Green Nephrology and Eco-Dialysis Position Statement

Green Nephrology, Ecodialisi: parole o proposte?
Laudato si’, mi’ Signore, per sora nostra matre Terra, la quale ne sustenta et governa, et
produce diversi fructi con coloriti flori et herba

“La sﬁda urgente di proteggere la nostra casa
comune comprende la preoccupazione di unire tu5a
la famiglia umana nella ricerca di uno sviluppo
sostenibile e integrale, poiché sappiamo che le cose
possono cambiare.”
.”

Ques% problemi sono in%mamente lega% alla cultura dello scarto, che colpisce tanto
gli esseri umani esclusi quanto le cose che si trasformano velocemente in spazzatura.
Rendiamoci conto, per esempio, che la maggior parte della carta che si produce
viene ge<ata e non riciclata.
Sten%amo a riconoscere che il funzionamento degli
ecosistemi naturali è esemplare: le piante sinte%zzano
sostanze nutri%ve che alimentano gli erbivori; ques% a loro
volta alimentano i carnivori, che forniscono importan%
quan%tà di riﬁu% organici, i quali danno luogo a una nuova
generazione di vegetali.

Then there is another viewpoint, not
just a question of ethics but a
question of our own survival. The
environment is very important not
only for this generation but also for
future generations. If we exploit the
environment in extreme ways, even
though we may get some money or
other benefit from it now, in the long
run we ourselves will suffer and
future generations will suffer. (…)
When they change dramatically, the
economy and many other things
change as well. So this is not merely
a moral question but also a question
of our own survival.

… The free-rider problem is well-known to
generate the “tragedy of commons”, as
illustrated by a myriad of case studies in
other realms. When herders share a common
parcel of land on which their herds graze,
overgrazing is a standard outcome, because
each herder wants to reap the private benefit
of an additional cow without taking account
of the fact that what he gains is matched by
someone else’s loss. Similarly, hunters and
fishers do not internalize the social cost of
their catches; overhunting and overfishing
led to the extinction of species, from the
Dodo of the island of Mauritius to the bears
of the Pyrenees and of the buffalos of the
Great Plains.

rsta.royalsocietypublishing.org
Research
Cite this article: Stahel WR. 2013 Policy for
material efficiency—sustainable taxation as a
departure from the throwaway society. Phil
Trans R Soc A 371: 20110567.
http://dx.doi.org/10.1098/rsta.2011.0567
One contribution of 15 to a Discussion Meeting
Issue ‘Material efficiency: providing material
services with less material production’.
Subject Areas:
materials science
Keywords:
sustainable taxation, circular economy,
regional job creation, caring, reuse,
service-life extension
Author for correspondence:
Walter R. Stahel
e-mail: walter_stahel@genevaassociation.org
Policy for material
efficiency—sustainable
taxation as a departure from
the throwaway society
Walter R. Stahel
7 chemin des Vignettes, Conches 1231, Switzerland
The present economy is not sustainable with
regard to its per capita material consumption. A
dematerialization of the economy of industrialized
countries can be achieved by a change in course,
from an industrial economy built on throughput
to a circular economy built on stock optimization,
decoupling wealth and welfare from resource
consumption while creating more work. The business
models of a circular economy have been known since
the mid-1970s and are now applied in a number of
industrial sectors. This paper argues that a simple
and convincing lever could accelerate the shift to a
circular economy, and that this lever is the shift to a
tax system based on the principles of sustainability:
not taxing renewable resources including human
labour—work—but taxing non-renewable resources
instead is a powerful lever. Taxing materials and
energies will promote low-carbon and low-resource
solutions and a move towards a ‘circular’ regional
economy as opposed to the ‘linear’ global economy
requiring fuel-based transport for goods throughput.
In addition to substantial improvements in material
and energy efficiency, regional job creation and
national greenhouse gas emission reductions, such a
change will foster all activities based on ‘caring’, such
as maintaining cultural heritage and natural wealth,
health services, knowledge and know-how.
1. Introduction
Previous patterns of growth have brought
increased prosperity, but through intensive
and often inefficient use of resources. The
role of biodiversity, ecosystems and their
services is largely undervalued, the costs of
waste are often not reflected in prices, current
c
⃝ 2013 The Author(s) Published by the Royal Society. All rights reserved.
on March 27, 2016
http://rsta.royalsocietypublishing.org/
Downloaded from

Ma quel’è il ruolo della medicina e qual’è
il potere dei medici in questo campo?
Perchè scrivere un position statement sull’ecodialisi
e sulla green Nephrology?
Quale ruolo per la dialisi peritoneale?
Journal of Nephrology (2020) 33:681–698
https://doi.org/10.1007/s40620-020-00734-z
POSITION PAPERS AND GUIDELINES
Green nephrology and eco-dialysis: a position statement by the Italian
Society of Nephrology
Giorgina Barbara Piccoli1,2
· Adamasco Cupisti3
· Filippo Aucella4
· Giuseppe Regolisti5
· Carlo Lomonte6
·
Martina Ferraresi2
· D’Alessandro Claudia3
· Carlo Ferraresi7
· Roberto Russo8
· Vincenzo La Milia9
· Bianca Covella6
·
Luigi Rossi6
· Antoine Chatrenet1
· Gianfranca Cabiddu10
· Giuliano Brunori11
· On the Behalf of Conservative
treatment, Physical activity and Peritoneal dialysis project groups of the Italian Society of Nephrology
Received: 17 January 2020 / Accepted: 3 April 2020 / Published online: 15 April 2020
© The Author(s) 2020
Abstract
High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste
products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living
creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled
waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions,
the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring
for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which
produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable
materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the
position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden
of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting
drugs and favouring “natural” medicine focussing on lifestyle and diet; (3) encouraging the reuse of “household” hospital
material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing
energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and sup-
plies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly
approaches in the building of new facilities.
Keywords Dialysis · Ecology · Waste management · Sustainability · Pollution · Costs
* Giorgina Barbara Piccoli
gbpiccoli@yahoo.it
1
Nephrology, Centre Hospitalier Le Mans, Le Mans, France
2
Department of Clinical and Biological Sciences, University
of Torino, Turin, Italy
3
Department of Clinical and Experimental Medicine,
University of Pisa, Pisa, Italy
4
Nephrology and Dialysis Unit, IRCCS “Casa Sollievo Della
Sofferenza” Scientific Institute for Research and Health Care,
San Giovanni Rotondo, Italy
5
Department of Internal Medicine, Nephrology and Health
6
Division of Nephrology, Miulli General Hospital,
Acquaviva delle Fonti, Italy
7
Department of Mechanical and Aerospace, DIMEAS,
Politecnico of Torino, Turin, Italy
8
Nephology Unit. Azienda Ospedaliera Universitaria
Policlinico, Bari, Italy
9
Nephrology Unit. Hospital “A. Manzoni”, Lecco, Italy
10
Nephrology Unit. Hospital “G. Brotzu”, Cagliari, Italy
11
Nephrology and Dialysis Unit, Hospital of Trento, Trento,
Italy

Ma quel’è il ruolo della medicina e qual’è
il potere dei medici in questo campo?
non solo la tecnologia, anche la clinica....

CLINICA. LA PRIMA DELLE TRE “R”

Posi%on statement: outline: clinics
Towards personalised, non only pharmacologic approaches.
• Nutritional management in all CKD stages (healthy
eating habits, retarding dialysis, maintaining
nutritional status).
• Physical activity (idem plus reducing the pill
burden, improving quality of life).
• Choice of RRT; development of home dialysis;
implementation of incremental and tailored
schedules; optimisation of the access to kidney
transplantation (reducing the burden of dialysis,
reducing costs).

ridurre i
bisogni,
senza
ridurre i
risultati…
n engl j med 363;7 nejm.org august 12, 2010 609
The new england
journal of medicine
established in 1812 august 12, 2010 vol. 363 no. 7
A Randomized, Controlled Trial of Early versus Late
Initiation of Dialysis
Bruce A. Cooper, M.B., B.S., Ph.D., Pauline Branley, B.Med., Ph.D., Liliana Bulfone, B.Pharm., M.B.A.,
John F. Collins, M.B., Ch.B., Jonathan C. Craig, M.B., Ch.B., Ph.D., Margaret B. Fraenkel, B.M., B.S., Ph.D.,
Anthony Harris, M.A., M.Sc., David W. Johnson, M.B., B.S., Ph.D., Joan Kesselhut,
Jing Jing Li, B.Pharm., B.Com., Grant Luxton, M.B., B.S., Andrew Pilmore, B.Sc., David J. Tiller, M.B., B.S.,
David C. Harris, M.B., B.S., M.D., and Carol A. Pollock, M.B., B.S., Ph.D., for the IDEAL Study*
ABSTR ACT
From the Department of Renal Medicine,
Royal North Shore Hospital, Sydney Medi-
cal School (B.A.C., J.K., C.A.P.), the De-
partment of Nephrology, Children’s Hos-
pital at Westmead, Sydney School of
Public Health (J.C.C.), the School of Rural
Health, Sydney Medical School (D.J.T.),
the Centre for Transplantation and Renal
Research, Westmead Millennium Insti-
tute, University of Sydney (D.C.H.), and
the Department of Nephrology, Prince of
Wales Hospital, University of New South
Wales (G.L.) — all in Sydney; Monash
Medical Centre and Eastern Health Renal
Units, Melbourne (P.B.); the School of
Health and Social Development, Deakin
University, Burwood (L.B.); the Depart-
ment of Renal Medicine, Austin Hospital,
Heidelberg (M.B.F.); the Centre for Health
Economics, Monash University, Clayton
(A.H., J.J.L.); and the Centre for Kidney
Disease Research, University of Queens-
land at Princess Alexandra Hospital, Bris-
bane (D.W.J.) — all in Australia; and the
Department of Renal Medicine, Auckland
City Hospital, Auckland, New Zealand
(J.F.C., A.P.). Address reprint requests to
Dr. Cooper at the Department of Renal
Medicine, Royal North Shore Hospital,
St. Leonards, NSW 2065, Australia, or at
bcooper@med.usyd.edu.au.
*Participants in the Initiating Dialysis
Early and Late (IDEAL) Study are listed
in the Appendix.
This article (10.1056/NEJMoa1000552) was
published on June 27, 2010, at NEJM.org.
N Engl J Med 2010;363:609-19.
Copyright © 2010 Massachusetts Medical Society.
BACKGROUND
In clinical practice, there is considerable variation in the timing of the initiation of
maintenance dialysis for patients with stage V chronic kidney disease, with a world-
wide trend toward early initiation. In this study, conducted at 32 centers in Austra-
lia and New Zealand, we examined whether the timing of the initiation of mainte-
nance dialysis influenced survival among patients with chronic kidney disease.
METHODS
We randomly assigned patients 18 years of age or older with progressive chronic
kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and
15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the
Cockcroft–Gault equation) to planned initiation of dialysis when the estimated GFR
was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to
7.0 ml per minute (late start). The primary outcome was death from any cause.
RESULTS
Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years;
542 men and 286 women; 355 with diabetes) underwent randomization, with a me-
dian time to the initiation of dialysis of 1.80 months (95% confidence interval [CI],
1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the
late-start group. A total of 75.9% of the patients in the late-start group initiated
dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing
to the development of symptoms. During a median follow-up period of 3.59 years,
152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start
group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30;
P=0.75). There was no significant difference between the groups in the frequency
of adverse events (cardiovascular events, infections, or complications of dialysis).
CONCLUSIONS
In this study, planned early initiation of dialysis in patients with stage V chronic kid-
ney disease was not associated with an improvement in survival or clinical outcomes.
(Funded by the National Health and Medical Research Council of Australia and
others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)
The New England Journal of Medicine
Downloaded from nejm.org at UNIVERSITA STUDI DI TORINO on September 9, 2015. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.

