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A Survey of Environmental Sustainability Practices in Dialysis Facilities in

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 Article

A Survey of Environmental Sustainability Practices

in Dialysis Facilities in Australia and New Zealand
Benjamin Talbot ,1,2 Katherine Barraclough,3,4 Matthew Sypek,3,4 Pedro Gois,5,6 Leila Arnold,7 Stephen McDonald,8
1,2,9
and John Knight

Abstract
1
Background and objectives Climate change is the biggest global health threat of the twenty-first century. Health The George Institute
care itself is a significant contributor to greenhouse gas emissions, and dialysis programs contribute for Global Health,
Renal and Metabolic
disproportionately. Nephrology societies have called for increased recognition and action to minimize the Division, University of
environmental effect of dialysis care, but little data exist regarding environmental sustainability practices within New South Wales,
dialysis facilities worldwide. This survey reports a baseline of environmental sustainability practices of dialysis Sydney, New South
facilities in Australia and New Zealand. Wales, Australia
2
Ellen Medical Devices,
Sydney, New South
Design, setting, participants, & measurements An online survey was used to collect data regarding key areas of Wales, Australia
environmental sustainability practices within dialysis facilities between November 2019 and December 2020. An 3
School of Medicine,
invitation to complete the survey was sent to the heads of all dialysis facilities in Australia and New Zealand. University of
Melbourne, Melbourne,
Victoria, Australia
Results Responses were received from 132 dialysis facilities, representing 33% (122 of 365) of dialysis services 4
Department of
within Australia and New Zealand. Most responses were from public satellite facilities (53 of 132; 40%), in-center Nephrology, Royal
dialysis facilities (33 of 132; 25%), and co-located dialysis and home therapies facilities (28 of 132; 21%). Melbourne Hospital,
Opportunities for improvement in environmental sustainability practices were identified in three domains. Melbourne, Victoria,
Australia
(1) Culture. A minority of facilities reported having an environmental sustainability strategy in place (44 of 132; 5
Department of
33%) or undertaking sustainability audits (27 of 132; 20%). Only 7% (nine of 132) reported the inclusion of Nephrology, Fraser
environmental training in staff induction programs. (2) Building design, infrastructure, and energy use. Coast Hospital and
Few facilities reported the use of renewable energy (18 of 132; 14%), reclaiming reverse osmosis reject water Health Service, Hervey
(16 of 126; 13%), or the use of motion-sensor light switches (58 of 131; 44%). (3) Operations. A minority of facilities Bay, Queensland,
Australia
reported waste management education (47 of 131; 36%), auditing waste generation (23 of 132; 17%), or that 6
School of Medicine,
environmental sustainability was considered in procurement decisions (33 of 132; 25%). University of
Queensland, Brisbane,
Conclusions Environmental sustainability is not currently prioritized in clinical practice, building design and Queensland, Australia
7
Renal Service,
infrastructure, or management systems in Australian and New Zealand dialysis facilities responding to this
Wellington Regional
survey. Hospital, Wellington,
CJASN 17: 1792–1799, 2022. doi: https://doi.org/10.2215/CJN.08090722 New Zealand
8
Central and Northern
Adelaide Renal and
Transplantation Service,
Introduction greenhouse gas emissions (7), with health care respon- Royal Adelaide
Climate change is considered the biggest global health Hospital, Adelaide,
sible for 7% of total emissions in Australia (3) and up
South Australia,
threat of the twenty-first century (1). Although it has to 8% in Aotearoa New Zealand (8). Growing recogni- Australia
been suggested that health care professionals must lead tion of the environmental effect of health care has led 9
University of Sydney
in responding to the health threat of climate change (2), to ten medical colleges within Australia declaring cli- School of Medicine,
health care itself is a significant contributor to green- mate change a health emergency and launching the Sydney, New South
Wales, Australia
house gas emissions (3,4), and within health care, dialy- Healthy Climate Future campaign (9). The Australian
sis programs have a disproportionately large carbon Medical Association and the Doctors for the Environ-
Correspondence:
footprint, waste generation, and resource consumption ment Australia have also called on the Australian Dr. Benjamin Talbot,
profile (5). Despite this, little data currently exist regard- health care sector to reduce carbon emissions by 80% Renal and Metabolic
ing environmental sustainability practices within dialy- by 2030 and achieve net zero by 2040 (10). Achieving Division, The George
sis facilities worldwide. Institute for Global
these ambitious targets, which mirror those set by the
Health, PO Box M201,
In Australasia, climate trends and extreme weather National Health Service in England (11), will take con- Missenden Road, NSW
events have already combined to cause irreversible change certed effort from each specialty, in addition to sup- 2050, Australia. Email:
to natural systems, increasing health effects and socioeco- port from government and health policy. btalbot@georgeinstitute.
nomic costs (6). Yet, in 2018, Australia and New Zealand In 2011, the per patient annual carbon footprint of org.au
were among the highest global producers of per capita conventional satellite hemodialysis (HD) in Australia

