• Energy Research

Climate change, driven by rising atmospheric carbon dioxide and other greenhouse gasses released primarily from the use of fossil fuels,1 is occurring at such a rapid pace that the United Nations and its Intergovernmental Panel on Climate Change consider it as one of the major global challenges of our time.2 Along with a changing climate, overuse and pollution of natural resources, dwindling water supplies, and extensive contamination of the environment with plastics pose additional threats. The effects of this changing climate on ecosystems, biodiversity, and human communities are increasingly obvious, although debates surrounding the scope and nature of the actions required to combat climate change remain contested and complex owing to competing political and economic priorities. Sadly, the burden of climate change and environmental pollution disproportionately affects vulnerable populations, particularly in low- and middleincome countries,3 which are less equipped to deal with the consequences. The 2022 International Society of Nephrology Emerging Leaders1 Correspondence: Letizia De Chiara, Department of Clinical and Experimental Biomedical Sciences “Mario Serio”, University of Florence, Viale Pieraccini 6, Florence, FI 50139, Italy. E-mail: letizia.dechiara@ unifi.it 1Members of The 2022 International Society of Nephrology Emerging Leaders are listed in the Appendix. Ironically, the health care sector, which is dedicated to improving peoples’ lives, is an important contributor to climate change and environmental decline. The business of health care generates more than 4% of global greenhouse emissions and as high as 8% in some high-income countries.1 Medical supply chains account for a large proportion of this carbon footprint. The problem was exacerbated by the COVID-19 pandemic, which created a tidal wave of medical waste in the face of single-use personal protective equipment and diagnostic tools. In addition, the treatment of advanced kidney disease (e.g., by dialysis) has among the highest carbon footprints in clinical care. As recognition of the environmental impact of health care has grown, many, mostly high-income, countries have made a formal commitment to providing health-related services in a more environmentally sustainable manner. This commitment includes reducing unnecessary consumption of resources, decarbonization of power generation, and investment in preventative care. However, creating sustainable health care is challenging, requiring parity between the mandate to deliver high-quality care and addressing the needs of the environment. Recognizing this pressing issue, Kidney International is launching series of minireviews dedicated to the topic of Green Nephrology. Our aim is to increase awareness of the climate and environmental impact of health care among the members of the nephrology community, conduct a deep dive into the relationship between kidney care and the environment, and promote environmentally friendly practices in nephrology. To this end, Kidney International partnered with the International Society of Nephrology’s Emerging Leaders 2022 Program (ISN-ELP 2022) to coordinate this initiative.

The accelerating environmental degradation as a result of modernisation and climate change is an urgent threat to human health. Environment change can impact kidney health in a variety of ways such as water scarcity, global heating and changing biodiversity. Ever increasing industrialization of health care has a large carbon footprint, with dialysis being a major contributor. There have been calls for all stakeholders to adopt a ‘one health approach’ and develop mitigation and adaptation strategies to combat this challenge. Because of its exquisite sensitivity to various elements of environment change, kidney health can be a risk marker and a therapeutic target for such interventions. In this narrative review, we discuss the various mechanisms through which environmental change is linked to kidney health and the ways that the global kidney health communities can respond to environmental change.

In response to Earth's accelerating climate crisis, we, an international group of nephrologists, call on our global community to unite and align kidney care in accordance with United Nation's 26th Conference of the Parties health sector principles. We announce a global and inclusive initiative, "GREEN-K": Global Environmental Evolution in Nephrology and Kidney Care, with a vision of "sustainable kidney care for a healthy planet and healthy kidneys" and mission to "promote and support environmentally sustainable and resilient kidney care globally through advocacy, education, and collaboration." A patient-centric approach that permits climate change mitigation and adaptation is proposed. Multi-stakeholder GREEN-K action and focus areas will include education, sustainable clinical care, and advances toward environmentally sustainable innovations, procurement, and infrastructure. Mindful of the disproportionately high climate impact of kidney therapies, we welcome the opportunity to work together in shared accountability to patients and Earth's natural systems.

