Dialysis Waste Management: Why Won’t Anybody Listen?

This blog post was made by Dr. John Agar on April 28, 2016.
Dialysis Waste Management: Why Won’t Anybody Listen?

The 2015 USRDS Report records that, in round figures at the end of 2013, nearly 470,000 Americans were on dialysis. Of these, 420,000+ were on some option of haemodialysis (HD) and 47,000+ were on some option of peritoneal dialysis (PD).

  1. That amounts to an awful lot of Americans.

    2. But…

  2. That also amounts to an awful lot of waste left over after each treatment.

While the mean weight of plastic discarded after each HD treatment varies depending on the system used, weights range ~2.25 to ~2.75 kg. Let us use 2.50 kg for ease of the math!

In PD, while the weight of plastic waste is less—again varying between automated PD (APD) and continuous ambulatory PD (CAPD)—it averages ~1.25 kg per treatment.

Assume that all (or essentially all) HD patients dialyse 3 times/week = 156 treatments/year, and all PD patients dialyse every day = 365 treatments/year. Simple mathematics can then calculate the generated annual weight of plastic waste:

  • HD plastic waste = 2.5 kg x 156 treatments/year x 420,000 HD patients = 163,800,000 kg = 163,800 tonnes/year.
  • PD plastic waste = 1.25 kg x 365 treatments/year x 47,000 PD patients = 21,443,750 kg = 21,444 tonnes/year.

This amounts to the annual creation of a staggering ~185,250 tonnes of post-dialysis plastic waste in the US alone!

Have you ever thought what happens to this discarded plastic after use? Well, as it is regarded as “infectious medical waste,” it is either sent to landfill (= yuk) or to incineration (= even more yuk). Just consider the eons of soil contamination and breakdown time if it is buried in landfills, or the atmospheric pollution if it is incinerated. It boggles the mind, and poisons our planet.

Might there be a better solution? Well, yes! You bet there is!

First, think of the delivery truck from the dialysis company that pulls in, once or twice each week (facility delivery) or each month (home delivery), full of new, sterile, neatly packaged, plastic consumables. So far, so good...but then, after it unloads, it turns around and returns to base…empty.

Next, think of the medical waste truck (facility pick-up) or council garbage truck (home pick-up) that calls, just as often, to remove the yellow-bagged, post-dialysis plastic waste and take it to the tip, or to the incinerator.

What if the delivery truck and the waste removal truck were one and the same? What if the truck could be divided into two sections, a sterile compartment up front and a “dirty” compartment at the back, delivering and removing at the same time?

Moreover, what if the waste was NOT carted off to a landfill or an incinerator, but was taken back to the company warehouse to a waiting “re-processor”?

A re-processor? What on earth is that?

Well, in use for some time in Europe, and now here in Australia…please tell me this happens in the US, too…are machines that first autoclave, then shred medical plastic waste. There are many available: SteriMed, Sterishred, Meteka, Celitron, just to name four. These systems steam-sterilize, then chop up the plastic waste—all of it—just like your kitchen blender chops up fruit and vegetables. They create a fine, confetti-sized, sterile end-product suitable for re-use. The following pictures show the transformation!

Consider, then, that each consumable distribution centre not only stored and distributed fresh consumables but installed a used plastic re-processor, one of sufficient size and “grunt” to centrally re-process and render a sterile shreddate for on-use. They come in sizes small enough for a small dialysis centre to purchase for on-site re-processing, or in sizes large enough to provide a centralized option. Once processed, the shreddate is suitable for on-sale or re-use as a re-cycled plastic resource.

Problem: there are seven main grades of plastic, ranging from PET to PVC, from PP to PS, and beyond. See: https://en.wikipedia.org/wiki/Resin_identification_code. But, as many recycling options require separation into type, and as this is both tedious and costly, finding a use for mixed plastics would be a better option.

Solution: Although this blog does not intend to canvas all options, two come immediately to mind. Both have (1) been tested and (2) are already in use.

One potential use for mixed plastics is their incorporation into building materials – eg: concrete bricks ... see:

Perhaps as an even better option, mixed plastics can be added to molten bitumen (in the US = asphalt) for road surfacing ... see:

Studies in India and the Netherlands have shown that the ideal ratio of plastic to bitumen is a 1:10 mix…1 part shredded plastic to 10 parts bitumen. Plasticization of road surfaces has been shown to (1) increase the flexibility and durability of the surface, (2) offer better resistance to both extremes of heat and cold, (3) prevent pothole formation, and (4) reduce cracking.

In July 2015, Fortune 500 reported that Rotterdam (the Netherlands) was moving to plasticize d road surfaces for its city streets, using—yes—recycled plastics.

Australian data records that ~7 tonnes of bitumen is required to surface each kilometre of a one-lane-each-way secondary road. Using plasticized bitumen at a ratio of 1:10 would therefore use ~0.7 tonnes plastic waste/kilometer of road. Considering the annual US creation generation of ~185,250 tonnes of dialysis plastic, some 265,000 kilometres of 1:10 plasticized road surface could be laid. In US parlance, that is 165,625 miles of single lane roadway. And...how cool it would be for dialysis patients, out for a Sunday drive, to think...hey, I helped build that!

Now, this approach begs several questions: (1) That all plastic is re-used, (2) That none is wasted, and (3) That the re-cycling loop is tightly closed. In practice, these would never happen. But, even if only half the plastic shreddate were to find its way into road resurfacing, it would still resurface a lot of road!

One thing is certain: we need to do better at the back-end of care than we are now. For the future of our planet, and those who come after us, we need to think about this stuff.

I have published widely on the topic of dialysis and the environment, from the broader impact of climate change on nephrology(1), to the re-use or dialysis water resources (2,3,4), the use of alternative power for dialysis(5), the contribution of dialysis to the healthcare carbon footprint(6) and on the environmental imperatives facing dialysis and in particular, the impact of dialysis-generated waste(7, 8).

Despite this, a wide disinterest still pervades our space. But somewhere, somehow, and sooner or later, someone must take up the running on this—before it is too late.

References

  1. Barraclough K, Holt SD, Agar JWM. Climate Change and Us: What Nephrologists need to know. Nephrology (Carlton). 2015: 20(10): 760-766.
  2. Agar JWM, Simmonds RE, Knight R. Using water wisely: New, essential and affordable water conservation practices for both facility and home hemodialysis. Hemodialysis International 13(1):32-37, January 2009.
  3. Agar JWM. Recycling Dialysis Wastewater: ‘The Elephant in the Room’. (Requested Editorial) American Journal Kidney Disease.2008. 52(1): 10-12.
  4. Agar JWM. Re-using and Re-cycling Dialysis Reverse Osmosis Reject Water. Kidney International: [‘Sans Fronteires’ Special Article]. 2015. 88, 653-657.
  5. Agar JWM, Perkins A, Tjipto A. Solar-assisted Hemodialysis. CJASN. 2012: 7 (2); 310-314. February 2012.
  6. Lim AE, Perkins A, Agar JWM. The Carbon Footprint of an Australian Satellite Haemodialysis Unit. Australian Health Review. 2013. 37(3): 369-74.
  7. Agar JWM. It is time for Green Dialysis. (Editorial). Hemodialysis International. 2013. 17 (4): 474-478.
  8. Agar JWM. Green Dialysis: The Environmental Challenges Ahead. Seminars in Dialysis [Special Edition “Views, Visions and Vistas in Dialysis”]. 2015. 28(2). 186-192.

Comments

  • Sandy

    Apr 29, 2024 7:30 AM

    This is a very informative article. Proper waste management really is the key to ensure a greener future. In the hospital that I worked on, by the way I'm a nurse, we hired a company to handle all our medical waste.
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  • Errol Buendia

    Jul 20, 2021 7:08 PM

    I could suggest this to our start-up company so we can utilize each visit and make sure we don't destroy our environment. "What if the delivery truck and the waste removal truck were one and the same? What if the truck could be divided into two sections, a sterile compartment upfront and a “dirty” compartment at the back, delivering and removing at the same time?" I am quoting this because this is a very good idea.
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  • Mary Thro

    Oct 11, 2020 4:36 PM

    Thank you for the insight and information. I have been concerned about this issue since March 2020 when my sister moved in with us after a debilitating stroke. We perform PD nightly and I have marveled over the plastic waste and was very disappointed when told to place it in regular trash. In an act of defiance I have started to save the outer plastic bags, tubing caps, and tubing organizer. Then putting those in the appropriate recycling collection points.
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  • Jan brown

    Nov 26, 2019 5:11 PM

    Is there anyone who will come pick up boxes of unused dialysis fluids that have expired. We have a relative in Amelia island Florida who has 100 boxes of expired fluids unused and we need to dispose of them
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    • Dori Schatell

      Nov 26, 2019 5:18 PM

      Jan, this is a perpetual problem for almost anyone who stops doing PD. PD fluid is a prescription drug. Clinics are not allowed to take it back, and neither are the companies that make it. Vets can sometimes use the fluid for dehydrated dogs/cats, but you would probably have to move it to them. Some people just end up slashing the bags and dumping the fluid on plants (there are some nutrients in it) or down a drain.
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  • David Wark

    May 16, 2019 4:19 PM

    Here's another approach to the problem. Today I talked to my nephrologist about modifying my home dialysis prescription. I've been using 2 bags of fluid, but only using a small part of the second. So I have to throw out a lot of plastic and a lot of fluid.