Guidelines CMAJ
112 CMAJ, February 4, 2014, 186(2) © 2014 Canadian Medical Association or its licensors
I
nitiating chronic dialysis has major impli-
cations for patients and health care sys-
tems. Within the spectrum of severity of
chronic kidney disease, there is a need to iden-
tify a threshold before which starting dialysis
offers no benefit to the patient but beyond
which there may be some measurable risk.
Identifying this threshold remains a challenge
because of the inaccuracy of creatinine-based
measures of kidney function;1–3
a body of evi-
dence composed of potentially biased observa-
tional data; and reliance on poorly validated
nutritional surrogate markers,4
with an under-
emphasis on patient-important outcomes such as
hospital admission and quality of life. Collec-
tively, these factors may account in part for the
recent increase in earlier (i.e., at a higher level of
kidney function) initiation of dialysis in Canada
and the United States.5
Considering the enor-
mous burden imposed by dialysis on patients and
health care systems, there is a need for a judi-
cious approach to dialysis initiation.
The Initiating Dialysis Early and Late
(IDEAL) study,6
builds on the prior observational
experience with timing of dialysis initiation and
has prompted us to revisit the previous guide-
lines by the Canadian Society of Nephrology.7,8
Scope
Our target audience includes Canadian nephrolo-
gists, primary care physicians, general internists,
and other internal medicine subspecialists and
nursing specialists who care for patients with
chronic kidney disease and play a critical role in
referring patients and comanaging their treatment.
The target population includes adults (aged
> 18 yr) with stage 5 chronic kidney disease (i.e.,
estimated glomerular filtration rate [eGFR]
< 15 mL/min per 1.73 m2
) for whom initiation of
elective dialysis is planned. This guideline pertains
to all forms of dialysis for chronic kidney disease
in adults but does not consider timing of preemp-
tive transplantation, dialysis for acute kidney
injury, pediatric populations or patients choosing
conservative management without dialysis.
Methods
Guideline panel composition
This guideline was developed by the Canadian
Kidney Knowledge Translation and Generation
Network (CANN-NET) Ad-Hoc Guidelines
Working Group on Timing of Dialysis Start.
Cochairs were nominated by the Canadian Soci-
ety of Nephrology Clinical Practice Guidelines
Committee. We assembled a nationally represen-
tative panel consisting of practising nephrologists
from academic and community dialysis pro-
grams. Panel members had expertise in one or
more of guideline development, knowledge trans-
lation, clinical nephrology and research methods.
Guideline development methods
We used the Grading of Recommendations,
Assessment, Development and Evaluation
(GRADE) system for guideline development
(Box 1).9–16
We first formulated a clinical man-
agement question as follows: “Among adult
patients with stage 5 chronic kidney disease for
whom chronic dialysis is anticipated, is ‘early,’
Canadian Society of Nephrology 2014 clinical practice
guideline for timing the initiation of chronic dialysis
Gihad E. Nesrallah MD MSc, Reem A. Mustafa PhD MD, William F. Clark MD, Adam Bass MD MSc,
Lianne Barnieh MSc PhD, Brenda R. Hemmelgarn PhD MD, Scott Klarenbach MSc MD, Robert R. Quinn MD PhD,
Swapnil Hiremath MD MPH, Pietro Ravani PhD MD, Manish M. Sood MD, Louise M. Moist MD MSc
• Traditional criteria for initiation of dialysis have limitations because
they are based on creatinine-based measures of kidney function.
• Early initiation of dialysis does not improve survival, quality of life or
hospital admission rates compared with late or deferred initiation of
dialysis.
• We recommend an “intent-to-defer” strategy, whereby patients with
an estimated glomerular filtration rate (eGFR) below 15 mL/min per
1.73 m2
are closely monitored by a nephrologist, with dialysis initiated
when clinical indications emerge or the eGFR is 6 mL/min per 1.73m2
or
less, whichever of these should occur first.
• Our recommendation places a high value on the avoidance of a
burdensome and resource-intensive therapy that does not provide
measurable benefit when started before the development of a clinical
indication, such as uremic symptoms.
Key points
Competing interests: None
declared.
This article has been peer
reviewed.
Correspondence to:
Louise Moist,
louise.moist@lhsc.on.ca
CMAJ 2014. DOI:10.1503
/cmaj.130363
CME
ridurre i
bisogni,
senza
ridurre i
risultati…

ridurre i bisogni, senza ridurre i risultati…
“Globalization was purported to be the rising tide that
would lift all boats. However, the reality has been that it
lifted the big boats but tended to sink or swamp many
smaller ones”, Margaret Chan, World Conference on
Social Determinants of Health, 2011 (REF.1
).
Healthy people, living healthy lives on a healthy and
peaceful planet — these are the ultimate objectives of the
17 Sustainable Development Goals (SDGs), which were
formally adopted by all United Nations member states
in 2015, to be achieved by 2030 (REF.2
). The SDGs high-
light that achieving health and well-being for all requires
a robust, multisectoral approach.
Kidney disease is often a consequence of, or is exacer-
bated by, the lack of access to primary health care, early
diagnosis and essential medications. Consequently,
kidney disease disproportionately affects vulnerable
populations and exacerbates poverty. Kidney dysfunc-
tion is also associated with a high cost of care and is a
major contributor to morbidity and mortality, although
this effect is often obscured by its comorbid diseases3
.
Approximately 850 million people worldwide are esti-
mated to have kidney disease, including chronic kidney
disease (CKD), acute kidney injury (AKI) and kidney
failure, for which patients require kidney replacement
therapy (KRT) — dialysis or kidney transplantation —
for survival4
. Lack of access to dialysis has long been a
reality in low-income countries (LICs), but its impact has
now been dramatically highlighted even in high-income
countries (HICs), owing to critical shortages of dialysis
equipment and staff during the coronavirus disease 2019
(COVID-19) pandemic5
. CKD is the leading cause of
catastrophic health expenditure (that is, out-of-pocket
expenditure on health above 40% of household income
that further impoverishes the household) worldwide6
.
Global mortality from kidney disease might be as high
as 5 million annually, given the widespread lack or
limited access to life-saving KRT3,7,8
. CKD is projected
to become the world’s fifth leading cause of death by
2040 (REF.9
).
The recognition that health is key to maximizing our
individual capabilities underscores the importance of
ensuring that the SDGs do not become perpetual tar-
gets but instead become realized goals, leaving no one
behind10
(BOX 1). In this Review, we outline the relevance
Sustainable Development Goals
relevant to kidney health: an update
on progress
Valerie A. Luyckx 1,2,3 ✉, Ziyad Al-Aly 4,5
, Aminu K. Bello6
, Ezequiel Bellorin-Font7
,
Raul G. Carlini8
, June Fabian 9
, Guillermo Garcia-Garcia 10
, Arpana Iyengar11
,
Mohammed Sekkarie12
, Wim van Biesen 13
, Ifeoma Ulasi14
, Karen Yeates15
and
John Stanifer16
Abstract | Globally, more than 5 million people die annually from lack of access to critical
treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth
leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because
they are pathologically diverse and are often asymptomatic. As such, kidney disease is often
diagnosed late, and the global burden of kidney disease continues to be underappreciated. When
kidney disease is not detected and treated early, patient care requires specialized resources that
drive up cost, place many people at risk of catastrophic health expenditure and pose high
opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but
requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the
potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce
the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress
is disjointed and uneven among and within countries. The six SDG Transformations framework
can be used to examine SDGs with relevance to kidney health that require attention and reveal
inter-linkages among the SDGs that should accelerate progress.
✉e-mail: Valerie.luyckx@
uzh.ch
https://doi.org/10.1038/
s41581-020-00363-6
REVIEWS
NATURE REVIEWS | NEPHROLOGY VOLUME 17 | JANUARY 2021 | 15
SUSTAINABLE DEVELOPMENT GOALS AND KIDNEY DISEASE
of the population has routine access to diagnostic tests
for kidney disease, including routine blood and urine
tests67
(FIG.2).
In 2017, a global survey reported that haemodialysis
was available in over 90% of countries68
. However, access
to and distribution of KRT across nations remains highly
inequitable and is often dependent on out-of-pocket
expenditure and access to private facilities in LICs.
Chronic peritoneal dialysis was available in over 90% of
upper-middle-income countries and HICs, in contrast
to 64% of LMICs and 35% of LICs68
. Acute peritoneal
dialysis had the lowest availability globally. Over 90% of
upper-middle-income countries and HICs offered kid-
ney transplantation, with over 85% of these countries
reporting both living and deceased donor programmes.
tion of risk factors and disease burdens, achievement of
universal health coverage (UHC) and delivery of quality
health care.
Poverty. Poverty (SDG 1) impacts how and where indi-
viduals live, their food choices, access to education,
employment opportunities, access to technology and
innovations, and their knowledge and exercise of their
rights70
. The proportion of people living in extreme pov-
erty(thatis,livingon<US$1.90aday)declinedfrom36%
in 1990 to 8.6% in 2018; however, the rate of decline has
slowed2
. Importantly, 8% of employed people live below
the poverty line, which reflects unjust working condi-
tions. More women than men live in poverty, and pov-
erty rates are higher in rural and conflict-affected areas.
Kidney health
in children
• Child rights
• Child advocacy
• Paediatric bioethics
• Regulations and policies
• Antenatal screening
• Genetic counselling
• Safe pregnancy
• Safe delivery
• Optimal maternal nutrition
• Maternal health
• Nutrition
• Education
• Equity
• Safety
• Low birthweight
• Prematurity
• Intrauterine
growth retardation
• Neonatal acute
kidney injury
• Adolescent health
• Self-care
• Sexual and
reproductive
education
• Distance to health centre
• Resources, infrastructure and supplies
• Referral system and continuity of care
• Lack of universal health coverage
• Out-of-pocket expenditure
• Catastrophic expenditure
• Safe homes
• Climate
• Sanitation
• Safe water
• Vulnerability to
infections and toxins
• Stunting
• Wasting
• Failure to thrive
• Obesity and overweight
• Nutritional deﬁciencies
• Family structure
• Socioeconomic status
• Racism
• Education
• Cultural factors
• Social habits
• Child education
• Health awareness
• Safety measures
Fig. 1 | Multiple structural factors influence kidney health in children.Conditionsexperiencedduringfetallifeandearly
childhoodaffectthephysicalandpsychosocialdevelopmentofchildren.Theeffectsoftheseconditionspersistthroughout
the life course and influence an individual’s future health and that of their children. Achievement of the Sustainable
Development Goals (SDGs) is urgent to enable each child to maximize their own capabilities and to improve the health
of future generations. Poverty has an overarching impact on child health and well-being. Children require a safe home
and school environment, access to healthy food, good education, freedom from forced labour and access to recreational
time and space to thrive and grow up healthy. Moreover, healthy and educated mothers have healthier children.
NATURE REVIEWS | NEPHROLOGY VOLUME 17 | JANUARY 2021 | 21

Nephrol Dial Transplant (2015) 0: 1–11
doi: 10.1093/ndt/gfv233
Full Review
Cost of renal replacement: how to help as many as possible
while keeping expenses reasonable?
Raymond Vanholder1
, Norbert Lameire1
, Lieven Annemans2
and Wim Van Biesen1
1
Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium and 2
Department of Public Health,
University Ghent, Ghent, Belgium
Correspondence and offprint requests to: Raymond Vanholder; E-mail: raymond.vanholder@ugent.be
ABSTRACT
The treatment of kidney diseases consumes a substantial
amount of the health budget for a relatively small fraction of
the overall population. If the nephrological community and so-
ciety do not develop mechanisms to contain those costs, it will
become impossible to continue assuring optimal outcomes and
quality of life while treating all patients who need it. In this art-
icle, we describe several mechanisms to maintain sustainability
of renal replacement therapy. These include (i) encouragement
of transplantation after both living and deceased donation; (ii)
stimulation of alternative dialysis strategies besides classical
hospital haemodialysis, such as home haemodialysis, peritoneal
dialysis or self-care and necessitating less reimbursement; (iii)
promotion of educational activities guiding the patients towards
therapies that are most suited for them; (iv) consideration of one
or more of cost containment incentives such as bundling of
reimbursement (if not affecting quality of the treatment), timely
patient referral, green dialysis, start of dialysis based on clinical
necessity rather than renal function parameters and/or preven-
tion of CKD or its progression; (v) strategically planned adapta-
tions to the expected growth of the ageing population in need of
renal replacement; (vi)the necessityfor support of researchinthe
direction of helping as large as possible patient populations for
acceptable costs; and (vii) the need for more patient-centred ap-
proaches. We also extend the discussion to the specific situation
of kidney diseases in low- and middle-income countries. Finally,
we point to the dramatic differences in accessibility and reim-
bursement of different modalities throughout Europe. We
hope that this text will offer a framework for the nephrological
community, including patients and nurses, and the concerned
policy makers and caregivers on how to continue reaching all
patients in need of renal replacement for affordable expenses.
Keywords: cost, dialysis, kidney transplantation, peritoneal
dialysis, quality of life, socio-economics
INTRODUCTION
Even before end-stage renal disease (ESRD) develops, the num-
ber of hospitalizations and health costs increase, especially in
the months preceding dialysis, due to the presence of complica-
tions and/or comorbidities [1, 2]. Dialysis and transplantation
can prolong survival of ESRD, but generate substantial health
expenditures [3, 4], and increase the pressure on social security
when it is available, such as in high- and some middle-income
countries [3]. In low-income countries, it is impossible to reim-
burse treatment for every ESRD patient, and as a consequence,
most families are unable to pay long-term dialysis out of
pocket [5].
In contrast with the stable or even decreasing incidence of
renal replacement in most developed countries, their preva-
lence keeps rising. Projections for the coming decade, e.g. for
USA, predict a further increase [6]. At the same time, the trea-
ted population becomes older and sicker, with more complica-
tions, hospitalizations and hidden costs [7]. In other parts of the
world, incidence of ESRD steadily grows together with its
causes [8]. The total societal cost of ESRD patients is severalfold
that of non-ESRD patients, whereas the percentage of beneficiar-
ies is proportionallysmaller than the percent of moneyspent [9].
Nevertheless, regulators worldwide hesitate to reorganize the
financing of renal replacement therapy (RRT) [10].
It should be noted that the options presented here are a
selection of solutions as proposed in literature. They should
not be perceived as the sole solutions, and there might be
other valid alternatives. In addition, although ethical aspects
© The Author 2015. Published by Oxford University Press
on behalf of ERA-EDTA. All rights reserved.
1
NDT Advance Access published June 24, 2015 Postponed start of dialysis
Several observational trials show that start of dialysis at
high glomerular filtration rate (GFR) results in higher
mortality [76], which in one study was confirmed even if
bias by start of dialysis because of precarious condition
was excluded [77]. (…)
The randomized IDEAL trial showed no advantage
of early start in really asymptomatic patients [79],
shifting the current paradigm of starting
dialysis towards considering the presence of
symptoms rather than estimated glomerular
filtration rate (eGFR) [80, 81]. The
implementation of a later start is, together with
prevention, a potential cause of the current
decreasing incidence of dialysis patients [82].
Early start of dialysis also implies higher costs
without a gain in quality of life [83].
ridurre i bisogni, senza ridurre i risulta1…

Nephrol Dial Transplant (2015) 0: 1–11
doi: 10.1093/ndt/gfv233
Full Review
Cost of renal replacement: how to help as many as possible
while keeping expenses reasonable?
Raymond Vanholder1
, Norbert Lameire1
, Lieven Annemans2
and Wim Van Biesen1
1
Nephrology Section, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium and 2
Department of Public Health,
University Ghent, Ghent, Belgium
Correspondence and offprint requests to: Raymond Vanholder; E-mail: raymond.vanholder@ugent.be
ABSTRACT
The treatment of kidney diseases consumes a substantial
amount of the health budget for a relatively small fraction of
the overall population. If the nephrological community and so-
ciety do not develop mechanisms to contain those costs, it will
become impossible to continue assuring optimal outcomes and
quality of life while treating all patients who need it. In this art-
icle, we describe several mechanisms to maintain sustainability
of renal replacement therapy. These include (i) encouragement
of transplantation after both living and deceased donation; (ii)
stimulation of alternative dialysis strategies besides classical
hospital haemodialysis, such as home haemodialysis, peritoneal
dialysis or self-care and necessitating less reimbursement; (iii)
promotion of educational activities guiding the patients towards
therapies that are most suited for them; (iv) consideration of one
or more of cost containment incentives such as bundling of
reimbursement (if not affecting quality of the treatment), timely
patient referral, green dialysis, start of dialysis based on clinical
necessity rather than renal function parameters and/or preven-
tion of CKD or its progression; (v) strategically planned adapta-
tions to the expected growth of the ageing population in need of
renal replacement; (vi)the necessityfor support of researchinthe
direction of helping as large as possible patient populations for
acceptable costs; and (vii) the need for more patient-centred ap-
proaches. We also extend the discussion to the specific situation
of kidney diseases in low- and middle-income countries. Finally,
we point to the dramatic differences in accessibility and reim-
bursement of different modalities throughout Europe. We
hope that this text will offer a framework for the nephrological
community, including patients and nurses, and the concerned
policy makers and caregivers on how to continue reaching all
patients in need of renal replacement for affordable expenses.
Keywords: cost, dialysis, kidney transplantation, peritoneal
dialysis, quality of life, socio-economics
INTRODUCTION
Even before end-stage renal disease (ESRD) develops, the num-
ber of hospitalizations and health costs increase, especially in
the months preceding dialysis, due to the presence of complica-
tions and/or comorbidities [1, 2]. Dialysis and transplantation
can prolong survival of ESRD, but generate substantial health
expenditures [3, 4], and increase the pressure on social security
when it is available, such as in high- and some middle-income
countries [3]. In low-income countries, it is impossible to reim-
burse treatment for every ESRD patient, and as a consequence,
most families are unable to pay long-term dialysis out of
pocket [5].
In contrast with the stable or even decreasing incidence of
renal replacement in most developed countries, their preva-
lence keeps rising. Projections for the coming decade, e.g. for
USA, predict a further increase [6]. At the same time, the trea-
ted population becomes older and sicker, with more complica-
tions, hospitalizations and hidden costs [7]. In other parts of the
world, incidence of ESRD steadily grows together with its
causes [8]. The total societal cost of ESRD patients is severalfold
that of non-ESRD patients, whereas the percentage of beneficiar-
ies is proportionallysmaller than the percent of moneyspent [9].
Nevertheless, regulators worldwide hesitate to reorganize the
financing of renal replacement therapy (RRT) [10].
It should be noted that the options presented here are a
selection of solutions as proposed in literature. They should
not be perceived as the sole solutions, and there might be
other valid alternatives. In addition, although ethical aspects
© The Author 2015. Published by Oxford University Press
on behalf of ERA-EDTA. All rights reserved.
1
NDT Advance Access published June 24, 2015
… (iii) promotion of educational
activities guiding the patients towards
therapies that are most suited for them;
(iv) …green dialysis, start of
dialysis based on clinical necessity
rather than renal function
parameters and/or prevention of
CKD or its progression; (v)
strategically planned adaptations to the
expected growth of the ageing
population in need of renal
replacement; (vi) the necessity for support of
research … (vii) the need for more patient-
centred approaches.

Journal of
Clinical Medicine
Concept Paper
Dialysis Reimbursement: What Impact Do Different
Models Have on Clinical Choices?
Giorgina Barbara Piccoli 1,2,* , Gianfranca Cabiddu 3 , Conrad Breuer 4, Christelle Jadeau 5,
Angelo Testa 6 and Giuliano Brunori 7
1 Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy
2 Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France
3 Nephrology, Brotzu Hospital, 09100 Cagliari, Italy; gianfranca.cabiddu@tin.it
4 Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France; cbreuer@ch-lemans.fr
5 Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France; cjadeau@ch-lemans.fr
6 Association ECHO, 44000 Nantes, France; atesta@echo-sante.com
7 Nefrologia, Ospedale di Trento, 38100 Trento, Italy; gcbrunori@hotmail.com
* Correspondence: gbpiccoli@yahoo.it; Tel.: +33-669-733-371
Received: 12 January 2019; Accepted: 21 February 2019; Published: 25 February 2019
!"#!$%&'(!
!"#$%&'
Abstract: Allowing patients to live for decades without the function of a vital organ is a medical
miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic
terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care
expenditure in countries where dialysis is available without restrictions. While transplantation is
the preferred treatment in patients without contraindications, old age and comorbidity limit its
indications, and low organ availability may result in long waiting times. As a consequence, 30–70%
of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs
of dialysis are differently defined, and its reimbursement follows different rules. There are three
main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of
elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation,
hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements
in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a
core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs).
Each one has advantages and drawbacks, and impacts differently on the organization and delivery
of care: payment per session may favour fragmentation and make a global appraisal difficult; a
correct capitation system needs a careful correction for comorbidity, and may exacerbate competition
between public and private settings, the latter aiming at selecting the least complex cases; a bundle
system, in which the main elements linked to the dialysis sessions are considered together, may
be a good compromise but risks penalising complex patients, and requires a rapid adaptation to
treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for
predialysis care are not established and its development may be unfavourable for the provider.
A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high
quality of dialysis care.
Keywords: dialysis reimbursement; costs; renal replacement therapy; incremental dialysis;
predialysis care
1. Introduction
Renal replacement therapy (RRT) is a life-saving, long-lasting, expensive treatment. In Europe,
Japan, the United States and Canada, about one person in 1000 is presently alive thanks to dialysis or
J. Clin. Med. 2019, 8, 276; doi:10.3390/jcm8020276 www.mdpi.com/journal/jcm

https://doi.org/10.1007/s40620-018-00577-9
ORIGINAL ARTICLE
Incremental dialysis in ESRD: systematic review and meta-analysis
Carlo Garofalo1
· Silvio Borrelli1
· Toni De Stefano1
· Michele Provenzano2
· Michele Andreucci2
·
Gianfranca Cabiddu3
· Valerio Vizzardi5
· Massimo Sandrini5
· Giovanni Cancarini5
·
Adamasco Cupisti6
· Vincenzo Bellizzi7
· Roberto Russo8
· Paolo Chiodini9
· Roberto Minutolo1
· Giuseppe Conte1
·
Luca De Nicola1
Received: 24 November 2018 / Accepted: 18 December 2018 / Published online: 2 January 2019
© Italian Society of Nephrology 2019
Abstract
Background Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose
dialysis; however, available evidence is limited. We therefore compared all-cause mortality and residual kidney function
(RKF) loss in incremental and full-dose dialysis and time to full-dose dialysis in incremental hemodialysis (IHD) and incre-
mental peritoneal dialysis (IPD).
Methods We performed a systematic review and meta-analysis of cohort studies of adults with ESRD starting IHD and
IPD. We identified in PubMed and Web of Science database all cohort studies evaluating incremental dialysis evaluating
three outcomes: all-cause mortality, RKF loss, time to full dialysis. IPD was defined as <3 daily dwells in Continuous
Ambulatory Peritoneal Dialysis and <5 sessions per week in Automated Peritoneal Dialysis, while IHD was defined as <3
HD sessions per week.
Results 22 studies (75,292 participants), 15 in HD and 7 in PD, were analyzed. Mean age at dialysis start was 62 and 57 years
in IHD and IPD subjects, respectively. When compared to full dose, incremental dialysis (IHD or IPD) had an overall mor-
tality risk of 1.14 [95% CI 0.85–1.52] with high heterogeneity among studies (I2
86%, P<0.001), and lower mean RKF loss
(−0.58 ml/min/months, 95% CI 0.16–1.01, P=0.007). Overall, time to full-dose dialysis was 12.1 months (95% CI 9.8–14.3)
with no diﬀerence between IHD and IPD (P=0.217).
Conclusions Incremental dialysis allows longer preservation of RKF thus deferring full-dose dialysis, by about 1 year in HD
and PD, with no increase in mortality risk. Large and adequate studies are needed to confirm these findings.
Keywords Incremental hemodialysis · Incremental peritoneal dialysis · Meta-analysis · Systematic review · ESRD

Vol.:(0123456789)
1 3
https://doi.org/10.1007/s40620-018-00577-9
ORIGINAL ARTICLE
Carlo Garofalo1
· Silvio Borrelli1
· Toni De Stefano1
·
Gianfranca Cabiddu3
·
Adamasco Cupisti6
· Roberto Russo8
· Paolo Chiodini9
· Giuseppe Conte1
·
Luca De Nicola1
Abstract
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s40620-018-00577-9) contains
supplementary material, which is available to authorized users.
* Carlo Garofalo
carlo.garofalo@hotmail.it
1
Division of Nephrology, Department of Scienze Mediche
e Chirurgiche Avanzate, University of Campania “Luigi
Vanvitelli”, Via M. Longo 50, 80138 Naples, Italy
2
Nephrology and Dialysis Division, University Magna Graecia
in Catanzaro, Catanzaro, Italy
3
Nephrology and Dialysis Division, G. Brotzu Hospital,
Cagliari, Italy
4
Nephrology and Dialysis Division, E. Bassini Hospital,
Cinisello Balsamo, Milan, Italy
5
Nephrology and Dialysis Division, ASST Spedali Civili
and University of Brescia, Brescia, Italy
6
7
Ruggi d’Aragona Hospital in Salerno, Bari, Italy
8
Azienda Ospedaliera Universitaria Policlinico, Bari, Italy
9
Statistic and Epidemiologic Division, University L. Vanvitelli
in Naples, Naples, Italy
833
the “more physiologic” features of treatment, as suggested
by Golper et al. in their “reverse intact nephron” hypothesis
improve survival of dialysis access in HD by allowing the
gradual breaking in new vascular accesses (e.g., AVF or
Fig. 2 Overall risk of mortality
in subjects treated with incre-
mental versus full dialysis
Fig. 3 Random-eﬀect overall
mean diﬀerence in GFR loss in
subjects treated with incremen-
tal versus full dialysis

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https://doi.org/10.1007/s40620-018-00577-9
ORIGINAL ARTICLE
Carlo Garofalo1
· Silvio Borrelli1
· Toni De Stefano1
·
Gianfranca Cabiddu3
·
Adamasco Cupisti6
· Roberto Russo8
· Paolo Chiodini9
· Giuseppe Conte1
·
Luca De Nicola1
Abstract
* Carlo Garofalo
1
2
3
Cagliari, Italy
4
5
6
7
8
9
832 Journal of Nephrology (2019) 32:823–836
Table 3 Criteria for incremental start of haemodialysis in studies included in systematic review
Author (year) Criteria for incremental dialysis
Fernandez-Lucas (2012) Dialysis start for patients with GFR<6 ml/min with mild symptoms or higher level with uncontrolled symptoms. Two
HD/week if urea clearance>2.5 ml/min evaluating clinical status
Mathew (2016) No criteria
Merino (2017) GFR<6 ml/min (MDRD) in asymptomatic patient or greater in association with uremic symptoms. Residual
diuresis>1 L/24 h, clinical stability, absence of oedema, absence of hyperkalaemia>6.5 mEq/l and phospho-
remia>6 mg/dl, with acceptable comprehension of dietetic care
Ghajar (2017) No clinical criteria; urea clearance>3 ml/min
Hanson (1999) No criteria. Patients were generally older, more likely to be female and Caucasian, and more likely to have better
nutritional status according to serum albumin values compared with FD
Lin (2009) No criteria
Stankuviene (2010) No criteria. Patient were older and more likely to be female compared with FD
Lin (2011) No criteria. Patient were significantly younger, with lower BMI and greater albumin level compared to FD
Elamin (2012) No criteria. In Sudan, most patients are oﬀered twice weekly HD for economic reason
Caria (2014) GFR within 5 to 10 ml/min with fluid retention, inadequate control of BUN or severe secondary hyperparathyroidism
or hyperphosphatemia, reduced compliance to dietary treatment
Panaput (2014) No criteria. In Thailand patients with ESRD under the coverage of the Social Health Security Program are financially
supported only for twice-weekly HD
Obi (2016) No criteria
Hwang (2016) No criteria
Park (2017) No criteria
Mukherjee (2017) No criteria. Twice-weekly hemodialysis chosen only for aﬀordability and insurance coverage
Table 4 Criteria for incremental start of peritoneal dialysis in studies included in systematic review
Williams (1999) uKt/V 1.96±0.38 at beginning but not clear criteria for incremental dialysis
a"enzione: la dialisi incrementale
lo è per scelta e non per bisogno.....

