NEWS & VIEWS OUTLOOK
knowledge of the dietary and fluid restrictions required if dialysis is interrupted; stockpiling of requisite foods and medical supplies; and acquisition and storage of a potassium-binding resin.7 Mitigation (that is, primary prevention through decarbonization) and adaption (that is, secondary prevention by anticipation of the consequences) strategies to counter climate change and its effects are under-developed worldwide. Patz at al. correctly identify the important role of healthcare professionals in understanding and communicating the grave public health risk that inaction confers. Health-care professionals must advocate the changes required, at a population level, to the lifestyles of individuals in order to reduce per capita carbon output. These changes include reducing unnecessary travel; active transport when travel is necessary (walking or cycling in place of passive transport, which requires fossil fuel consumption); and reduction in meat intake, balanced by increased vegetable intake. Each of these changes benefit not only the environment but also the individual. For example, exercise confers significant benefits to patients with CKD.8 A reduction in the prevalence of obesity would reduce the incidence of diabetic nephrop athy. Substitution of vegetable protein for meat reduces serum phosphate and FGF‑23 levels, improves uraemic acidosis, reduces the risk of kidney stones, and might reduce the incidence of diabetes and cancer. The health-care industry itself, together with its supply chain, contributes markedly
Implications of climate change for nephrology Charles Tomson and Andrew Connor
It is now accepted that climate change is occurring as a result of human activity and that it will have potentially devastating effects on health. Nephrologists are likely to see a changing spectrum of disease as a consequence of climate change and are ideally placed to lead mitigating strategies in health-care provision.
In a comprehensive assessment of the health risks relating to climate change, Patz et al. provide a timely reminder that anthropogenic climate change is happening, and that the resultant heat waves, floods, droughts, poorer air quality, altered patterns of transmissible diseases, changes in food yields and population displacement are unquestionably having major adverse effects on global health.1 In the light of these findings, nephrologists worldwide must be prepared for changes in patterns of disease, and should share responsibility for mitigating the progression of climate change.
‘‘
...nephrologists worldwide must be prepared for changes in patterns of disease...
’’
To many nephrologists the implications of climate change on global kidney health will seem obvious but also distant from the populations they currently treat; it is also true that the greatest health impacts will be felt by those who have contributed the least to the accumulated reservoir of greenhouse gas emissions and for whom access to health-care resources is most limited.2 Extreme weather events will become more common as the climate changes. Flooding is associated with increased diarrhoeal i llness—a major cause of acute kidney injury (AKI) in low-income countries—and higher incidences of leptospirosis, vectorborne diseases, and hantavirus infections.3 Poor access to clean drinking water combined with prolonged exposure to high
temperatures, causing cyclical dehydration, likely contributes to the epidemics of chronic kidney disease (CKD) reported in Mesoamerica and Sri Lanka.4 In their report, Patz et al. concentrate on the health impacts expected within the USA; however, nephrologists in many other developed countries will also see changing patterns of disease.1 Studies undertaken in different continents have reported increases in hospital admissions for AKI during heat waves. 5 High-risk groups include those already familiar to nephrologists—patients with CKD and those receiving medications that inhibit thermoregulation (including diuretics and β‑blockers). Repeated episodes of AKI contribute to the pathogenesis of CKD and increase the risk of end-stage renal disease. In addition, higher mean annual temperatures and increasing numbers of extreme heat days promote nephrolithiasis: the current rate of rise in temperature will probably result in an increase of 2 million lifetime cases of stone disease in the USA by 2050.6 Climate change is also likely to have a destabilizing impact on the provision of health care to patients with kidney disease, particularly in developing countries. Extreme weather events (including floods, hurricanes, ice storms and snow storms) will disrupt the supply of clean water and power for haemodialysis, and also the transport of supplies for haemodialysis and peritoneal dialysis. Adaptation requires that nephrologists and their patients prepare disaster plans. For patients on dialy sis, for example, preparedness requires
