Perspectives on Water Utilization in Hemodialysis: Nephrologists' Responsibilities.

Background: Hemodialysis is a water-intense procedure, needing large quantities of water for preparation of small volumes of dialysate. The resulting large volumes of reject water is usually discarded. With the rising water crisis both in the United States and the world, it is essential to understand water utilization and identify ways to minimize its utilization and maximize the use of the reject water.

Summary: Unfortunately, water from the city sources cannot be used to produce dialysate unless it undergoes further purification. This results in a large amount of reject water, which can be from 50-70% of total water use, resulting in an enormous waste of resources. A review of solutions for water sustainability is broadly classified into solutions that decrease water utilization and solutions for increased reject water utilization. Those that are aimed at decreasing water utilization were mainly based in innovations in technology - examples are NxStage PureFlow™SL, Aquaboss by Braun and AquaBPlus by Fresenius, and those that focused on increased reuse of RO reject water rely on data that it can be safely utilized for various purposes such as irrigation and flushing toilets. These strategies can be cost-effective. Although the need for sustainability has been recognized there needs to be further awareness and participation among nephrologists to further this cause. In addition, there need to be policies put forward by the government that could encourage sustainability.

Key messages: Hemodialysis continues to heavily tax the environment. Although the need for sustainability has been recognized, there still remains a lot of work that needs to be done. Further buy-in is needed from all participating entities - nephrologists, dialysis manufacturers and organizations and the government in order to safeguard our limited resources.