    As an experiment, we are moderating the dialysis prescription to use one bag of fluid. We will run for a while and check adequacy, to see if we can make a change.

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  • MOHANDAS G

    May 01, 2019 2:11 PM

    Please tell how to dispose of infectious plastic bags and tubes properly without harm to natural resources in Indian villages.
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    • John Agar

      May 07, 2019 6:37 AM

      This is a vexed question as it depends very much on local regulations and practices. It is a question best asked of your local nephrology team. They will likely know what are the practices appropriate to your region. While it is true that we are working on more global solutions/options, these are not yet to the point of implementation.
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  • pat ligon USA

    May 14, 2016 2:56 AM

    I love your idea of recycling. Currently I save the caps from the various lines and the line holder from my PD even though I haven't figured out what I can do with them. Craft project?? In 8 months I have accumulated a gigantic bag. If it were possible to get a recycling program going, perhaps the small profit from selling the plastic could go towards nephrology research. That might encourage dialysis patients to participate in the recycling. Together we can save the planet.
    Thank you for all you do to move nephrology and dialysis forward, Dr. Agar
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    • John Agar

      May 14, 2016 6:35 AM

      Thanks, Pat. Your idea is a great one. I will put it up on my Australian www.greendialysis.org.au website. As a matter of fact, the U.K. already has an established nationwide program for cap collection and recycling ... see the UK green nephrology website @ networks.sustainablehealthcare.org.uk and search 'caps'. There are many uses for these and local plastic recyclers will likely take them - I not sure about the US, but here, they certainly will - but it is a great idea to try and 'organise' a more structured program. As we run nearly 50 home HD patients from our small regional city dialysis centre, Collecting for recycling soon amounts to a significant plastic volume and is exactly what am I suggesting that others - like you - begin to do.
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  • Carl Schleg RN, CDN, LMT, CDL

    May 02, 2016 8:46 PM

    For 6 + years I was an unofficial salesman for the the company 'Startech Envirnmental'. This machine would resolve this and many other problems we face ( could make LOVE CANAL safe). Approached millionaires, CEO's of hospitals etc. and was ignored.......
    Look UP the technologhy.....it works, the system does not want it.....
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  • Dori

    May 01, 2016 8:20 PM

    I LOVE the idea of incorporating used plastic into roads that last longer. It gives me hope for this beautiful green ball we all live on.
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  • Gale Schulke

    May 01, 2016 2:53 PM

    This has been one of my concerns for years without really knowing how to approach it or who to approach it to. It seems to me that California would be a prime place to start a movement to recycle dialysis waste. I, for one, will start with my Congress person and local legislator. If we all do this, we might be able to make this happen
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    • John agar

      May 03, 2016 9:05 PM

      Thanks Gale. Your support and enthusiasm to get this happening in the US too is much appreciated.
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  • Fred Kilgus

    Apr 30, 2016 1:57 PM

    Two comments: 1) In Ct, at least, the home PD plastic is considered regular waste & goes to the huge incinerators we have in CT. Also, 2) I can't picture a commercial company accepting back that plastic to recycle it because it's expensive and not a profit maker for them. Other than that, I think of all you said, every time I toss my daily accumulation in the trash.
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    • John Agar

      Apr 30, 2016 9:59 PM

      Thanks for making the effort to respond, Fred. Whilst here it is still regarded as 'infectious waste' - as it is in many but not all jurisdictions - it is still waste and is still generally either burnt or buried. And, burning and/or burying contaminated plastic is (or should be) a significant long-term environmental issue for us all ... especially if re-direction to re-use is feasible. And it is - with a resale value attached to it, too. Maybe it's not not high end $$$'s, but some $'s. Then, there is the added cudos to the company of being truly 'green' ... here, not insignificant. Plus there is a moral and ethical argument. Even government(s), the likely purchaser if the by-product were to be re-used for road surfacing, might be prepared to subsidise the sterilising/shredding process costs as the end beneficiary. We need to do this kind of thing. And, though I recognise that in the US, nothing is done unless a $ value can be attached to it and where benefit seems consistently to be trumped (that word is forever tarnished) by cost, elsewhere, environmental ideas do take root and flourish. Not all who read these blogs are from the US, and they may prove better positioned to seek benefit over cost.
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