NATURE REVIEWS | NEPHROLOGY
Getty
Tomson, C. & Connor, A. Nat. Rev. Nephrol. advance online publication 4 November 2014; doi:10.1038/nrneph.2014.199
ADVANCE ONLINE PUBLICATION | 1 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS to climate change; 8% of all carbon emissions in the USA derive from health-care provision.9 An opportunity therefore exists for health-care providers in developed countries to lead by example and influence public attitudes to carbon reduction, similar to the way in which attitudes to smoking cessation were led by health-care professionals. The renal community is well placed to take the lead in this regard. The carbon footprints of renal services and specific treatments (including dialysis) are already understood.10 We know, for instance, that 65% of the carbon emissions of a renal service derive from dialysis provision. Many opportunities for, and benefits of, low carbon kidney care have already been evaluated, published and adopted. Examples include: solar-powered dialysis; the reuse of water from reverse osmosis dialysis water-purification plants; central dialysate acid delivery; recycling of dialysis consumables; retrofitting heat-exchangers to dialysis machines; and remote care initi atives such as telephone clinics. The great majority of carbon emissions in renal care derive from the supply chains for pharmaceuticals and medical equipment rather than from travel or building energy use. Strategies such as shared decision-making to ensure that drugs are only dispensed if patients are likely to take them, will, therefore, also contribute to reducing carbon emissions. Shared learning among renal services and collaboration with the renal industries are
vital to promote the wider adoption of such initiatives. In addition to these technical advances, a continued focus on reducing the number of people on dialysis (by better preventive care, increasing transplantation rates and ensuring that only patients who will derive benefit from dialysis initiate treatment) would make a major contribution to reducing the carbon footprint of kidney care, as well as to improving outcomes for our patients. The examples given above illustrate the indirect benefits of carbon reduction strategies within health-care settings. Many examples, most obviously those intended to reduce the energy use of buildings, also offer financial savings—a powerful lever for change in the current economic climate. Other examples, such as those that eliminate waste through streamlining care pathways, also offer improved patient experience, greater involvement of patients in their own care, and have the potential to improve care co-ordination and reduce costs, particularly for patients with more than one chronic disease. Richard Bright Renal Unit, Brunel Building, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol BS10 5NB, UK (C.T.). South West Transplant Centre, Derriford Hospital, Derriford Road, Crownhill, Plymouth, Devon PL6 8DH, UK (A.C.). Correspondence to: C.T. [email protected]
2 | ADVANCE ONLINE PUBLICATION
Competing Interests The authors declare no competing interests. 1.
Patz, P. A., Frumkin, H., Holloway, T., Vimont, D. J. & Haines, A. Climate change: challenges and opportunities for global health. JAMA http://dx.doi.org/10.1001/ jama.2014.13186. 2. Costello, A. et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 373, 1693–1733 (2009). 3. Lameire, N. H. et al. Acute kidney injury: an increasing global concern. Lancet 382, 170–179 (2013). 4. Johnson, R. J. et al. Hyperosmolarity drives hypertension and CKD—water and salt revisited. Nat. Rev. Nephrol. 10, 415–420 (2014). 5. Hansen, A. L., Peng, B., Nitschke, M., Pisaniello, D. & Tucker, G. The effect of heat waves on hospital admissions for renal disease in a temperate city of Australia. Int. J. Epidemiol. 37, 1359–1365 (2008). 6. Fakheri, R. J. & Goldfarb, D. S. Ambient temperature as a contributor to kidney stone formation: implications of global warming. Kidney Int. 79, 1178–1185 (2011). 7. Foster, M. et al. Personal disaster preparedness of dialysis patients in North Carolina. Clin. J. Am. Soc. Nephrol. 6, 2478–2484 (2011). 8. Heiwe, S. & Jacobson, S. H. Exercise training for adults with chronic kidney disease. Cochrane Database of Systematic Reviews, issue 10. Art. No.: CD003236. http://dx.doi.org/ 10.1002/14651858.CD003236.pub2. 9. Connor, A. & O’Donoghue, D. Sustainability: the seventh dimension of quality in health care. Hemodialysis Int. 16, 2–5 (2012). 10. Connor, A., Lillywhite, R. & Cooke, M. W. The carbon footprints of home and in-centre maintenance hemodialysis in the UK. Hemodialysis Int. 15, 39–51 (2011).
