This project explores how an incremental approach to prescribing peritoneal dialysis can reduce environmental impact while maintaining safe and effective patient care.
Traditionally, patients begin peritoneal dialysis with 4 exchanges per day, every day. The incremental model starts with fewer exchanges – typically 1-2 per day – and increases only as clinically necessary. This approach reduces the use of plastic, water and packaging and lowers carbon emissions.
To support broader adoption, the project team at Western Renal Services in Western Sydney Local Health District (WSLHD) developed a web-based application that enables clinicians to prescribe incremental dialysis and instantly calculate environmental savings. The tool is designed to be user-friendly and adaptable across services, with beta testing planned for nursing staff in other LHDs.
Addressing treatment that results in significant waste
Dialysis is a life-sustaining treatment for patients with kidney failure, but comes with a significant environmental cost. Each treatment involves large volumes of plastic, packaging and water, and generates substantial waste. Western Renal Services is the largest provider of home dialysis in Australia and New Zealand. In 2019, the service introduced incremental peritoneal dialysis to address these concerns.
The model was supported by the development of:
- clear policy and procedure documents
- comprehensive staff education
- strong engagement from renal physicians and nurses.
Patients were actively involved in shared decision-making, and their feedback helped refine the approach and inform the design of the web-based application. