Challenges to Implementing Environmentally Sustainable Kidney Care in LMICs: An Opinion Piece

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Journal canadien de la santé et de la maladie rénale
https://doi.org/10.1177/20543581241246835
Canadian Journal of Kidney Health
and Disease
Volume 11: 1 –11
© The Author(s) 2024
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Sustainable Nephrology – Introduction, Perspectives, and Pathways to Low Carbon Quality Kidney Care – Opinion Piece
1246835CJKXXX10.1177/20543581241246835Canadian Journal of Kidney Health and DiseaseBajpai et al
research-article20242024
1Department of Nephrology, King Edward (VII) Memorial Hospital and
Seth Gordhandas Sunderdas Medical College, Mumbai, India
2Unit of Nephrology, Department of Internal Medicine, University of
Gondar, Ethiopia
3Directorate of Internal Medicine, Mulago National Specialized Hospital,
Kampala, Uganda
4University of Nigeria Teaching Hospital, Enugu, Nigeria
5Electron Microscopy Department, Clinical Laboratory Division, Theodor
Bilharz Research Institute, Giza, Egypt
6Department of Medicine, Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana
7Renal Unit, Department of Medicine, Komfo Anokye Teaching Hospital,
Kumasi, Ghana
8Department of Clinical Medicine, Faculty of Medicine, University of
Colombo, Sri Lanka
9Department of Physiology, Makerere University and Mulago Hospital,
Kampala, Uganda
10Division of Nephrology and Hypertension, Department of Internal
Medicine, University of Minnesota, Minneapolis, USA
11Division of Nephrology and Hypertension, Department of Medicine,
American University of Beirut, Lebanon
12Research Department, Pro-rim Foundation and School of Medicine,
UNIVILLE, Joinville, Brazil
13Division of Nephrology, Centre Hospitalier de l’Université de Montréal,
Québec, Canada
14Health Innovation and Evaluation hub, Centre de Recherche du Centre
Hospitalier de l’Université de Montréal, Québec, Canada
15Divisions of Nephrology and Experimental Medicine, Department of
Medicine, McGill University, Montreal, Quebec, Canada
16MEDIC, Research Institute of the McGill University Health Centre,
Montreal, Quebec, Canada
Corresponding Author:
Divya Bajpai, Department of Nephrology, King Edward (VII) Memorial
Hospital and Seth Gordhandas Sunderdas Medical College, Ward 34A,
Third Floor, Mumbai 400012, India.
Email: divyaa24@gmail.com
Challenges to Implementing
Environmentally Sustainable Kidney
Care in LMICs: An Opinion Piece
Divya Bajpai1, Workagegnehu Hailu2, Peace Bagasha3,
Onu Ugochi Chika4, Ehab Hafiz5, Elliot Koranteng Tannor6,7 ,
Eranga Wijewickrama8, Robert Kalyesubula9,
Sabine Karam10,11, Viviane Calice-Silva12, Isabelle Ethier13,14,
and Shaifali Sandal15,16
Keywords
climate change, environmentally sustainable kidney care, barriers, physician perspective, low- and middle-income countries
Received December 8, 2023. Accepted for publication March 22, 2024.
Introduction
Kidney care, especially dialysis, has a substantial environ-
mental impact through greenhouse emissions and waste gen-
eration.1-4 Thus, the Canadian Society of Nephrology
implemented a Sustainable Nephrology Action Planning
(SNAP) committee to inform best practices in environmen-
tally sustainable kidney care (ESKC).5 The committee out-
lined the necessity of ESKC, provided an overview of the
existing literature, proposed a planetary health care frame-
work of redesigned kidney care, and developed a toolkit
called “Creating a Sustainable Canadian Health System in a
Climate Crisis.”6-8
Developing and implementing such a framework and
toolkit in low- and middle-income countries (LMICs)
requires a better understanding of the challenges faced by
these health systems as many have substantially lower health
expenditure per capita when compared with Canada.