1792 Copyright © 2022 by the American Society of Nephrology www.cjasn.org Vol 17 December, 2022
CJASN 17: 1792–1799, December, 2022 Environmental Sustainability Practices, Talbot et al. 1793

was approximately 10.2 t CO2-eq, which represented more
than half an average Australian household’s annual emissions
at that time (12). Although fewer data exist regarding perito-
neal dialysis, its environmental effect is also likely to be sub-
stantial (13). Currently, 17,558 patients are treated with dialysis
across Australia and New Zealand, representing between 567
and 590 per million population (14). Although this presents a
huge opportunity for greenhouse gas emissions reduction,
progress toward environmentally sustainable kidney care in
Australia and New Zealand remains in the early stages, with
available data regarding baseline environmental attitudes,
knowledge, and practice patterns currently limited to a single
state (Victoria) (15).
This survey of environmental sustainability practices within
dialysis facilities in Australia and New Zealand seeks to
expand existing data and provide a baseline against which
improvements can be made.
Materials and Methods
Study Design, Recruitment, and Data Collection
Between November 2019 and December 2020, an online
survey was used to collect data regarding key areas of envi-
ronmental sustainability practices within dialysis care, includ-
ing environmental strategy, building infrastructure and energy
use (lighting, heating, and electrical equipment), water, waste
management, transport, procurement practices, paper use, and
climate change preparedness (Supplemental Material). An
invitation to complete the survey was sent to the heads of all
dialysis facilities in Australia and New Zealand, with the
option of delegating the task to an appropriate person within
their facility. A single follow-up telephone call was made to
non-responding dialysis facilities to ensure the link had been
received and encourage participation. The individual complet-
ing the survey remained anonymous. Data were recorded elec-
tronically using REDCap 8.3.2 (2019 Vanderbilt University).
The study received ethical approval from the University
of New South Wales Human Research Ethics Committee
(HC190771).
Data Linkage
Following closure of the survey, data linkage was used to
associate dialysis facility–specific metadata held by the Aus-
tralia and New Zealand Dialysis and Transplant Registry
(ANZDATA) to survey responses. ANZDATA is a clinical
quality registry that collects data on the treatment and out-
comes of patients with kidney failure in Australia and New
Zealand. Dialysis services recorded within ANZDATA may
incorporate multiple facilities; for example, a home thera-
pies dialysis facility and a co-located in-center or satellite
dialysis facility may be recorded under a single dialysis ser-
vice code. No patient-level data linkage was performed for
this study.
To aid interpretation of data, both the number of responses
to each question and the proportion of responses out of the
total number of respondents are presented because not all
respondents answered every question.
Results
Responses to the survey were received from 132 dialysis
facilities, representing 122 different dialysis services and 33%
(122 of 365) of dialysis services listed within the ANZDATA
registry (Table 1). Responders were overwhelmingly nurse
unit managers or dialysis nurses (118 of 132; 89%), with neph-
rologists (seven of 132; 5%) and service managers (five of 132;
4%) completing the majority of remaining surveys. Most
responses were from dialysis facilities in Victoria (52 of 132;
39%) and New South Wales (35 of 132; 27%), although when
the number of responding services is viewed as a proportion
of the total number of services within each state, Tasmania
ranked the highest, with responses received from 100%
(four of four) of dialysis services (Table 1). Most responses
were from public satellite facilities (53 of 132; 40%), followed

Table 1. Dialysis facilities that responded to the survey of environmental sustainability practices in Australia and New Zealand

No. of Dialysis Facilities No. of Dialysis

Proportion of
No. of Dialysis Responding as a Services
No. of Dialysis Dialysis Services
State Facilities Proportion of the Total Represented by
Services in State within the Region
Responding, n No. of Dialysis Facilities Responding
that Responded, %
Included in Analyses, % Facilities
Australian Capital 1 1 1 6 17
Territory
New South Wales 35 27 33 91 36
Northern Territory 4 3 4 17 24
Queensland 19 14 16 71 23
South Australia 7 5 6 27 22
Tasmania 4 3 4 4 100
Victoria 52 39 48 92 52
Western Australia 4 3 4 28 14
New Zealand 6 5 6 29 21

The number of dialysis facilities responding (n) is shown as a proportion (percentage) of the total number of responding facilities
included in the analysis. Dialysis services recorded within the Australia and New Zealand Dialysis and Transplant Registry
may incorporate multiple facilities; therefore, the number of dialysis services represented by responding dialysis facilities is
also presented as the number of responding services in each state and the proportion (percentage) of the total number of services
within each state. No., number.
1794 CJASN

facilities reported a formal green group within their organi-

zation, and 26 of 131 (20%) had a formal green group within
their department. Despite this, 70% (92 of 132) of facilities
reported efforts to raise awareness of environmental sustain-
ability, which was mostly through either informal discussion
(87 of 92; 95%) or having systems in place to allow staff to
provide suggestions around carbon reduction and recycling
(36 of 92; 39%). Less than half of responding units (63 of 132;
48%) had previously attempted to introduce a “green” pro-
ject, but of those that had, 81% (51 of 63) felt that it had been
successful. Only 7% (nine of 132) of dialysis facilities
In-Center Dialysis Facility 33/132 (25%) reported the inclusion of environmental training in staff
Public Satellite Dialysis Facility 53/132 (40%) induction programs (Figure 2).
Co-Located Dialysis and Home Therapies Facility 28/132 (21%)
Private Satellite Dialysis Facility 7/132 (5) Building Infrastructure and Energy Use
Co-Located In-Center and Satellite Facility 3/132 (2%) Lighting. Although the majority of responding facilities
Home Dialysis Training Facility 7/132 (5%) reported that lights were switched off when not required
Other 1/132 (1%) most or all of the time (114 of 127; 90%), less than half had
motion-sensor light switches (58 of 131; 44%). Fluorescent
tube lighting was the most common lighting type within
Figure 1. | Type of responding dialysis facility. Responding dialysis
responding facilities (62 of 130; 48%), with a lesser number
facility type presented as a proportion (percentage) of all responding
dialysis facilities. reporting the use of light-emitting diode lighting (35 of
130; 27%).
by in-center dialysis facilities (33 of 132; 25%) and co-located Heating. Most facilities reported that appropriate temper-
dialysis and home therapies facilities (28 of 132; 21%) (Figure 1). atures were generally maintained (103 of 132; 78%), although
a lesser number had accessible thermostats or heating con-
Environmental Strategy (Policies, Plans, and Initiatives) trols (72 of 132; 55%). Sixty-one percent of facilities reported
A minority of facilities reported having an environmental shading over north-facing windows (79 of 130).
sustainability strategy in place (44 of 132; 33%), whereas Electrical Equipment. Almost all facilities reported con-
even fewer reported ever having undertaken a sustainability figuring computers/monitors (125 of 132; 95%) and photo-
audit (27 of 132; 20%). Thirty-nine percent (51 of 131) of copiers (118 of 132; 89%) to automatically enter sleep or