Vol.:(0123456789)
1 3
https://doi.org/10.1007/s40620-018-00577-9
ORIGINAL ARTICLE
Carlo Garofalo1
· Silvio Borrelli1
· Toni De Stefano1
·
Gianfranca Cabiddu3
·
Adamasco Cupisti6
· Roberto Russo8
· Paolo Chiodini9
· Giuseppe Conte1
·
Luca De Nicola1
Abstract
* Carlo Garofalo
1
2
3
Cagliari, Italy
4
5
6
7
8
9
RKF as moderator because studies evaluating survival did
not include data on RKF; therefore, future studies should
specifically verify the potential survival advantage of pre-
served renal function in incremental dialysis. As suggested
by Kalanthar-Zadeh et al., incremental HD could be offered
only to patients with a diuresis of ≥600 ml/day and urea
clearance>3 ml/min [51]. Similarly, in the study by San-
drini et al. in PD patients, the fully adjusted survival model
showed that urine output was the only factor that signifi-
cantly improved survival [49].
As regards IHD, it is also important to note that this
and pharmacological therapy, besides and beyond selec-
tion criteria, should be therefore considered and correctly
planned when designing a study on incremental RRT.
The rate of RKF loss was lower in patients treated with
incremental dialysis than in those treated with full dose, with
a mean difference of about 0.6 ml/min/month. This finding
is particularly relevant because maintaining RKF allows an
increased fluid intake and may provide benefits related to
improved clearance of medium and large molecules [54–57],
reduction of inflammation [58] and increased quality of life
[59]. Interestingly, a similar small decline in renal function
Panaput (2014) No criteria. In Thailand patients with ESRD under the coverage of the Social Health Security Program are financially
supported only for twice-weekly HD
Obi (2016) No criteria
Hwang (2016) No criteria
Park (2017) No criteria
Mukherjee (2017) No criteria. Twice-weekly hemodialysis chosen only for affordability and insurance coverage
Table 4 Criteria for incremental start of peritoneal dialysis in studies included in systematic review
Williams (1999) uKt/V 1.96±0.38 at beginning but not clear criteria for incremental dialysis
De Vecchi (2000) Presence of uremic complications, uncontrollable hypervolemia, hyperkalemia, or CCr below 3–4 mL/
min. If Kt/V<1.5 or symptoms of uremia increment to 3 exchanges/day
Neri (2003) GFR within 7–9 ml/min (mean creatinine and urea clearance normalized for BSA)
Viglino (2008) GFR>5 ml/min and presence of uremic complications (following NFK-DOQI 2001 criteria)
Domenici (2011) Modality choice in the whole cohort was determined by patient’s preference
Jeloka (2013) uKt/V≈1 with “significant” urinary output
Sandrini (2016) RRF>3 and <10 ml/min (mean of ClCr and ClUr normalized BSA) and “renal indication” for dialysis
Sebbene la dialisi incrementale sia “figlia” della dialisi peritoneale, i
criteri riportati sono quanto mai vari, e le scelte sono molto
“experience based” più che “evidence based”, ma un RCT sarebbe
eticamente corretto?
E, all’epoca della medicina personalizzata, un approccio
experience based è realmente negativo?

la medicina di precisione si adatta bene alla dialisi
incrementale... che può anche essere “decrementale”
CURRENT
OPINION Precision medicine approach to dialysis including
incremental and decremental dialysis regimens
Mariana Murea
Purpose of review
Conventional standardization of haemodialysis for treatment of end-stage kidney disease (ESKD) is
predicated upon the fixed construct of one disease stage and one patient category. Increasingly
recognized are subgroups of patients for whom less-intensive haemodialysis, such as incremental or
decremental haemodialysis, could be employed.
Recent findings
Almost 30% of patients with incident ESKD have clinical and residual kidney function (RFK) parameters that
could accommodate less-intensive haemodialysis. In one study, patients with incident ESKD and substantial
RKF treated with low-dose haemodialysis had similar mortality rate as those treated with standard-dose
haemodialysis, adding to the evidence that endogenous kidney function – when present – can complement
less-intensive haemodialysis schedules. Hazards related to incremental haemodialysis include insidious
development of fluid overload and higher rates of fluid removal. Finally, deintensification of haemodialysis
treatment could be employed in patients with ESKD who seek conservative care.
Summary
A shift in approach to ESKD from a dichotomous frame – disease presence versus absence – to stages of
dialysis-dependent kidney disease, each stage associated with attuned haemodialysis intensity, has been
proposed. Haemodialysis standardization and personalization – often considered mutually exclusive – can
be combined in incremental haemodialysis. Data from ongoing and future randomized clinical trials,
comparing less-intensive with standard haemodialysis schedules, are required to change practice.
Keywords
clinical trials, decremental, end-stage kidney disease, haemodialysis, incremental
INTRODUCTION
End-stage kidney disease (ESKD) is marked by initi-
ation of kidney replacement therapy of which
chronic haemodialysis is the most common form
of dialysis therapy in the USA and other developed
countries. In its fundamental approach, the treat-
ment of patients with ESKD with chronic haemo-
dialysis has five main components: dialysis
frequency, treatment time per dialysis session, con-
trol of uremic symptoms, control of volume status
and management of metabolic imbalances. Among
these components and boxed by clinical practice
guidelines and reimbursement policies, providers
have little room to edit the haemodialysis pro-
gramme, in spite of the fact that many elements
of haemodialysis prescription (e.g. lower treatment
frequency, ultrafiltration rate, treatment time, dial-
ysate electrolyte concentrations) have not been val-
programme, equally prescribed to patients who
transition from chronic kidney disease to ESKD
(incident dialysis) and those with long-term ESKD
(prevalent dialysis). This ‘one-size-fits-all’ approach
to treating patients with ESKD is the norm in many
developed countries, even though some patients,
due to disease heterogeneity or by choice, might
fare better with different haemodialysis treatment
programs. Exemplary haemodialysis treatment
doses [i.e. minimum delivered single pool Kt/Vurea
(spKt/Vurea) !1.2 and urea reduction ratio (URR)
!65%] are the benchmark in all dialysis
Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
Correspondence to Mariana Murea, MD, Department of Internal Medi-
cine – Section on Nephrology,Wake Forest School of Medicine, Medical
Center Boulevard, Winston-Salem, NC 27157-1053, USA.
Tel: +1 336 716 4650; fax: +1 336 716 4318;
REVIEW
costs o
with
person
patien
patien
come
does n
betwee
haemo
experi
today’
owner
ingly e
need t
motiva
in thei
Gr
intens
of incr
case o
residua
case o
multip
tive ap
review
KEY POINTS
! There is significant heterogeneity among patients with
ESKD; a shift from ‘one-size-fits-all’ approach to
haemodialysis therapy to ‘stage-based’ approach has
been proposed to tailor haemodialysis by
patient subgroups.
! At least one-third of patients with incident ESKD have
substantial RKF; these patients might not derive
additional benefit from being treated with standard
haemodialysis as opposed to less-
intensive haemodialysis.
! Patients treated with reduced-frequency haemodialysis
can develop insidious volume overload and be exposed
to high rates of fluid removal; adjuvant pharmacologic
therapy and timely adjustment in haemodialysis
prescription are of paramount importance.
! Combining standardized and personalized care in well
selected subgroups of patients with ESKD might
surmount some of the challenges of incremental HD.
! Multicentre clinical trials on comparative effectiveness
between less-intensive and standard haemodialysis
schedules are required to change current practice.
Novel therapeutic approaches in nephrology and hypertension

Esiste probabilmente spazio per aumentare la dialisi
incrementale: l’esperienza di Le Mans è riassunta
così : periodo 2017-2021
DP : 18.6% dei nuovi pazienti
Tutti hanno iniziato in dialisi peritoneale
incrementale;
Tutti i pazienti che hanno iniziato la DP erano seguiti
in precedenza; 80% erano seguiti nell’unità di follow-
up “intensivo” UIRAV

Le Mans, emodialisi: periodo 2017-2021
105 pazienti iniziano
l’emodialisi in maniera
“non standard” :
incrementale (90) e
decrementale (15).
Solo 53 su 158 iniziano
e continuano in dialisi
trisettimanale.
ridurre i bisogni, senza ridurre i risultaG…

“i giochi sono fatti” nel periodo pre-dialisi:
All patients who started on PD started with incremental schedles; all
were followed previously, 80% in UIRAV
PD prevalence: 18.6% of new cases