www.nature.com/nrneph © 2014 Macmillan Publishers Limited. All rights reserved
knowledge of the dietary and fluid restrictions required if dialysis is interrupted; stockpiling of requisite foods and medical supplies; and acquisition and storage of a potassium-binding resin.7 Mitigation (that is, primary prevention through decarbonization) and adaption (that is, secondary prevention by anticipation of the consequences) strategies to counter climate change and its effects are under-developed worldwide. Patz at al. correctly identify the important role of healthcare professionals in understanding and communicating the grave public health risk that inaction confers. Health-care professionals must advocate the changes required, at a population level, to the lifestyles of individuals in order to reduce per capita carbon output. These changes include reducing unnecessary travel; active transport when travel is necessary (walking or cycling in place of passive transport, which requires fossil fuel consumption); and reduction in meat intake, balanced by increased vegetable intake. Each of these changes benefit not only the environment but also the individual. For example, exercise confers significant benefits to patients with CKD.8 A reduction in the prevalence of obesity would reduce the incidence of diabetic nephrop athy. Substitution of vegetable protein for meat reduces serum phosphate and FGF‑23 levels, improves uraemic acidosis, reduces the risk of kidney stones, and might reduce the incidence of diabetes and cancer. The health-care industry itself, together with its supply chain, contributes markedly
Implications of climate change for nephrology Charles Tomson and Andrew Connor
It is now accepted that climate change is occurring as a result of human activity and that it will have potentially devastating effects on health. Nephrologists are likely to see a changing spectrum of disease as a consequence of climate change and are ideally placed to lead mitigating strategies in health-care provision.
In a comprehensive assessment of the health risks relating to climate change, Patz et al. provide a timely reminder that anthropogenic climate change is happening, and that the resultant heat waves, floods, droughts, poorer air quality, altered patterns of transmissible diseases, changes in food yields and population displacement are unquestionably having major adverse effects on global health.1 In the light of these findings, nephrologists worldwide must be prepared for changes in patterns of disease, and should share responsibility for mitigating the progression of climate change.
‘‘
...nephrologists worldwide must be prepared for changes in patterns of disease...
’’
To many nephrologists the implications of climate change on global kidney health will seem obvious but also distant from the populations they currently treat; it is also true that the greatest health impacts will be felt by those who have contributed the least to the accumulated reservoir of greenhouse gas emissions and for whom access to health-care resources is most limited.2 Extreme weather events will become more common as the climate changes. Flooding is associated with increased diarrhoeal i llness—a major cause of acute kidney injury (AKI) in low-income countries—and higher incidences of leptospirosis, vectorborne diseases, and hantavirus infections.3 Poor access to clean drinking water combined with prolonged exposure to high
temperatures, causing cyclical dehydration, likely contributes to the epidemics of chronic kidney disease (CKD) reported in Mesoamerica and Sri Lanka.4 In their report, Patz et al. concentrate on the health impacts expected within the USA; however, nephrologists in many other developed countries will also see changing patterns of disease.1 Studies undertaken in different continents have reported increases in hospital admissions for AKI during heat waves. 5 High-risk groups include those already familiar to nephrologists—patients with CKD and those receiving medications that inhibit thermoregulation (including diuretics and β‑blockers). Repeated episodes of AKI contribute to the pathogenesis of CKD and increase the risk of end-stage renal disease. In addition, higher mean annual temperatures and increasing numbers of extreme heat days promote nephrolithiasis: the current rate of rise in temperature will probably result in an increase of 2 million lifetime cases of stone disease in the USA by 2050.6 Climate change is also likely to have a destabilizing impact on the provision of health care to patients with kidney disease, particularly in developing countries. Extreme weather events (including floods, hurricanes, ice storms and snow storms) will disrupt the supply of clean water and power for haemodialysis, and also the transport of supplies for haemodialysis and peritoneal dialysis. Adaptation requires that nephrologists and their patients prepare disaster plans. For patients on dialy sis, for example, preparedness requires