Environmental sustainability strategy/policy in place (44/132, 33%)

Environmentally sustainable strategy, policy, or initiative

Ever having undertaken a sustainability audit (27/132, 20%)

Green group within organization (51/131, 39%)

Green group within nephrology department (26/131, 20%)

Ever having introduced a “green” project (63/132, 48%)

Currently undertaking a “green” project (42/132, 32%)

Efforts to raise awareness of sustainability (92/132, 70%)

Environmental training in staff induction programs (9/132, 7%)

0 10 20 30 40 50 60 70 80

Proportion of dialysis facilities with environmentally sustainable strategy in place (%)

Figure 2. | Environmental strategies in place at responding dialysis facilities. Data presented as the proportion (percentage) of responding
dialysis facilities with each environmental strategy, policy, or initiative in place.
CJASN 17: 1792–1799, December, 2022
Clinical areas with recycling bins for hard plastics
Clinical areas with recycling bins for soft plastics
Waste management strategy
Clinical areas with recycling bins for PVC
Suppliers of dialysis products collect pallets on delivery
Formal staff education regarding optimal waste management
Formal auditing of the amount and type of waste generated
0 10
Proportion of dialysis facilities with waste management strategy in place (%)
Figure 3. | Waste management strategies in place at responding dialysis facilities. Data presented as the proportion (percentage) of
responding dialysis facilities with each waste management strategy in place. PVC, polyvinyl chloride.
hibernation mode when not in use. Fewer reported actively
encouraging staff to shut computers down (85 of 132; 64%),
and less than half indicated that energy-efficient appliances
were preferentially purchased (61 of 131; 47%).
Energy Supply. Nearly half of respondents were unaware
of whether renewable energy was used within their dialysis
facility (56 of 132; 42%). A minority of facilities reported use of
renewable energy (18 of 132; 14%), with solar energy predomi-
nating (13 of 18; 72%).
Water
The majority of responding facilities reported dual flush
toilets (106 of 132; 80%); however, water-saving taps were
present in less than half of the facilities (58 of 128; 45%). Of
the 126 facilities providing HD treatments, 13% (16 of 126)
reported reclaiming reverse osmosis reject water, which was
mostly redirected for use in toilets or gardens. Roof rainwa-
ter salvage occurred in 17% (22 of 131) of units.
Waste Management
More than half of facilities reported recycling bins in clini-
cal areas for hard plastics (89 of 132; 67%), but fewer than half
had recycling bins for soft plastics (41 of 131; 31%) or polyvi-
nyl chloride (50 of 132; 38%). Sixty-seven percent of facilities
reported collection of pallets by dialysis product suppliers
on delivery (89 of 132), but in the facilities where this did not
occur, only 41% (seven of 17) recycled them themselves
(Figure 3).
Efforts to recycle were described as good or moderate in
half of dialysis facilities (65 of 129; 50%). Formal staff edu-
cation regarding optimal waste management was reported
by only 36% (47 of 131), and auditing of the amount of
Environmental Sustainability Practices, Talbot et al. 1795
(89/132, 67%)
(41/131, 31%)
(50/132, 38%)
(89/132, 67%)
(47/131, 36%)
(23/132, 17%)
20 30 40 50 60 70 80
waste generated was reported by less than one fifth of the
facilities (23 of 132; 17%) (Figure 3).
Transport
Fifty-eight percent (77 of 132) of facilities reported secure
parking for bicycles, with similar availability of showers/
changing facilities (75 of 132; 57%) and public transport access
(76 of 132; 58%). Carpool/share programs for staff were avail-
able at 17% (22 of 132) of facilities. Transport services for
patients on dialysis were available at 37% (49 of 132) of facili-
ties, and information about public transport was provided to
patients in 44% (58 of 132). Walking and cycling were
encouraged where appropriate to patients in only 14%
(19 of 132) of facilities, and low-emission vehicles were used
for patient transport in 2% (two of 132). The use of phone or
videoconference was reported in more than half of facilities
for consultations with patients (80 of 132; 61%) and for regu-
lar staff meetings that would usually require staff to travel
(77 of 130; 59%) (Figure 4).
Procurement Practices
A minority of facilities reported that sustainability was
considered when choosing products or suppliers (33 of 132;
25%). Products were mostly delivered weekly (84 of 132;
64%), with delivery frequency determined by storage space
in the majority of facilities (96 of 132; 73%).
Paper
Electronic health records were in use in 67% (88 of 132) of
facilities. Printing was actively discouraged in 77% (102 of
132), and double-sided printing was reported as routine in
84% (111 of 132). The use of recycled paper for copying was
reported by 61% (80 of 131). Automatic hand dryers were
1796 CJASN

