Sustainable and accessible hemodialysis: life cycle assessment on central acid delivery system | BMC Nephrology

Sustainability performance

This study conducted a full life cycle analysis comparing canister and centralized concentrate delivery systems. At the University Medical Center Utrecht (UMC Utrecht), switching from the canister to central delivery system cut carbon emissions by 58% through reduced transportation and packaging, demonstrating a clear improvement in sustainability. Given the proximity of the manufacturing site in Germany to the delivery location in the Netherlands, additional scenarios involving longer transport distances were modeled to improve generalizability of our findings. Even when delivered to the Philippines, the global warming potential of the central concentrate delivery system remained relatively low, underscoring its environmental advantage. However, at extreme transport distances, some of the benefits of centralized delivery are offset by the increased environmental impacts associated with long-haul shipping. Container ships are major polluters, contributing substantially to acidification and particulate pollution [30]. As a result, when transported over very long distances, the overall endpoint impacts of central delivery may approach those of canister systems delivered over shorter distances for hospitals situated near canister manufacturers.

The sensitivity analysis further underscores the critical role of container reuse. Impacts associated with the production and end-of-life treatment of plastics are substantially reduced through the return and reuse of containers, even when accounting for the additional transportation involved in return shipping over long distances. As shown in Fig. 5, without container reuse would increase the associated impacts for Kenya by nearly 20%, even when return shipping to Europe is excluded. This is because packaging reuse significantly reduces emissions by approximately one order of magnitude, assuming 15 cycles of reuse. In contrast, most transport related emissions originate from outbound shipments due to the greater weight of filled containers, while return trips with empty containers contribute minimally.

Improved accessibility

Access to dialysis remains critically limited in LMICs, where fewer than 10% of patients with end-stage kidney disease receive treatment due to economic, infrastructural, and logistical barriers [31, 32]. Central delivery systems offer practical advantages by significantly reducing the volume and weight of acid concentrate shipments, which can lower transportation costs and simplify logistics. Moreover, by promoting the local production of dialysates from dry concentrate, these systems can reduce reliance on imported pre-packaged solutions, fostering more resilient and self-sufficient dialysis infrastructure in resource-limited settings.

Clinical considerations

Beyond environmental gains, central delivery systems also enhance operational efficiency by minimizing manual handling and streamlining concentrate distribution, thereby reducing clinical staff burden and allowing greater focus on patient care. In UMC Utrecht, where acid concentrates are used for more than one patients, residue is minimal. However, in hospitals where residual acid is discarded, these systems provide additional benefit [25]. Maintenance requirements are minimal, with no routine disinfection and only a filter replacement every two years (~ 300 g) [33]. The concentrates have a long shelf life (12 months in dry form and up to 24 months after formulation), allowing for better stock management and reduced risk of supply shortages, especially in remote or high-volume centers [33].

Limitations

Capital goods such as manufacturing equipment and machinery were excluded due to data limitations and are commonly omitted in assessments in healthcare [34, 35]. However, their impact is expected to be low, given the high production volume at the manufacturing sites in Germany diluting their per-unit impact. Similarly, the centralized system at UMC Utrecht supports over 7,000 dialysis sessions annually and has a lifespan of at least 20 years minimizing its per-unit impact. Literature suggests capital goods typically contribute less than 10% of total environmental impact [27].

Water and electricity use was based on supplier data, with consumption for the canister system estimated as equivalent to the central concentrate system and scaled by weight. As raw chemical inputs drive most production impacts, the influence of water and energy use is minimal on the final results, as confirmed by sensitivity analysis.

End-of-life modeling assumed local recycling and excluded waste transport, negligible compared to the product transport from the manufacturer. While high recycling rates justify this assumption in the Netherlands, incineration was modeled in the sensitivity analysis to reflect regions with limited waste management infrastructure, such as LMICs. It showed only modest increases in impact: 5.3% (canister) and 0.4% (central delivery), suggesting that central delivery systems remain the more sustainable option also in settings with poor waste treatment infrastructure.

Future research

Implementing central delivery systems would require an additional investment, particularly in Europe, where most dialysis centers are built around canister systems. In contrast, in Japan, where central delivery systems are more widely adopted, both initial and maintenance costs are reported to be lower [22].

To support broader adoption, future research should assess the total cost of ownership, including procurement, labor, maintenance, repair, and end-of-life disposal, and integrate this with environmental analysis through life cycle assessment. Using methods such as environmental pricing [36] and cost-benefit analysis [37] would allow comparison of the social costs of central concentrate delivery and canister systems, supporting better decision making.

Particular attention is needed for LMICs, where healthcare systems may face higher financial and environmental burdens due to longer distances for technical support, limited local infrastructure, and increased vulnerability to system failures [38, 39]. While our analysis indicates that the central delivery system maintains favorable environmental performance even with long-distance transport, broader global implementation, especially LMICs, would likely require more local production of key components such as chemicals. This would reduce dependence on international supply chains and strengthen the long-term feasibility of the system.

While this study highlights the environmental benefits of central delivery systems, further work is needed to develop business models that incentivize adoption in both high- and low-resource settings. This includes financing strategies aligning hospital decision-making with long-term sustainability and ensuring manufacturer profitability in diverse global markets.