24. Kleinbongard P, Dejam A, Lauer T, et al. Plasma nitrite concentrations reflect the
degree of endothelial dysfunction in humans. Free Radic Biol Med. 2006;40
(2):295-302.
25. Pereira EC, Ferderbar S, Bertolami MC, et al. Biomarkers of oxidative stress and
cancer: the cytotoxic and hyperproliferative effects of dietary heme. Cancer Res.
1999;59(22):5704-5709.
33. Huang X. Iron overload and its association with cancer risk in humans: evidence
for iron as a carcinogenic metal. Mutat Res. 2003;533(1-2):153-171.
INVITED COMMENTARY
Holy Cow! What’s Good for You
Is Good for Our Planet
Is red meat bad for you? In a word, yes. In this is-
sue, Pan et al1
describe the outcomes from more than
37 000 men from the Harvard Health Professionals
Follow-Up Study and more than 83 000 women from the
Harvard Nurses Health Study who were followed up for
almost 3 million person-years.
This is the first large-scale prospective longitudinal
study showing that consumption of both processed and
unprocessed red meat is associated with an increased risk
of premature mortality from all causes as well as from
cardiovascular disease and cancer. In a related study by
Pan et al,2
red meat consumption was also associated with
an increased risk of type 2 diabetes mellitus.
Substitution of red meat with fish, poultry, nuts, le-
gumes, low-fat dairy products, and whole grains was as-
sociated with a significantly lower risk of mortality. We
have a spectrum of choices; it’s not all or nothing.3
Plant-based foods are rich in phytochemicals, biofla-
vonoids, and other substances that are protective. In other
words, what we include in our diet is as important as what
we exclude, so substituting healthier foods for red meat
provides a double benefit to our health.
Pan et al1
reported that adjustment for saturated fat,
dietary cholesterol, and heme iron accounted for some
but not all of the risk of eating red meat. Thus, other
mechanisms such as nontraditional risk factors may be
involved.
For example, a recent study by Smith4
found that high-
fat, high-protein, low-carbohydrate (HPLC) diets (which
are usually high in red meat, such as the Atkins and Pa-
leolithic diets) may accelerate atherosclerosis through
mechanisms that are unrelated to the classic cardiovas-
cular risk factors. Mice that were fed an HPLC diet had
almost twice the level of arterial plaque as mice that were
fed a Western diet even though the classic risk factors
were not significantly different between groups. The mice
that were fed the HPLC diet had markedly fewer circu-
lating endothelial progenitor cells and higher levels of
nonesterified fatty acids (promoting inflammation) than
mice that were fed the Western diet.5
Therefore, studies of HPLC diets that only examine
their effects on changes in weight, blood pressure, and
lipid levels may not adequately reflect the negative in-
fluence of HPLC diets on health outcomes, such as mor-
bidity and mortality.
There is an emerging consensus among most nutri-
tion experts about what constitutes a healthy way of
eating:
v little or no red meat;
v high in “good carbs” (including vegetables, fruits,
whole grains, legumes, and soy products in their natu-
ral forms);
v low in “bad carbs” (simple and refined carbohy-
drates, such as sugar, high-fructose corn syrup, and white
flour);
v high in “good fats” (!-3 fatty acids found in fish oil,
flax oil, and plankton-based oils);
v low in “bad fats” (trans fats, saturated fats, and hy-
drogenated fats);
ARCH INTERN MED/VOL 172 (NO. 7), APR 9, 2012 WWW.ARCHINTERNMED.COM
563
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Universita Torino User on 11/09/2015
ridurre
l’impatto
ambientale...
l’importanza
della dieta

take and risk of coronary disease among men. Circulation. 1994;89(3):969-974.
18. Klipstein-Grobusch K, Grobbee DE, den Breeijen JH, Boeing H, Hofman A, Wit-
teman JC. Dietary iron and risk of myocardial infarction in the Rotterdam Study.
Am J Epidemiol. 1999;149(5):421-428.
19. van der A DL, Peeters PH, Grobbee DE, Marx JJ, van der Schouw YT. Dietary
haem iron and coronary heart disease in women. Eur Heart J. 2005;26(3):257-
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20. Qi L, van Dam RM, Rexrode K, Hu FB. Heme iron from diet as a risk factor for
coronary heart disease in women with type 2 diabetes. Diabetes Care. 2007;
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21. Menke A, Muntner P, Fernández-Real JM, Guallar E. The association of biomark-
ers of iron status with mortality in US adults [published online ahead of print
February 15, 2011]. Nutr Metab Cardiovasc Dis. doi:10.1016/j.numecd.2010.11
.011.
22. Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary
salt reductions on future cardiovascular disease. N Engl J Med. 2010;362(7):
590-599.
23. Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. Population
strategies to decrease sodium intake and the burden of cardiovascular disease:
a cost-effectiveness analysis. Ann Intern Med. 2010;152(8):481-487, W170-
W173.
24. Kleinbongard P, Dejam A, Lauer T, et al. Plasma nitrite concentrations reflect the
degree of endothelial dysfunction in humans. Free Radic Biol Med. 2006;40
(2):295-302.
25. Pereira EC, Ferderbar S, Bertolami MC, et al. Biomarkers of oxidative stress and
endothelial dysfunction in glucose intolerance and diabetes mellitus. Clin Biochem.
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26. World Cancer Research Fund/American Institute for Cancer Research. Food, Nu-
trition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Wash-
ington, DC: American Institute for Cancer Research; 2007.
27. Hughes R, Cross AJ, Pollock JRA, Bingham S. Dose-dependent effect of dietary
meat on endogenous colonic N-nitrosation. Carcinogenesis. 2001;22(1):199-
202.
28. Skog K, Steineck G, Augustsson K, Jägerstad M. Effect of cooking temperature
on the formation of heterocyclic amines in fried meat products and pan residues.
Carcinogenesis. 1995;16(4):861-867.
29. Sinha R, Rothman N, Salmon CP, et al. Heterocyclic amine content in beef cooked
by different methods to varying degrees of doneness and gravy made from meat
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rectal cancer. Environ Mol Mutagen. 2004;44(1):44-55.
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for iron as a carcinogenic metal. Mutat Res. 2003;533(1-2):153-171.
INVITED COMMENTARY
Holy Cow! What’s Good for You
Is Good for Our Planet
Is red meat bad for you? In a word, yes. In this is-
sue, Pan et al1
describe the outcomes from more than
37 000 men from the Harvard Health Professionals
Follow-Up Study and more than 83 000 women from the
Harvard Nurses Health Study who were followed up for
almost 3 million person-years.
This is the first large-scale prospective longitudinal
study showing that consumption of both processed and
unprocessed red meat is associated with an increased risk
of premature mortality from all causes as well as from
cardiovascular disease and cancer. In a related study by
Pan et al,2
red meat consumption was also associated with
an increased risk of type 2 diabetes mellitus.
Substitution of red meat with fish, poultry, nuts, le-
gumes, low-fat dairy products, and whole grains was as-
sociated with a significantly lower risk of mortality. We
have a spectrum of choices; it’s not all or nothing.3
Plant-based foods are rich in phytochemicals, biofla-
vonoids, and other substances that are protective. In other
words, what we include in our diet is as important as what
we exclude, so substituting healthier foods for red meat
provides a double benefit to our health.
Pan et al1
reported that adjustment for saturated fat,
dietary cholesterol, and heme iron accounted for some
but not all of the risk of eating red meat. Thus, other
mechanisms such as nontraditional risk factors may be
involved.
For example, a recent study by Smith4
found that high-
fat, high-protein, low-carbohydrate (HPLC) diets (which
are usually high in red meat, such as the Atkins and Pa-
leolithic diets) may accelerate atherosclerosis through
mechanisms that are unrelated to the classic cardiovas-
cular risk factors. Mice that were fed an HPLC diet had
almost twice the level of arterial plaque as mice that were
fed a Western diet even though the classic risk factors
were not significantly different between groups. The mice
that were fed the HPLC diet had markedly fewer circu-
lating endothelial progenitor cells and higher levels of
nonesterified fatty acids (promoting inflammation) than
mice that were fed the Western diet.5
Therefore, studies of HPLC diets that only examine
their effects on changes in weight, blood pressure, and
lipid levels may not adequately reflect the negative in-
fluence of HPLC diets on health outcomes, such as mor-
bidity and mortality.
There is an emerging consensus among most nutri-
tion experts about what constitutes a healthy way of
eating:
v little or no red meat;
v high in “good carbs” (including vegetables, fruits,
whole grains, legumes, and soy products in their natu-
ral forms);
v low in “bad carbs” (simple and refined carbohy-
drates, such as sugar, high-fructose corn syrup, and white
flour);
v high in “good fats” (!-3 fatty acids found in fish oil,
flax oil, and plankton-based oils);
v low in “bad fats” (trans fats, saturated fats, and hy-
drogenated fats);
ARCH INTERN MED/VOL 172 (NO. 7), APR 9, 2012 WWW.ARCHINTERNMED.COM
563
©2012 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Universita Torino User on 11/09/2015
ridurre l’impa+o ambientale

la “riscoperta” dell’a0vità ﬁsica ada4ata al paziente.
Original Investigation
Exercise Training in Adults With CKD: A Systematic Review and
Meta-analysis
Susanne Heiwe, RPT, PhD,1,2,3
and Stefan H. Jacobson, MD, PhD1,4
Background: Whether exercise can affect health outcomes in people with chronic kidney disease (CKD)
and what the optimal exercise strategies are for patients with CKD remain uncertain.
Study Design: Systematic review and meta-analysis of randomized controlled trials.
Setting & Population: Adults with CKD stages 2-5, dialysis therapy, or a kidney transplant.
Selection Criteria for Studies: Trials evaluating regular exercise training outcomes identified by searches
in Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, BIOSIS, PEDro, AMED, AgeLine,
PsycINFO, and KoreaMed, without language restriction.
Intervention: Regular exercise training for at least 8 weeks.
Outcomes: Vary by study but could include aerobic capacity, muscular functioning, cardiovascular function,
walking capacity, and health-related quality of life. Treatment effects were summarized as standardized
difference with 95% CIs using random-effects meta-analysis.
Results: 41 trials (928 participants) comparing exercise training with sham exercise or no exercise were
included; overall, improved aerobic capacity, muscular functioning, cardiovascular function, walking capacity,
and health-related quality of life were associated with various exercise interventions, although the
preponderance of data were for dialysis patients and used aerobic exercise programs.
Limitations: Unclear or high risk of bias in 32% of the trials, few trial data concerning resistance training,
and limited data for several important outcomes.
Conclusions: Regular exercise training generally is associated with improved health outcomes in in-
dividuals with CKD. Correctly designed exercise rehabilitation may be an effective part of care for adults with
CKD. Future studies should examine longer term outcomes and strategies to translate exercise done in a
supervised setting to the home setting for broader applicability.
Am J Kidney Dis. 64(3):383-393. ª 2014 by the National Kidney Foundation, Inc.
INDEX WORDS: Kidney disease, chronic; exercise; physical fitness; exercise training; systematic reviews;
meta-analysis.