Nontraumatic rhabdomyolysis is an important but under-recognized cause of acute renal failure. In alcoholics, rhabdomyolysis most frequently develop following muscle necrosis during alcohol-induced coma, but has also been described rarely in those without prolonged coma or seizures. We describe a patient who developed myoglobinuric acute renal failure requiring dialysis following binge drinking in the absence of convulsions or coma. The renal biopsy showed acute tubular necrosis with pigment casts.

Key Points A multinational survey of health care professionals on the kidney health impacts of climate change and the environmental burden of kidney care was conducted.Most participants reported knowledge gaps and high level of concern on these interconnected issues.Only a minority report personal or organizational initiatives in environmentally sustainable kidney care; this did not vary by country income level. Background Given the threat of climate change to kidney health and the significant environmental effect of kidney care, calls are increasing for health care professionals and organizations to champion climate advocacy and environmentally sustainable kidney care. Yet, little is known about their engagement, and existing literature is primarily emerging from high-income countries. Methods We conducted a cross-sectional survey to understand the knowledge, attitude, and practice of health care professionals on the interconnectedness of climate change and kidney health; to identify personal and organizational initiatives in sustainable kidney care and strategies to increase their engagement; and to compare responses by their country's income level as classified by the World Bank. Results Participants (n=972) represented 108 countries, with 64% from lower- or middle-income countries. Ninety-eight percent believed that climate change is happening, yet <50% possessed knowledge about the effect of climate change on kidney health or the environmental effect of kidney care. Only 14% were involved in climate change and kidney health initiatives (membership, knowledge/awareness, research, and advocacy), 22% in sustainable kidney care initiatives (education/advocacy, preventative nephrology, sustainable dialysis, promoting transplant/home therapies, and research), and 26% reported organizational initiatives in sustainable kidney care (sustainable general or dialysis practices, preventative/lean nephrology, and focused committees). Participants from lower-income countries generally reported higher knowledge and variable level of concern. Engagement in sustainable kidney care did not vary by income level. Guidance/toolkit (79%), continuing education (75%), and opportunities (74%) were the top choices to increase engagement. National initiatives (47%), preventative measures (35%), and research endeavors (31%) were the top avenues for organizational engagement. These varied by income level, suggesting that the vision and priorities vary by baseline resource setting. Conclusions We have identified knowledge and practice gaps among health care professionals on the bidirectional relationship between kidney disease and climate change in a multinational context and several avenues to increase their engagement.