(77/132, (75/132, (76/132,

58%) 57%) 58%)
60
Proportion of dialysis facilities reporting travel support

50 (58/132,
44%)

(49/132, (47/132,
37%) 36%)
40
options available (%)

30

(22/132, (21/132,
17%) 16%) (19/132,
20
(16/132, 14%)
12%)

10
(2/132,
2%)

0
Secure parking Showers and Buildings Carpool/car Low-emission None of these Dialysis Provide Appropriate Low-emission None of these
for bicycles changing accessible by share vehicles for are provided patient information walking & vehicles used are provided
facilities public programs unit-based transport about public cycling for patient
transport activities/visits services transport encouraged transport

Travel support options available for staff Travel support options available for patients

Figure 4. | Transportation practices of responding dialysis facilities. Data presented as the proportion (percentage) of responding dialysis
facilities with each transportation practice in place.

infrequently used in place of paper towels, with availability Discussion

reported in clinical areas by only 2% (three of 131) and public This study provides a baseline for environmental sustain-
areas by 13% (17 of 131). ability practices within dialysis facilities in Australia and
New Zealand. It highlights major deficiencies and thereby
opportunities in three major domains.
Climate Preparedness Environmental sustainability practices, education, and
Most facilities reported educating patients regarding pre- improvements are currently not prioritized. Most facilities
paredness for extreme weather events (112 of 132; 85%), reported only informal efforts to raise awareness of environ-
while 82% (106 of 130) reported having a defined emer- mental sustainability, and strategies or policies to drive this
gency strategy in place for these. were not often in place. The survey indicated that audits
were infrequent, that few facilities included formal training
in staff induction programs, that green groups were not
Home Therapies prominent in either dialysis facilities or umbrella organiza-
Thirty-five home training facilities responded to the sur- tions, and that green projects had been instigated in less than
vey, representing 35 of 102 (34%) home training services in half of facilities.
Australia and New Zealand. These were either co-located Environmental sustainability has not been prioritized in
dialysis and home therapy facilities (28 of 35; 80%) or dialysis facility development to date. Although responding
stand-alone home therapies facilities (seven of 35; 20%). facilities reported attempts to minimize energy use where
Only 40% (14 of 35) of home therapy facilities reported possible (e.g., switching off lights or configuring electronic
access of patients to either cardboard or polyvinyl chloride devices to enter hibernation modes), these attempts were
recycling. Of the 29 home HD facilities, around half not universal. Environmentally sustainable building design
reported having patients who reclaimed reverse osmosis features were reported in the minority of facilities.
reject water at home (15 of 29; 52%), although in most cases Responses suggest that waste management systems are
(13 of 15; 87%), only a minority (1%–25%) of patients at the mostly inadequate, with recycling and collection of dialysis
facility were involved. Formal assistance to help establish pallets not available in all facilities and audits of waste gen-
water capture or reuse systems was provided in only 24% eration only infrequently performed. Use of paper was not
(seven of 29) of facilities. Forty-one percent (12 of 29) of optimized in all facilities, and sustainability was not often
home HD facilities reported patients using renewable considered in procurement decisions.
energy, although formal assistance to establish such sour- These results suggest that although environmental aware-
ces of power was offered by only one facility (one of ness may have increased in the nephrology sector overall
29; 3%). (16,17), little progress has been made in terms of unified
CJASN 17: 1792–1799, December, 2022
environmental sustainability strategies and practices in Aus-
tralia and New Zealand since the survey of Victorian facili-
ties was conducted in 2017 (15). It should also be noted that
the facilities responding to this survey are likely to represent
the most environmentally engaged facilities in Australia and
New Zealand, suggesting that overall environmental perfor-
mance is likely to be even poorer than the results of this
survey suggest. The fact that only 5% of responders were