However, resource-limited countries are more vulnerable to
the impact of climate change and other disasters despite hav-
ing lower CO2 emissions per capita when compared with
many resource-rich countries.9-13 Also, similar to high-
income countries, health care in LMICs is a carbon-intensive
activity including kidney care as hemodialysis is the only
available or most readily available therapy in many LMICs.14
As the prevalence of chronic kidney disease (CKD) is rising,
the burden of kidney care will likely grow substantially as
more countries commit to the UN Sustainable Development
Goal 3.8 of increasing access to health care.15-17 Thus, the
increasing prevalence of CKD, a commitment to improving
access to health care by many nations and hemodialysis

2 Canadian Journal of Kidney Health and Disease
being the main option available to those with kidney failure
further necessitates the need to implement ESKC practices in
LMICs.
This opinion piece synthesizes the perspectives of health
care professionals (HCPs) who work in LMICs. These mem-
bers were identified from the two cohorts of the International
Society of Nephrology’s Emerging Leaders Program.2,18
This program brings together and mentors a worldwide net-
work of future leaders in kidney care who work collabora-
tively on issues relevant to the nephrology community. Those
who participated, shared their perspectives narratively on the
challenges and solutions to providing ESKC in their respec-
tive regions. Two co-authors synthesized these inductively
into themes (D.B. and S.S.). Implications were then devel-
oped collectively.
Characteristics
Ten participants representing 9 different LMICs provided
their narratives. Participants represented 1 upper-middle
income country (Brazil), 6 lower-middle countries (Egypt,
Ghana, India, Lebanon, Nigeria, Sri Lanka), and 2 low-
income countries (Ethiopia, Uganda). Hemodialysis is avail-
able as a renal replacement therapy in all countries, whereas
peritoneal dialysis and transplantation are available in some
but not all (Table 1).
The health care expenditure and CO2 emissions per cap-
ita for all these 9 countries were substantially lower when
compared with Canada. The prevalence of patients on
hemodialysis in Brazil and Lebanon (a former upper-mid-
dle income country) was at par with Canada and slightly
lower in Egypt. The prevalence of patients on peritoneal
dialysis was much lower in all countries when compared
with Canada (Figure 1).
Barriers to Implementing Environmentally
Sustainable Kidney Care
A health system comprises several levels,24,25 and we strati-
fied barriers by patient level, provider level, and system level
(Figure 2).
Patient-Level Barriers
Poor and inequitable access to health care. All participants
report the lack of universal health care as the most critical
barrier to implementing ESKC. Sustainability is not a prior-
ity for patients when most cannot afford medications, trans-
plantation, or dialysis, such as in Uganda, where 90% of
patients in need of kidney replacement therapy cannot afford
it.26 In addition, access to care is inequitable as most dialysis
and transplant programs are located in urban centers,14,20 and
many patients incur substantial out-of-pocket expenses
(Table 1).
Poor appreciation of preventative approaches and delay in seek-
ing care. Lack of awareness of CKD and delay in seeking
care is another critical barrier. In Nigeria, for instance,
patients either live in denial of disease even with overt symp-
toms or consider it as “the will of God” and thus resort to
faith-based healing practices or use of herbal concoctions.
Thus, many present with uremic symptoms limiting opportu-
nities to initiate early treatments to prevent CKD progres-
sion. It is well recognized that the carbon footprint of kidney
care increases with increasing CKD stages.3,6 Also, patients
are largely unaware of the risk factors for CKD, such as dia-
betes. Similarly, India is called the diabetes capital of the
world.27 Increasing obesity, sedentary lifestyle, cost of
healthy food choices, and increased consumption of cheaper
high-carbohydrate diets contribute to the burden of diabetes
and CKD.28,29
Lack of patient education and empowerment. Most patients
are not fully aware of the environmental impact of kidney
care and unaware of practices in ESKC. They are not empow-
ered to engage in self-care and home-based practices, such as
through home monitoring of blood pressure, blood glucose,
and proteinuria detection. These simple interventions could
lower the travel footprint of kidney care and help with early
CKD detection and management.