Une insuffisance rénale chronique (IRC) non associée à des facteurs de risque connus a été signalée dans certaines régions de l'Inde et est présumée similaire à une IRC d'étiologie inconnue (CKDu) décrite en Amérique centrale. Les rapports de l'Inde ont été fragmentés sans description claire du phénotype de la maladie ou de ses déterminants. Cet article résume l'état actuel des connaissances sur la CKDu en Inde sur la base d'une revue de la littérature, d'une consultation multipartite et d'une enquête auprès des néphrologues indiens. Nous avons également contacté des groupes de recherche individuels pour solliciter des données. Nos résultats suggèrent que la CKDu est signalée dans la plupart des régions de l'Inde ; cependant, elle est interprétée différemment du phénotype décrit en Amérique centrale et au Sri Lanka. Les différences comprennent l'absence d'un groupe démographique ou professionnel clair, l'âge plus avancé des participants touchés et la présence d'une hypertension légère et d'une protéinurie de bas grade. Des études prospectives de terrain bien conçues avec un bilan diagnostique approprié sont nécessaires pour établir le fardeau de la maladie et identifier les étiologies, ainsi que les conséquences socio-économiques et sanitaires, l'intersection avec l'environnement et la réponse de santé publique. La recherche communautaire devrait phénotyper l'ensemble de la population CKD plutôt que d'être limitée aux cas de CKDu présumés sur la base de critères prédéfinis. Des lignes directrices sont nécessaires pour l'évaluation clinique, l'orientation, la gestion et l'harmonisation de la documentation clinique et des dossiers de santé. Davantage de données sont nécessaires pour étayer l'existence d'un phénotype unique de CKDu en Inde. La enfermedad renal crónica (ERC) no asociada con factores de riesgo conocidos se ha informado en partes de la India y se presume que es similar a la ERC de etiología desconocida (ERCu) que se ha descrito en América Central. Los informes de la India se han fragmentado sin una descripción clara del fenotipo de la enfermedad o sus determinantes. Este documento resume el estado actual del conocimiento sobre CKDu en la India basado en una revisión de la literatura, la consulta de múltiples partes interesadas y una encuesta de nefrólogos indios. También nos pusimos en contacto con grupos de investigación individuales para solicitar datos. Nuestros hallazgos sugieren que la CKDu se reporta en la mayoría de las regiones de la India; sin embargo, se interpreta de manera diferente al fenotipo descrito en América Central y Sri Lanka. Las diferencias incluyen la falta de un grupo demográfico o de ocupación claro, la edad avanzada de los participantes afectados y la presencia de hipertensión leve y proteinuria de bajo grado. Se necesitan estudios de campo prospectivos bien diseñados con un diagnóstico adecuado para establecer la carga de la enfermedad e identificar las etiologías, junto con las consecuencias socioeconómicas y de salud, la intersección con el medio ambiente y la respuesta de salud pública. La investigación basada en la comunidad debe fenotipar a toda la población de ERC en lugar de restringirse a los casos con ERC presunta basada en criterios predefinidos. Se necesitan pautas para la evaluación clínica, la derivación, el manejo y la armonización de la documentación clínica y los registros de salud. Se necesitan más datos para respaldar la existencia de un fenotipo único de CKDu en la India. Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India. تم الإبلاغ عن مرض الكلى المزمن (CKD) غير المرتبط بعوامل الخطر المعروفة من أجزاء من الهند ويفترض أن يكون مشابهًا لمرض الكلى المزمن غير المعروف المسببات (CKDu) الذي تم وصفه من أمريكا الوسطى. تم تجزئة التقارير الواردة من الهند دون وصف واضح للنمط الظاهري للمرض أو محدداته. تلخص هذه الورقة الحالة الحالية للمعرفة حول CKDu في الهند بناءً على مراجعة الأدبيات، واستشارة أصحاب المصلحة المتعددين، ودراسة استقصائية لأطباء الكلى الهنود. كما اتصلنا بمجموعات بحثية فردية لطلب البيانات. تشير النتائج التي توصلنا إليها إلى أن CKDu يتم الإبلاغ عنه من معظم المناطق في الهند ؛ ومع ذلك، يتم تفسيره بشكل مختلف عن النمط الظاهري الموصوف من أمريكا الوسطى وسريلانكا. وتشمل الاختلافات عدم وجود مجموعة ديموغرافية أو مهنية واضحة، والعمر الأكبر للمشاركين المتضررين، ووجود ارتفاع معتدل في ضغط الدم وبيلة بروتينية منخفضة الدرجة. هناك حاجة إلى دراسات ميدانية مستقبلية جيدة التصميم مع عمل تشخيصي مناسب لتحديد عبء المرض وتحديد المسببات، إلى جانب العواقب الاجتماعية والاقتصادية والصحية، والتقاطع مع البيئة، واستجابة الصحة العامة. يجب أن تحدد الأبحاث المجتمعية النمط الظاهري لمجموعة أمراض الكلى المزمنة بأكملها بدلاً من أن تقتصر على الحالات التي يُفترض فيها الإصابة بأمراض الكلى المزمنة بناءً على معايير محددة مسبقًا. هناك حاجة إلى مبادئ توجيهية للتقييم السريري والإحالة والإدارة ومواءمة الوثائق السريرية والسجلات الصحية. هناك حاجة إلى مزيد من البيانات لدعم وجود نمط ظاهري فريد من نوعه في الهند.