nephrologists is important, possibly reflecting a lack of
perceived responsibility with regard to environmental sustain-
ability among this group. Targeted engagement may therefore
be important in generating the change that is needed.
In recognition of this lack of progress and the need for mean-
ingful change in environmental sustainability practices in kid-
ney care in Australia and New Zealand, the Australia New
Zealand Society of Nephrology, through its Environmental
Sustainability Committee, has proposed two major initiatives:
(1) a comprehensive set of environmentally sustainable
design guidelines, which are to be appended to the Aus-
tralasian Health Infrastructure Alliance guidelines for
dialysis facilities, to help integrate best-practice sustain-
ability considerations into dialysis facility design, con-
struction, and operation; and
(2) a Green Stars program to provide a framework through
which kidney care services can be supported in imple-
menting green initiatives and demonstrate their achieve-
ments against a set of national criteria.
It is important to acknowledge that infrastructure imple-
mentation, such as installing water-saving taps and energy-
efficient lighting and retrofitting reverse osmosis reject water
salvage, may involve up-front costs and that opportunities to
introduce such changes may be more restricted where dialy-
sis facilities are placed within larger hospitals or leased build-
ings. However, these measures are typically cost saving in the
medium term and should therefore be encouraged through
formal support from hospitals, health services, and govern-
ments. A number of simple measures that were absent in a
proportion of dialysis facilities surveyed, such as ensuring
that all lights and electrical equipment are switched off when
not required, universal use of recycled paper and double-
sided printing, and appropriate shading for sun-facing win-
dows, should be a requirement in all dialysis facilities (and
health care facilities more broadly) and could be maintained
through staff education at little or no additional cost.
One area where this survey has demonstrated a change
from the earlier surveys in Victoria (15) and the United King-
dom (18) is in the increased frequency of videoconferencing
for consultations with patients and to replace in-person staff
meetings. Where appropriate, the ongoing use of telemedi-
cine may be beneficial in reducing the carbon footprint of
travel related to dialysis care and improving convenience;
however, digital platforms also contribute a carbon footprint,
and a formal analysis of telehealth is necessary to adequately
inform improvement initiatives.
Nephrology societies around the world advocate for
expanding home therapies treatment programs, which can
increase patient autonomy, improve quality of life, and
reduce financial costs (19). Home HD is, however, associated
with a higher carbon footprint (20) and water consumption
profile (21) than in-center HD. Accordingly, priority should
Environmental Sustainability Practices, Talbot et al. 1797
be given to providing formal assistance (practical and finan-
cial) to patients on home HD to enable them to utilize renew-
able energy and recapture reverse osmosis reject water.
The support of industry is critical in reducing the environ-
mental effect of dialysis care. As a nephrology community,
we must move toward incorporating sustainability criteria
into procurement contracts, transferring the responsibility for
waste and environmental innovation to dialysis companies
from financially stretched health services. Contracts should
necessitate recycling of waste by dialysis providers and incen-
tivize improvements and development among competitors at
all stages of the product life cycle. This shift will be particu-
larly important in supporting environmental sustainability
practices in lower- and middle-income countries, where dial-
ysis provision is forecast to grow the most (22). Disruptive
innovations, such as the Ellen Medical Devices Point-of-Care
Affordable Peritoneal Dialysis System (23) and sorbent tech-
nologies for dialysis regeneration (24), may also offer environ-
mental savings in the future, and further research should be
prioritized. Dialyzer reuse may offer another opportunity,
with the potential to lead to large reductions in raw material
use and medical waste generation (25). However, there
would simultaneously be increased liquid waste from the ger-
micides used for dialyzer disinfection, notwithstanding that
