Green nephrology: mitigating the environmental burden of dialysis and promoting sustainable kidney care

The relationship between kidney health and the environment is increasingly recognized as a bidirectional "vicious cycle." As global temperatures rise due to climate change, the incidence of heat-stress nephropathy, acute kidney injury (AKI), and nephrolithiasis increases, thereby increasing demand for renal care. Paradoxically, the life-saving treatment for end-stage kidney disease (ESKD)-hemodialysis (HD)-is among the most resource-intensive interventions in modern medicine, with high water use, energy consumption, and waste generation. This Perspective article argues that nephrology must move from passive awareness to active mitigation. We summarize recent evidence showing that immediate clinical measures-such as reducing dialysate flow rates and adopting incremental HD-can lower environmental impact without compromising key treatment outcomes. We further argue that the sustainability hierarchy should begin upstream: delaying or avoiding dialysis through kidney-protective strategies, including appropriate dietary intervention, structured exercise, conservative kidney management, and transplantation where feasible. Finally, we emphasize that sustainable kidney care must also be patient-centered; interventions such as telemedicine are only truly sustainable when they are feasible, equitable, and acceptable for patients. Green nephrology should therefore integrate clinical optimization, engineering innovation, and patient-centered implementation into routine quality improvement.