la “riscoperta” dell’attività fisica adattata al paziente.
NOTE: Weights are from random effects analysis
Overall (I−squared = 0.0%, p = 0.635)
Schardong et al.
Wu et al.
Dobsak et al.
Study or Subgroup
Fuzari et al.
Medeiros er al.
Dobsak et al.
Koh et al.
Pellizzaro et al.
Koh et al.
Thompson et al.
Esteve Simo et al.
Samara et al.
Matsufuji et al.
Cheema et al.
Pellizzaro et al.
Groussard et al.
Thompson et al.
Roxo et al.
Hristea et al.
Manfredini et al.
DePaul et al.
Thompson et al.
2017
2014
2012
Year
2018
2018
2012
2010
2013
2010
2016
2014
2016
2015
2007
2013
2015
2016
2016
2016
2017
2002
2016
11
32
11
(n)
8
12
11
14
11
14
7
14
15
6
24
Intervention
14
10
8
20
7
104
20
8
10
33
5
(n)
8
12
5
8
7
8
2.67
26
12
11
25
Control
7
8
2.67
20
9
123
18
2.67
33.641 (23.740, 43.542)
12.780 (−78.056, 103.616)
51.000 (−8.593, 110.593)
40.200 (−24.197, 104.597)
ES (95% CI)
17.750 (−46.366, 81.866)
20.140 (−3.004, 43.284)
70.800 (−0.925, 142.525)
42.000 (−58.042, 142.042)
64.600 (−26.743, 155.943)
28.000 (−79.501, 135.501)
63.500 (−80.911, 207.911)
109.900 (−19.310, 239.110)
111.500 (24.369, 198.631)
37.700 (−23.627, 99.027)
19.600 (0.022, 39.178)
30.100 (−47.140, 107.340)
64.000 (38.180, 89.820)
47.700 (−122.147, 217.547)
25.600 (−30.070, 81.270)
86.200 (−61.132, 233.532)
36.000 (7.688, 64.312)
−0.100 (−46.276, 46.076)
51.000 (−99.668, 201.668)
100.00
1.19
2.76
2.36
Weight
2.38
18.30
1.91
0.98
1.17
0.85
0.47
0.59
1.29
2.61
25.58
%
1.64
14.71
0.34
3.16
0.45
12.23
4.60
0.43
33.641 (23.740, 43.542)
12.780 (−78.056, 103.616)
51.000 (−8.593, 110.593)
40.200 (−24.197, 104.597)
ES (95% CI)
17.750 (−46.366, 81.866)
20.140 (−3.004, 43.284)
70.800 (−0.925, 142.525)
42.000 (−58.042, 142.042)
64.600 (−26.743, 155.943)
28.000 (−79.501, 135.501)
63.500 (−80.911, 207.911)
109.900 (−19.310, 239.110)
111.500 (24.369, 198.631)
37.700 (−23.627, 99.027)
19.600 (0.022, 39.178)
30.100 (−47.140, 107.340)
64.000 (38.180, 89.820)
47.700 (−122.147, 217.547)
25.600 (−30.070, 81.270)
86.200 (−61.132, 233.532)
36.000 (7.688, 64.312)
−0.100 (−46.276, 46.076)
51.000 (−99.668, 201.668)
100.00
1.19
2.76
2.36
Weight
2.38
18.30
1.91
0.98
1.17
0.85
0.47
0.59
1.29
2.61
25.58
%
1.64
14.71
0.34
3.16
0.45
12.23
4.60
0.43
Favours usual care Favours exercise training
0
−250 −150 −50 0 50 150 250
Fig. 4. Forest plots of the effect estimates (ES) with 95% confidence intervals (CI) for the distance walked during the 6-min walk test between exercise
interventions and usual care control groups for all included studies.
F865
EXERCISE AND PHYSICAL FUNCTION IN PATIENTS ON DIALYSIS
REVIEW
Exercise interventions for improving objective physical function in patients
with end-stage kidney disease on dialysis: a systematic review and meta-
analysis
X Matthew J. Clarkson,1
Paul N. Bennett,2,3
Steve F. Fraser,1
and X Stuart A. Warmington1
1
Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong,
Victoria, Australia; 2
Medical and Clinical Affairs, Satellite Healthcare, Adelaide, South Australia, Australia; and 3
School of
Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
Submitted 2 July 2018; accepted in final form 12 February 2019
Clarkson MJ, Bennett PN, Fraser SF, Warmington SA. Exercise interven-
tions for improving objective physical function in patients with end-stage kidney
disease on dialysis: a systematic review and meta-analysis. Am J Physiol Renal
Physiol 316: F856–F872, 2019. First published February 13, 2019; doi:10.1152/
ajprenal.00317.2018.—Patients with end-stage kidney disease on dialysis have
increased mortality and reduced physical activity, contributing to impaired physical
function. Although exercise programs have demonstrated a positive effect on
physiological outcomes such as cardiovascular function and strength, there is a
reduced focus on physical function. The aim of this review was to determine
whether exercise programs improve objective measures of physical function indic-
ative of activities of daily living for patients with end-stage kidney disease on
dialysis. A systematic search of Medline, Embase, the Cochrane Central Register of
Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature
identified 27 randomized control trials. Only randomized control trials using an
exercise intervention or significant muscular activation in the intervention, a usual
care, nonexercising control group, and at least one objective measure of physical
function were included. Participants were !18 yr of age, with end-stage kidney
disease, undergoing hemo- or peritoneal dialysis. Systematic review of the litera-
ture and quality assessment of the included studies used the Cochrane Collabora-
tion’s tool for assessing risk bias. A meta-analysis was completed for the 6-min
walk test. Data from 27 studies with 1,156 participants showed that exercise,
regardless of modality, generally increased 6-min walk test distance, sit-to-stand
time or repetitions, and grip strength as well as step and stair climb times or
repetitions, dynamic mobility, and short physical performance battery scores. From
the evidence available, exercise, regardless of modality, improved objective mea-
sures of physical function for end-stage kidney disease patients undergoing dialysis.
It is acknowledged that further well-designed randomized control trials are re-
quired.
dialysis; end-stage kidney disease; intradialytic exercise; physical function; sys-
tematic review
INTRODUCTION
End-stage kidney disease (ESKD) is near or complete and
permanent kidney failure requiring renal replacement therapy
(RRT) via dialysis or transplantation to account for kidney
function that is inadequate to sustain life (71). The prevalence
of ESKD is proportional to the escalating worldwide epidemic
of lifestyle-related diseases such as type 2 diabetes and hyper-
tension (28). Combined with an aging population in many
countries and approximately one in eight people developing
chronic kidney disease (CKD), of which 10% progress to
ESKD, the result is almost double the already large number of
patients requiring RRT over the last decade, with !53% of
these receiving hemodialysis (HD) (1, 10a, 44).
Among patients on HD, there is a strong link between the
increase in mortality and the low levels of both objective and
self-reported physical function (65). This is exacerbated by
patients on HD being significantly more sedentary than other-
wise healthy inactive populations (38). In fact, patients on HD
classified as sedentary are more than 60% more likely to die
each year compared with patients on HD who are regularly
physically active (63). Although survival rates are slowly
Address for reprint requests and other correspondence: M. Clarkson, School
of Exercise and Nutrition Science, Deakin Univ., 221 Burwood Highway,
Burwood, VIC 3125, Australia (e-mail: mclarks@deakin.edu.au).
Am J Physiol Renal Physiol 316: F856–F872, 2019.
First published February 13, 2019; doi:10.1152/ajprenal.00317.2018.
1931-857X/19 Copyright © 2019 the American Physiological Society http://www.ajprenal.org
F856
Downloaded from journals.physiology.org/journal/ajprenal at Univ Studi Di Torino Bib Ctral Di Med E (130.186.099.159) on September 15, 2021.

la “riscoperta” dell’attività fisica adattata al paziente.
An Exercise Program for Peritoneal Dialysis Patients
in the United States: A Feasibility Study
Paul N. Bennett, Wael F. Hussein, Kimberly Matthews, Mike West, Erick Smith, Marc Reiterman,
Grace Alagadan, Bryan Shragge, Jignesh Patel, and Brigitte M. Schiller
Background: People with end-stage kidney disease
receiving peritoneal dialysis (PD) are generally
physically inactive and frail. Exercise studies in PD
are scarce and currently there are no PD exercise
programs in the United States. The primary
objective of this study was to test the feasibility of a
combined resistance and cardiovascular exercise
program for PD patients under the care of a
dedicated home dialysis center in the United States.
Study Design: Parallel randomized controlled
feasibility study.
Setting & Participants: PD patients were recruited
from a single center and randomly assigned to the
intervention (exercise; n = 18) or control (non-
exercise; n =18) group.
Intervention: The intervention group received
monthly exercise physiologist consultation, exer-
cise prescription (resistance and aerobic exercise
program using exercise bands), and 4 exercise
support telephone calls over 12 weeks. The control
group received standard care.
Outcomes: The primary outcome was study
feasibility as measured by eligibility rates, recruit-
ment rates, retention rates, adherence rates,
adverse events, and sustained exercise rates.
Secondary outcome measures were changes in
physical function (sit-to-stand test, timed-up-and-
go test, and pinch-strength tests) and patient-
reported outcome measures.
Results: From a single center with 75 PD patients,
57 (76%) were deemed eligible, resulting in a
recruitment rate of 36 (63%) patients. Participants
were randomly assigned into 2 groups of 18 (1:1).
10 patients discontinued the study (5 in each arm),
resulting in 26 (72%) patients, 13 in each arm,
completing the study. 10 of 13 (77%) intervention
patients were adherent to the exercise program. A t
test analysis of covariance found a difference be-
tween the treatment groups for the timed-up-and-
go test (P = 0.04) and appetite (P = 0.04). No
serious adverse events caused by the exercise
program were reported.
Limitations: Single center, no blinded assessors.
Conclusions: A resistance and cardiovascular ex-
ercise program appears feasible and safe for PD
patients. We recommend that providers of PD
therapy consider including exercise programs co-
ordinated by exercise professionals to reduce the
physical deterioration of PD patients.
Funding: None.
Trial Registration: NCT03980795.
atients with end-stage kidney disease receiving peri- Patients undergoing PD are less likely to be constantly
Complete author and article
information provided before
references.
Correspondence to
P.N. Bennett (bennettp@
satellitehealth.com)
Kidney Med. 2(3):267-275.
Published online March 17,
2020.
doi: 10.1016/
j.xkme.2020.01.005
© 2020 The Authors.
Published by Elsevier Inc.
on behalf of the National
Kidney Foundation, Inc. This
is an open access article
under the CC BY-NC-ND
license (http://
creativecommons.org/
licenses/by-nc-nd/4.0/).
Original Research
75 pazienti,
57 eleggibili,
36 reclutati,
10 drop-
outs, 3 non
compliance..
10 casi e 13
controlli
analizzabili..