Low uptake of sustainable treatments. In some regions, the
uptake of kidney transplantation and home dialysis is low
either due to lack of availability (Table 1) or significant cul-
tural and religious barriers.30 In Lebanon, deceased organ
donation is commonly refused because of unfamiliarity with
the concept of brain death, denial, and the expectation of a
miracle. In some regions, conservative kidney care manage-
ment is not pursued as it is perceived to be a pathway of
abandonment.
High travel footprint. Care delivery tends to be concentrated
in urban centers contributing to a significant travel foot-
print.20 In India, up to 60% of patients must travel >50 km to
access hemodialysis.27 In Uganda, dialysis facilities are pres-
ent in 4 districts that cater to the country, as well as to the
Eastern Democratic Republic of Congo and South Sudan. In
Ethiopia, most hemodialysis centers are situated in the capi-
tal. Furthermore, patients often prefer taking individual
transportation, such as a fuel-inefficient but cheap ride called
a Tuk-tuk in Sri Lanka (Figure 3) rather than public transpor-
tation. In other regions, such as Lebanon, public transporta-
tion is quasi-inexistent or unreliable.
Provider-Level Barriers
Lack of education. The greatest barrier is a lack of awareness
of ESKC. Some consider it to be a relatively new concept
with limited evidence to support practices. Thus, many HCPs

3
Table 1. Participants, Their Backgrounds, Available Renal Replacement Therapies, and Health Systems in Their Countries.
Name
Country and income level of the
country and available therapies Current practice setting Renal replacement therapies available and access Health system in the country
Divya Bajpai
India, Lower-middle income
HD+
PD+
KT+
Nephrologist at one of the busiest public sector
hospitals and medical colleges in Mumbai that caters
to the most underprivileged strata of society and
provides services (general nephrology and transplant)
to both pediatric and adult patients
All therapies available (HD, PD, KT) but are
generally centered in urban India. CAPD is
out of reach of many patients as it is costly
and not covered under the majority of state
government insurance schemes. Most patients
travel to metropolitan cities for KT. Care for
AKI is compromised in remote areas
Universal health coverage is unavailable, though
services are subsidized to those below the
poverty line. The cost is usually borne jointly by
the patient and by the state. However, there are
still significant out-of-pocket expenses for the
patients
Workagegnehu Hailu
Ethiopia, Low income
HD+
One of the few nephrologists in the country and the
only practicing nephrologist in the northwest part
of Ethiopia working as a consultant nephrologist at a
comprehensive specialized hospital in Gondar
HD only (both for AKI and ESKD) Ethiopia has no universal health coverage
program. Recently, community-based health
insurance (CBHI) was adopted which primarily
covers essential health service packages.
However, most of the care for kidney diseases
including HD is out-of-pocket
Peace Bagasha
&
Robert Kalyesubula
Uganda, Low income
HD+
PD+
One of the few nephrologists in the country who work
at Makerere University and Mulago National Referral
Hospital in Kampala
HD available at limited locations but PD erratic.
No KT services in the country yet
Uganda has no universal health coverage program,
and most of the care for kidney disease is out
of pocket
Onu Ugochi Chika
Nigeria, Lower-middle income
HD+
Living donor KT+
Work as a nephrologist in a government owned
university teaching hospital which serves as a major
nephrology referral center for southeast Nigeria and
beyond
HD is the major form of renal replacement
therapy but centers are mainly located in big
cities. Living donor KT services are available
in very few cities. However, both transplant
and hemodialysis are generally unaffordable for
most patients
Out-of-pocket payment is the norm. Few patients,
mainly civil servants, benefit from national health
insurance scheme which only cover drugs (when
available) and first 6 acute hemodialysis sessions
Ehab Hafiz
Egypt, Lower-middle income
HD+
PD+
KT+
A pathologist, one of the very few who specialize in
renal pathology in Egypt. Working in governmental
hospital (Theodor Bilharz Research Institute) in Giza
which has an electron microscopy unit serves as a
major hub for renal biopsies referral center receiving
renal biopsies from all over Egypt territories as well
as many countries in Africa and the Middle East.