questions remain about safety. Both life cycle environmental
research and high-quality studies of the safety would be
required before this could be recommended.
This study has several limitations. Compromises were nec-
essary in the design of the survey to ensure that it remained
user-friendly and minimally burdensome. High-quality data
addressing key areas of environmental sustainability practi-
ces were sought, but it was not feasible to incorporate every
aspect of dialysis care. Despite the use of different recruit-
ment strategies, 33% of dialysis services in Australia and
New Zealand responded. Moreover, responders were volun-
teers and therefore may represent dialysis facilities with an
interest in environmental sustainability. This could have
biased responses, and it is possible that our results are not
representative. The nature of this survey limited quantita-
tive data collection, and some of the data collected were
subjective. Hopefully, however, as environmental auditing
increases in dialysis facilities in the future, our ability to
collect objective data will also increase.
This study provides a baseline for environmental sustain-
ability practices in dialysis facilities in Australia and New
Zealand and proves the feasibility for broad surveying of
environmental attitudes, knowledge, and practice patterns.
In turn, this allows for better understanding of differences
and opportunities for change across world regions.
Disclosures
L. Arnold reports employment with and ownership interest in
M and M Renal Limited. K. Barraclough reports research funding
from Fresenius Medical Care. P. Gois reports consultancy agree-
ments with the atypical Hemolytic Uremic Syndrome Board Com-
mittee of Alexion Pharmaceuticals; honoraria from Alexion Pharma-
ceuticals (atypical Hemolytic Uremic Syndrome Board Committee);
a patent request in Brazil (under analysis) for the secondary use of
allopurinol for rhabdomyolysis; and serving as a reviewer editor of
Frontiers in Physiology–Renal and as a section editor of International
Journal of Environmental Research and Public Health. J. Knight reports
employment with Ellen Medical Devices, which is developing the
1798 CJASN
Affordable Dialysis Program; ownership interest in Ellen Medical
Devices and Johnson & Johnson; serving as a mentor for the Med-
tech Actuator; and other interests or relationships with the Austra-
lian and New Zealand Society of Nephrology, The George Institute
for Global Health, the International Society of Nephrology, The
University of Sydney, and University of New South Wales. S.
McDonald reports ownership interest in AMP Limited; reports
research funding from Astellas Pharmaceuticals and Baxter Health-
care; and has had advisory or leadership roles with Fresenius Kid-
ney Care Australia. B. Talbot reports employment with Ellen Medi-
cal Devices, which is developing the Affordable Dialysis Program,
and George Clinical; ownership interest in Ellen Medical Devices;
research funding from Ellen Medical Devices; a scientific leadership
role at George Clinical; and other interests or relationships with The
George Institute for Global Health. B. Talbot reports receipt of a Sci-
entia scholarship from the University of New South Wales, Sydney,
Australia to complete a PhD in medical education. The remaining
author has nothing to disclose.
Funding
None.
Acknowledgments
We thank ANZDATA for their support in this study.
Author Contributions
K. Barraclough, J. Knight, and B. Talbot conceptualized the
study; B. Talbot was responsible for data curation; B. Talbot was
responsible for formal analysis; K. Barraclough, P. Gois, J. Knight,
S. McDonald, M. Sypek, and B. Talbot were responsible for meth-
odology; B. Talbot was responsible for project administration;
K. Barraclough and J. Knight provided supervision; B. Talbot
wrote the original draft; and L. Arnold, K. Barraclough, P. Gois,
J. Knight, S. McDonald, and M. Sypek reviewed and edited the
manuscript.
Data Sharing Statement
Deidentified data may be made available for sharing but are
subject to ethics committee approval.
Supplemental Material
This article contains the following supplemental material online
at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.
08090722/-/DCSupplemental.
Supplemental Material. The environmental survey of dialysis
practices in Australia and New Zealand.
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Received: July 8, 2022 Accepted: October 19, 2022
Published online ahead of print. Publication date available at
www.cjasn.org.