NATURE REVIEWS | NEPHROLOGY
Getty
Tomson, C. & Connor, A. Nat. Rev. Nephrol. advance online publication 4 November 2014; doi:10.1038/nrneph.2014.199
ADVANCE ONLINE PUBLICATION | 1 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS to climate change; 8% of all carbon emissions in the USA derive from health-care provision.9 An opportunity therefore exists for health-care providers in developed countries to lead by example and influence public attitudes to carbon reduction, similar to the way in which attitudes to smoking cessation were led by health-care professionals. The renal community is well placed to take the lead in this regard. The carbon footprints of renal services and specific treatments (including dialysis) are already understood.10 We know, for instance, that 65% of the carbon emissions of a renal service derive from dialysis provision. Many opportunities for, and benefits of, low carbon kidney care have already been evaluated, published and adopted. Examples include: solar-powered dialysis; the reuse of water from reverse osmosis dialysis water-purification plants; central dialysate acid delivery; recycling of dialysis consumables; retrofitting heat-exchangers to dialysis machines; and remote care initi atives such as telephone clinics. The great majority of carbon emissions in renal care derive from the supply chains for pharmaceuticals and medical equipment rather than from travel or building energy use. Strategies such as shared decision-making to ensure that drugs are only dispensed if patients are likely to take them, will, therefore, also contribute to reducing carbon emissions. Shared learning among renal services and collaboration with the renal industries are
vital to promote the wider adoption of such initiatives. In addition to these technical advances, a continued focus on reducing the number of people on dialysis (by better preventive care, increasing transplantation rates and ensuring that only patients who will derive benefit from dialysis initiate treatment) would make a major contribution to reducing the carbon footprint of kidney care, as well as to improving outcomes for our patients. The examples given above illustrate the indirect benefits of carbon reduction strategies within health-care settings. Many examples, most obviously those intended to reduce the energy use of buildings, also offer financial savings—a powerful lever for change in the current economic climate. Other examples, such as those that eliminate waste through streamlining care pathways, also offer improved patient experience, greater involvement of patients in their own care, and have the potential to improve care co-ordination and reduce costs, particularly for patients with more than one chronic disease. Richard Bright Renal Unit, Brunel Building, Southmead Hospital, Southmead Road, Westbury on Trym, Bristol BS10 5NB, UK (C.T.). South West Transplant Centre, Derriford Hospital, Derriford Road, Crownhill, Plymouth, Devon PL6 8DH, UK (A.C.). Correspondence to: C.T. [email protected]
2 | ADVANCE ONLINE PUBLICATION
Competing Interests The authors declare no competing interests. 1.
Patz, P. A., Frumkin, H., Holloway, T., Vimont, D. J. & Haines, A. Climate change: challenges and opportunities for global health. JAMA http://dx.doi.org/10.1001/ jama.2014.13186. 2. Costello, A. et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 373, 1693–1733 (2009). 3. Lameire, N. H. et al. Acute kidney injury: an increasing global concern. Lancet 382, 170–179 (2013). 4. Johnson, R. J. et al. Hyperosmolarity drives hypertension and CKD—water and salt revisited. Nat. Rev. Nephrol. 10, 415–420 (2014). 5. Hansen, A. L., Peng, B., Nitschke, M., Pisaniello, D. & Tucker, G. The effect of heat waves on hospital admissions for renal disease in a temperate city of Australia. Int. J. Epidemiol. 37, 1359–1365 (2008). 6. Fakheri, R. J. & Goldfarb, D. S. Ambient temperature as a contributor to kidney stone formation: implications of global warming. Kidney Int. 79, 1178–1185 (2011). 7. Foster, M. et al. Personal disaster preparedness of dialysis patients in North Carolina. Clin. J. Am. Soc. Nephrol. 6, 2478–2484 (2011). 8. Heiwe, S. & Jacobson, S. H. Exercise training for adults with chronic kidney disease. Cochrane Database of Systematic Reviews, issue 10. Art. No.: CD003236. http://dx.doi.org/ 10.1002/14651858.CD003236.pub2. 9. Connor, A. & O’Donoghue, D. Sustainability: the seventh dimension of quality in health care. Hemodialysis Int. 16, 2–5 (2012). 10. Connor, A., Lillywhite, R. & Cooke, M. W. The carbon footprints of home and in-centre maintenance hemodialysis in the UK. Hemodialysis Int. 15, 39–51 (2011).
www.nature.com/nrneph © 2014 Macmillan Publishers Limited. All rights reserved