Provide services (general nephrology and transplant)
to both pediatric and adult patients. Also, work at
a private renal pathology service and International
Society of Nephrology’s regional center of training
located in Cairo
HD is available in all cities and some suburban
areas. It is predominantly in-center and the
most used modality (83%)
Very few PD and erratic. KT is available in few
centers at big cities only and is exclusively living
donors (2.5%)14
Health services in Egypt are managed, financed,
and provided by agencies in all three sectors of
the economy—government, parastatal (Health
Insurance Organization), and private (including
for-profit and non-profit organizations). Egyptian
health care market is based mainly on out-of-
pocket expenses, about 60% of total health
expenditures.14
The cost of HD is usually afforded jointly with the
patient and other sector either governmental
or health insurance. However, there are still
significant out-of-pocket expenses for the
patients
Elliot Koranteng Tannor
Ghana, Lower-middle income
HD+
Living donor KT+
Senior Lecturer in the Kwame Nkrumah University
of Science and Technology and a consultant
Nephrologist at the Komfo Anokye Teaching Hospital
Mainly HD (96.2%) with few living related KT
(3.5%) mostly out of the country as there is
no established KT program.19 HD is present
in 9 of the 16 regions and with inequitable
distribution of HD centers.20 There are
occasional living donor KT done with external
expertise in a public teaching hospital and
recently a private facility
Ghana has a national health insurance scheme
for some medical conditions. The management
of kidney disease and kidney failure is not
reimbursed by the national health insurance
scheme. Patients pay out of pocket
(continued)

4
Name
Country and income level of the
country and available therapies Current practice setting Renal replacement therapies available and access Health system in the country
Eranga Wijewickrama
Sri Lanka, Lower-middle income
HD+
PD+
KT+
Consultant nephrologist at the University Medical Unit
of the National Hospital of Sri Lanka, the largest
hospital in Sri Lanka. Two other nephrologists work
in the unit and there are two other nephrology units
run by two other consultant nephrologists attached
to the Ministry of Health
All types of kidney replacement therapies
available except home HD. Predominantly in-
center HD. Few patients on PD—both CAPD
and APD. Well-functioning KT program—
predominantly living donor with an improving
deceased donor program
All health care is provided free of charge to
patients at state hospitals. However, HD
services are overwhelmed, and therefore,
majority of the patients are not given or given
substandard dialysis in the state sector. Many
have to pursue dialysis in the private sector
with private funds. Both CAPD and APD are
fully funded by the government. KT done in
state hospitals free of charge with lifelong supply
of medications, including immunosuppressive
medications provided free of charge
Sabine Karam
Lebanon, Since 2022 a lower-
middle income (was upper-middle
income)
HD+
PD+
KT+
Formally worked at one of the largest tertiary care
centers and university hospital in Lebanon in the
capital Beirut that hosts one of the largest chronic
dialysis centers and one of the two only pediatric
units in the country
All therapies available (HD, PD, KT); however,
the most used modality is by far HD (93%)
followed by PD around 5%, then KT 2%-3%
most exclusively living donors in the absence of
an efficient organ procurement system
Offers universal health coverage for kidney
replacement therapy to all its citizens since
1973; however, as the national currency has
lost more than 95% of its value as compared to
US dollars since a devastating economic crisis
started in 2019, government reimbursement in
local currency although increased not sufficient
and patients have now to pay significant out-of-
pocket expenses to have access to all modalities
Viviane Calice-Silva
Brazil, Upper-middle income
HD+
PD+
KT+
Adult nephrologist and clinical researcher at Pro-
rim Foundation, Joinville, Brazil, and an associated
professor at the school of Medicine at the Joinville’s
region university (UNIVILLE), Joinville, Brazil. Work
mainly with PD and CKD conservative care. There
are 8 other nephrologists running the HD units and
KT service including outpatient clinics as well as
the nephrology ward which are allocated in 3 public
hospitals and three private hospitals in the city
All available Most part of patients receive their treatment
funded by the government (85/90% for
conservative and dialysis and 100% for KT).