la “riscoperta” dell’a0vità ﬁsica ada4ata al paziente.
ridurre i bisogni, senza ridurre i risulta<…

Ridurre gli spostamenti: una COVID-lesson?
la medicina a distanza: ecologica o spersonalizzante?
Carbon Footprint of Telemedicine Solutions -
Unexplored Opportunity for Reducing Carbon Emissions
in the Health Sector
Åsa Holmner1
*, Kristie L. Ebi2,4
, Lutfan Lazuardi3
, Maria Nilsson4
1 Department of Radiation Sciences, Umeå University, Umeå, Sweden, 2 ClimAdapt, LLC, Seattle, Washington, United States of America, 3 Department of Public Health,
Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia, 4 Department of public health and clinical medicine, epidemiology and global health, Umeå
University, Umeå, Sweden
Abstract
Background: The healthcare sector is a significant contributor to global carbon emissions, in part due to extensive travelling
by patients and health workers.
Objectives: To evaluate the potential of telemedicine services based on videoconferencing technology to reduce travelling
and thus carbon emissions in the healthcare sector.
Methods: A life cycle inventory was performed to evaluate the carbon reduction potential of telemedicine activities beyond
a reduction in travel related emissions. The study included two rehabilitation units at Umeå University Hospital in Sweden.
Carbon emissions generated during telemedicine appointments were compared with care-as-usual scenarios. Upper and
lower bound emissions scenarios were created based on different teleconferencing solutions and thresholds for when
telemedicine becomes favorable were estimated. Sensitivity analyses were performed to pinpoint the most important
contributors to emissions for different set-ups and use cases.
Results: Replacing physical visits with telemedicine appointments resulted in a significant 40–70 times decrease in carbon
emissions. Factors such as meeting duration, bandwidth and use rates influence emissions to various extents. According to
the lower bound scenario, telemedicine becomes a greener choice at a distance of a few kilometers when the alternative is
transport by car.
Conclusions: Telemedicine is a potent carbon reduction strategy in the health sector. But to contribute significantly to
climate change mitigation, a paradigm shift might be required where telemedicine is regarded as an essential component
of ordinary health care activities and not only considered to be a service to the few who lack access to care due to
geography, isolation or other constraints.
Citation:Holmner Å, Ebi KL, Lazuardi L, Nilsson M (2014) Carbon Footprint of Telemedicine Solutions - Unexplored Opportunity for Reducing Carbon Emissions in
the Health Sector. PLoS ONE 9(9): e105040. doi:10.1371/journal.pone.0105040
Editor:Igor Linkov, US Army Engineer Research and Development Center, United States of America

Future Healthcare Journal 2021 Vol 8, No 1: e85–91 REVIEW
PROCESS AND SYSTEMS Does telemedicine reduce the carbon
footprint of healthcare? A systematic review
Authors: Amy Purohit,A
James SmithB
and Arthur HibbleC
In the rapidly progressing field of telemedicine, there is
a multitude of evidence assessing the effectiveness and
financial costs of telemedicine projects; however, there is
very little assessing the environmental impact despite the
increasing threat of the climate emergency. This report
provides a systematic review of the evidence on the carbon
footprint of telemedicine. The identified papers unanimously
report that telemedicine does reduce the carbon footprint
of healthcare, primarily by reduction in transport-associated
emissions. The carbon footprint savings range between
0.70–372 kg CO2e per consultation. However, these values are
highly context specific. The carbon emissions produced from
the use of the telemedicine systems themselves were found
to be very low in comparison to emissions saved from travel
reductions. This could have wide implications in reducing
the carbon footprint of healthcare services globally. In order
for telemedicine services to be successfully implemented,
further research is necessary to determine context-specific
considerations and potential rebound effects.
KEYWORDS: telemedicine, sustainability, e-health, carbon footprint
synchronous is real-time data transmission. The data may be
transmitted via a variety of media, such as audio, video or text.
This paper will focus on all forms of telemedicine involving direct
patient care where the carbon footprint of the telemedicine
project is compared to a face-to-face (FTF) scenario.
Telemedicine is a recent development within healthcare.
In this decade, there has been an explosion in telemedicine
research, focusing on specific medical specialties. The reported
advantages include lower financial costs, high patient
satisfaction, better rural access, decreased waiting times and
fewer missed appointment.2–7
There is less available evidence
from primary care; however, there are positive findings in
primary care chronic disease management.8–10
The main
disadvantages are erosion of the clinician–patient relationship
and concerns around quality of care. In terms of clinician–
patient relationship, this concern arises particularly from
elderly patients and healthcare providers themselves; however,
acceptance has been shown to be increasing.6,11,12
There are
mixed reports on the quality of care provided by telemedicine;
some sources report improved or maintained standards of care,
whereas others found a reduction in quality of care compared to
FTF scenarios.9,13–19
ABSTRACT

Telehealth for Home Dialysis in COVID-19 and Beyond:
A Perspective From the American Society of Nephrology
COVID-19 Home Dialysis Subcommittee
Susie Q. Lew, Eric L. Wallace, Vesh Srivatana, Bradley A. Warady, Suzanne Watnick, Jayson Hood,
David L. White, Vikram Aggarwal, Caroline Wilkie, Mihran V. Naljayan, Mary Gellens, Jeffrey Perl, and
Martin J. Schreiber
The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory
waivers, and user acceptance have converged to boost telehealth activities. Due to the state of
emergency, regulatory waivers in the United States have made it possible for providers to deliver and
bill for services across state lines for new and established patients through Health Insurance Portability
and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site
and without geographic restrictions. Platforms have been developed or purchased to perform video-
conferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth
experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have
exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of
devices to perform telehealth, and socioeconomic and language barriers. Future directions in tele-
health use, quality measures, and research in telehealth use need to be explored. Telehealth during the
public health emergency has changed the practice of health care, with the post–COVID-19 world
unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States
remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.
The coronavirus disease 2019 (COVID-19) pandemic,
new technologies, regulatory changes, and increased
patient acceptance have led to accelerated evolution of
telehealth in patient care settings. Telehealth delivers vir-
tual patient care, addresses patient’s medical concerns, and
identifies issues that warrant in-person visits, while at the
same time fostering social distancing in an effort to
decrease COVID-19 transmission among health care
workers and patients.1,2
Telehealth has benefits for clinicians, the interdisci-
plinary team (IDT), and patients. Due to the complexity of
patients receiving dialysis, telehealth may complement but
not totally replace the in-person visit3-5
and provide better
Regulatory Changes Facilitating Telehealth
In the United States, the 2018 Bipartisan Budget Act
extended telehealth access to home dialysis patients using
home as the originating site beginning in 2019.18
In a
survey of 30 PD patients conducted in August 2018, none
knew of the statute allowing them to opt for telehealth
from their home.19
Since 2019, nephrology and telehealth
journals have informed their readers about telehealth op-
tions for home dialysis patients and how to operationalize
them with little effect.15,20,21
However, during the COVID-19 pandemic, interest and
need for telehealth services have increased significantly,
Complete author and article
information provided before
references.
Am J Kidney Dis.
77(1):142-148. Published
online September 28, 2020.
doi: 10.1053/
j.ajkd.2020.09.005
© 2020 by the National
Kidney Foundation, Inc.
Perspective

Posi%on statement:
Spun% per la ricerca
• Qualità della dieta: la dieta
vegana planet- friendly
non è ...
• Qualità della dialisi: esiste l’ “iper-dialisi”?
• Valutazione dell’attività fisica anche in
termini di “risparmio” di farmaci, etc ...
• l’e-medicine dovrebbe essere un “plus”...

La clinica: in breve...
• La terapia nutrizionale, la terapia fisica, un
approccio olistico e personalizzato, la scelta di una
dialisi su misura non hanno solo un significato
clinico ma anche “ecologico”.
• Attenzione ai luoghi comuni, alle dimostrazioni
pleonastiche e agli alibi per ridurre il contatto con
i pazienti...
• La green nephrology è un “punto di vista”
“I did not become a vegetarian for my health, I did it for the
health of the chickens.”
Isaac Bashevis Singer

TECNOLOGIA: RECYCLE -REUSE
ma anche reduce.....

Posi%on statement: outline: technology
• Water conserva%on (reducing consump%on of natural
resources; recycling and reusing water).
• Energy conserva%on (reducing consump%on of natural
resources; employing alterna%ve energy).
• Waste management (reducing waste; promo%ng a wise
triage of contaminated and non contaminated waste;
introducing reuse and recycle whenever possible).
• Industrial design (inﬂuence the industry by considering
environmental impact a quality item; demand informa%on
throughout hardware, soDware and disposable lifecycle;
promote cradle to cradle approaches).

Green Nephrology and Eco-Dialysis Position Statement

Green Nephrology and Eco-Dialysis Position Statement

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