materials. In high-income countries, aging populations are increasing the prevalence of kidney disease, while in low-income settings, limited access to transplants often makes HD the only treatment. Reducing its environmental burden is therefore a global priority.
This thesis focuses on dialysate, the largest consumable in HD. The research begins by investigating current practices at UMC Utrecht and then evaluates two alternative technologies: (1) central delivery for concentrates and (2) forward osmosis (FO) for dialysate preparation.
The current system requires 41 tons of concentrates, 2.2 million liters of water, and 17 MWh of energy annually to treat 30 patients. Major environmental impacts arise from transport, packaging waste, and unused concentrate residues. In the water purification process, only about half of the input water becomes dialysate; the rest discharged as waste. Most of the energy is consumed by reverse osmosis (RO) pumps, which run continuously, even outside treatment hours. These inefficiencies result in 35 tons of CO₂-Eq emissions and €24,290 in annual environmental costs.
By transitioning to central concentrate delivery, UMC Utrecht reduced transport weight by 75%, plastic use by 95%, and acid concentrate-related emissions by 58%. Emissions were lowered by delivering dry powder instead of liquid and reusing packaging containers. The model performed well even over long distances, showing potential for global application.
FO, tested as an alternative to RO, achieved 90% water recovery and used only 4% of the energy. As a passive process, FO consumes far less energy than RO and shows strong promise for remote or resource-limited healthcare settings.
A future scenario combining both technologies was modeled, showing that carbon emissions could be cut to one-third of current levels and annual environmental costs halved to a €11,490. These outcomes align with Green Deal goals and highlight how circular strategies can reduce the environmental footprint of dialysis.
Importantly, many opportunities for improvement already exist without major technological investment. Hospitals are encouraged to reassess resource use. As seen at UMC Utrecht, turning off RO pumps outside treatment hours could already make a meaningful difference.
UMC Utrecht, as a leading academic hospital, is well positioned to drive this transition. Its example can inspire other institutions across Europe and globally. As demand for dialysis continues to grow, healthcare systems must rethink how essential treatments like HD are delivered. This thesis presents a clear, evidence-based approach to reduce environmental impact, increases resilience, and supports equitable access to treatment worldwide.