There is another dialysis unit which covers
only private patients which is ran by other 4
nephrologists and they offer mainly HD
Note. AKI = acute kidney injury; CAPD = continuous ambulatory peritoneal dialysis; ESKD = end-stage kidney disease; HD = hemodialysis; PD = peritoneal dialysis; KT = kidney transplantation;
CBHI = community-based health insurance; CKD = chronic kidney disease.
Table 1. (continued)

Bajpai et al 5
Figure 2. Patient-level, provider-level, and system-level barriers to implementing environmentally sustainable kidney care.
Figure 1. Characteristics of the nine countries whose participants provided narratives compared with Canada organized by the CO2
emissions per capita.21 Also provided income level,22 health expenditure per capita (2020; current US$),23 long-term dialysis centers
(pmp),14 and prevalence of long-term dialysis (pmp).14

6 Canadian Journal of Kidney Health and Disease
Figure 3. A Tuk-tuk, a fuel-inefficient cheap ride taken by many
patients when accessing kidney care in Sri Lanka. This was one
of the many sources of the high travel footprint of kidney care
(Picture credit: Eranga Wijewickrama).
struggle to adopt them and advocate for them. In addition,
changing behaviors and practices can be met with resistance
by institutions and some fear professional repercussions
depending on the political climate. Access to relevant educa-
tional resources and opportunities to engage in ESKC are
also barriers. Some are not well trained or prepared to dis-
cuss conservative options in kidney care.
Lack of adequately trained manpower. The lack of medical
doctors and pharmacists has been identified as a key barrier
to sustainability in Mpumalanga, South Africa;31 this reso-
nated with all participants. They described an increased bur-
den of undertaking primary care and other care facets due to
the lack of adequately trained ancillary staff, such as nutri-
tionists and social workers. Many participants are one of the
few specialists in their countries and have a huge patient load
to care for (Table 1). This limits the time HCPs can invest in
ESKC.
Poor remuneration. In general, many felt that HCPs with the
knowledge to deliver dialysis efficiently are inadequately
renumerated and relocate to other regions for economic and
security reasons. This is well described as the Japa syndrome
in Nigeria and further fuels manpower shortage.32 Moreover,
the lack of adequate physician and center reimbursement for
home therapies incentivizes the use of a more lucrative
option, ie, in-center hemodialysis.
Competing priorities. Chronic kidney disease care is complex
and combined with all the factors described above, many
HCPs find themselves prioritizing acute patient needs over
ESKC practices, such as deprescribing or incremental dialy-
sis. Other low-value aspects were identified, such as main-
taining health records on paper (instead of digital), which
leads to duplication of work and increases carbon footprint.
However, engagement needs organizational support.
System-Level Barriers
Limited resources and competing priorities. All participants
unanimously mentioned this as the biggest barrier to imple-
menting ESKC. Many countries at baseline have fragile
health care systems and lack the infrastructure to diagnose
and treat lower CKD stages. In Nigeria, the budgetary alloca-
tion to health was only 5.75% in 2023, far below the 15%
target proposed by the WHO.33 The focus is on communica-
ble and other non-communicable diseases (NCDs); kidney
disease is rarely a priority. When it is prioritized, the focus
is on accessibility and affordability, not sustainability. In
Sri Lanka, eg, when the Ministry of Health makes bulk pur-
chases for tubing and dialysis solutions, cost, quality and
immediate delivery are prioritized. Biodegradability or recy-
clability is generally not a consideration.
Poor recognition of kidney disease as a public health prob-
lem. Like patients and HCPs, many administrators, policy-
makers, and other governmental personnel are largely
unaware of the environmental impact of kidney care and the
benefits of ESKC. Chronic kidney disease is a neglected
NCD in many African regions.34,35 Thus, there is minimal
support and low governmental investment in the early detec-
tion of CKD and the implementation of preventative mea-
sures to delay progression.36
Political and economic instability. In many regions, unstable
governments, ongoing conflicts, and economic crises also
contribute. Lebanon, for instance, has been without a presi-
dent and a lasting government for more than a year. The lack
of stable governments challenges any investment toward
ESKC. Also, there are significant issues related to inflation
and increasing costs that not only impact accessibility and
affordability of kidney care but also implementing preventa-
tive care, such as healthy diets that are generally more expen-
sive than high fat, sugar and/or salt foods with little or no
nutritional value.
Disincentivizing Environmentally Sustainable Kidney Care.
Another major barrier is that currently there are no incentives
to generate the infrastructure toward ESKC. Many instead
reported disincentives due to corruption, bureaucratic inter-
ference, and privatization that have led to the prioritization
of short-term profits. In many countries, renewable energy
sources can be easily implemented; however, high startup

Bajpai et al 7
Figure 4. Pictures demonstrating the amount of waste
generated following dialysis sessions in Nigeria (Picture credit:
Onu Ugochi Chika).
Figure 5. Pictures demonstrating the poor waste
management infrastructure in Uganda (Picture credit: Robert
Kalyesubula).
costs, lack of enthusiasm, and lucrative commissions for
administrators from the fossil fuel sector are significant dis-
incentives. For example, the Nigerian economy is largely
dependent on crude oil exportation hindering any efforts to
invest in alternative sources of energy.
Poor waste management infrastructure. Many reported a
lack of proper waste management practices and policies.
Where policies exist, they are often not enforced or strictly
implemented due to a lack of resources or ineffective reg-
ulatory bodies. Most dialysis units generate enormous
waste (Figure 4) and do not have any clear measures for
decreasing waste or recycling it.
In some regions, there is no recycling infrastructure, and
incineration is the mainstay of waste management. Industrial
waste products, poor management of the wetlands, increased
urbanization, poor disposal mechanisms, and loose regula-
tions contribute to significant environmental pollution
(Figure 5). This directly impacts the risk of acute kidney
injury and indirectly the costs associated with kidney care.
For instance, removing high levels of arsenic and other com-
pounds from water sources used to generate dialysate in
Uganda adds to the cost of delivering dialysis.37 All these
factors contribute to the high costs of dialysis curbing any
effort to pursue ESKC.
Lack of access to home dialysis therapies and transplanta-
tion. In some countries, kidney transplantation is not
available, not widely available, or unaffordable. Patient
who can afford it, embark on medical tourism, and have
to travel to other countries to obtain a transplant. Perito-
neal dialysis is also not widely available due to infrastruc-
tural and logistical inconsistencies. Thus, patients have
access to hemodialysis only, the less sustainable therapy
(Table 1).
Poor investments or lack of enthusiasm in research and develop-
ment. There is limited infrastructure to implement telehealth
and telemedicine approaches to minimize the footprint asso-
ciated with travel in many regions. Before the COVID-19
pandemic, teleconsultations were considered illegal in India,
and there were legal repercussions for physicians who pur-
sued them.
In addition, the major worldwide footprint of the health
sector is primarily derived from the supply chain through the
production, transport, and disposal of goods and services.38
The industrial infrastructure to manufacture medications and
dialysis supplies locally are generally lacking. Thus, kidney
care relies on carbon-intensive imports. Of concern was also
that the economic instability in some regions has led many
multinational drug companies to shut down local manufac-
turing, worsening the situation.
Many mentioned that the lack of evidence demonstrating
the benefits of ESKC significantly hinders advocacy efforts.
Poor funding in health research is a major barrier to initiating
research projects. For the system to champion ESKC, effec-
tive implementation strategies and evidence-based data are
required. Without support for research, this cannot be gener-
ated. Thus, there is a lack of policy and guidelines on the
subject matter.
Policy and Practice Implications
Although large-scale projects have been implemented in
some countries, such as the Benban Solar Park project in
Egypt to increase renewable energy sources, there have been
minimal efforts to adopt such technologies in the health care
sector. At the grassroots level, some initiatives were reported.
For example, a dialysis center in Uganda utilizes its large
open window design to minimize the use of electricity for
light and air conditioning (Figure 6). However, participants
described the need for system-wide efforts and investments
rather than microlevel interventions to effectively promote

8 Canadian Journal of Kidney Health and Disease
and adopt ESKC.39 Many mentioned that global cooperation
is required as increasing access to health care must be priori-
tized in LMICs. We propose implications stratified by scope
of relevance (Figure 7).
Implications at a Global Level
Recognizing kidney disease as an important NCD. A key rec-
ommendation is the global recognition of CKD as an impor-
tant NCD to increase investment in early detection and
preventative care. Kidney health has traditionally received
far less attention than some other NCDs. The global burden
of CKD is enormous and rising.29 Recognition of CKD as an
important NCD will increase investment and promote prac-
tices in preventative nephrology and ESKC.
Education of all stakeholders. Educating leaders, politicians,
patients, HCPs, and other stakeholders on the environmental
burden of kidney care and measures to address them is
important. Chronic kidney disease awareness is a cost-effec-
tive approach to preventive nephrology as lack of awareness
was identified as a key barrier at the patient level, provider
level, and system level.
Research and development. There is a need to invest in
research and innovation in ESKC. Lack of evidence can sig-
nificantly hinder the uptake of practices by relevant stake-
holders. The development of newer technologies and
treatment methods that are both effective and eco-friendly
while being cost-effective will increase enthusiasm for
ESKC. Health care professionals can then champion devel-
oping and implementing such technologies and treatment
methods at regional levels.
Implications at a Regional Level
Health care accessibility. Although aspirational, one of the
strongest recommendations by all was the implementation of
universal, accessible, equitable, and affordable health care.
Given the most significant barrier to ESKC pertains to costs
associated with kidney care, improving access to home-based
dialysis and transplant will prove both cost-effective and
more sustainable over in-center hemodialysis. Also, improved
health care access that particularly strengthens primary care
access may promote early CKD detection allowing interven-
tions to decrease the risk of progression to kidney failure.
Cultivating local expertise. To implement ESKC practices
requires local expertise who understand the barriers and
are more equipped to develop implementation strategies.
Many participants mentioned the disheartening experi-
ences that increased the “brain drain” in their regions. Sup-
port mechanisms that promote and nurture the creation and
retention of HCPs and implementing appropriate remuner-
ation were key suggestions. Training surgeons in trans-
plantation will contribute to building or strengthening
transplant programs.
Investing in preventative measures. As the carbon footprint of
kidney care increases with increasing CKD stages, another
recommendation was to invest in early detection and preven-
tion of CKD as the best waste is the one which is never gen-
erated. Thus, preventive nephrology practices and timely
detection and management of risk factors are key strategies
toward ESKC.
Creating satellite units and optimizing telemedicine and telehealth
practices. Mobile and Internet connectivity is growing in
LMICs with half of the population using mobile Internet.40
Promoting telemedicine and virtual consultation and ensuring
appropriate compensation of HCPs will encourage optimal
implementation of preventative care, decrease the transporta-
tion-related costs, and environmental burden associated with
patient and HCP travel. Many respondents emphasized the
need to spread available dialysis services to remote areas that
can be virtually managed. This can also help implement tele-
health geared toward educating the public and patients on
CKD and risk factors. Patients can be empowered on self-
management and self-monitoring. Smartphone technology
with health-based apps can help track health parameters and
generate prompts for implementing automated educational
resources or a virtual visit with an HCP. Countries like India,
with over two thirds of the population using smartphones, can
quickly implement such measures.41
Waste management. Another big recommendation was to
invest in not just reducing waste generation, but toward
improving waste management, particularly the recycling
infrastructure. This was acutely described by some
Figure 6. A local initiative in energy conservation at a dialysis
unit in Uganda. Large and open windows in dialysis unit minimize
the need for air conditioning and electricity (Picture credit: Peace
Bagasha).

Bajpai et al 9
Figure 7. A visual representation of proposed practice and policy implications.
participants from Africa where incineration is a major method
of discarding waste. Varied mechanisms are needed depending
on the type of waste generated as has been detailed by the
World Health Organization.42 Practices monitoring waste in
dialysis units are also needed to inform measures toward
ESKC. This may increase governmental investment in it and
help plan a clear strategy to address it. At a regional level, in
Brazil, some facilities have implemented initiatives to become
more sustainable, but national policies would encourage more
uptake.
“Make local, buy local.”. Local manufacturing can signifi-
cantly decrease the costs of supplies and medications which
are major contributors to the carbon footprint of kidney care.
This may encourage low-carbon innovations and motivate
pharmaceutical companies and other manufacturers to com-
pete in finding such solutions. The “Atmanirbhar Bharat
movement” and the “Buy Uganda Build Uganda” policy
were cited as examples of governmental initiatives to make
India and Uganda self-reliant by increasing the local produc-
tion of goods. This will in turn reduce the carbon footprint of
importing drugs and devices.
Implications for the Nephrology Community
Implementing best practices toward environmentally sustainable
kidney care. Deprescribing, the process of tapering, stopping,
discontinuing, or withdrawing drugs that are not indicated or
have poor evidence of efficacy can also make a significant
difference by decreasing the environmental burden associ-
ated with manufacturing, supply chain, and disposal of
drugs.43-45 Approaches to incremental dialysis can also help
reduce waste generation.46,47 Cultivating local expertise and
generating guidelines to inform other HCPs can help cham-
pion ESKC.
“Transplant first” initiatives. Initiatives in increasing kidney
transplantation are relevant because it is the better treatment
option and generally believed to have a lower ecological bur-
den than dialysis. Implementing this requires significant
grassroots efforts in advocacy and education to overcome
cultural and religious barriers in some regions and increase
both living and deceased organ donation.
Inclusion and representation. Local HCPs with practical
knowledge are better equipped to know the barriers and
facilitators to implement practices in ESKC in their respec-
tive regions. Their inclusion and involvement are extremely
important to advocacy efforts. Initiatives from global orga-
nizations such as the International Society of Nephrology
that support training opportunities for nephrology work-
force and increase local expertise and manpower were
recommended.48,49

10 Canadian Journal of Kidney Health and Disease
Conclusions
In this opinion piece, we summarized the perspectives of
HCPs from 9 different LMICs. Several patient-level, pro-
vider-level, and system-level barriers to ESKC were sum-
marized of which lack of education and awareness of all
stakeholders are easily modifiable. The lack of universal
health care and the high costs of delivering kidney care
that prioritizes accessibility over sustainability were unan-
imously reported as barriers to ESKC. Investment and pro-
motion of lower-cost therapeutic options such as
transplantation and dignified conservative care among eli-
gible patients would also decrease the environmental bur-
den of delivering kidney care as they generally have a
lower ecological footprint than hemodialysis. Effective
development of ESKC and regional implementation
requires global collaborative efforts and system-level
changes with representation and inclusion of HCPs from
LMICs. The implications proposed may help develop an
implementation framework for ESKC in resource-poor
settings.
List of Abbreviations
CKD, chronic kidney disease; ESKC, environmentally sustainable
kidney care; HCP, health care provider; LMIC, low- and middle-
income country; NCD, non-communicable disease.
Acknowledgments
Drs S.S. and I.E. are supported by the Chercheur boursier clin-
icien—Junior 1 award from the Fonds de recherche du Québec—
Santé. Dr R.K. is supported by a grant from the Mulago Foundation
as the Rainer Anhold Fellow.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Dr S.K. is a scientific consultant for George Clinical. Dr
V.C.-S. is a speaker and consultant from Baxter Brazil. Dr S.S. has
received an education grant from Amgen Canada. The rest of the
authors have no relevant disclosures.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
Ehab Hafiz https://orcid.org/0000-0002-1551-4309
Elliot Koranteng Tannor https://orcid.org/0000-0002-5978-
0510
Shaifali Sandal https://orcid.org/0000-0003-1941-0598
Data Availability
No new data generated.
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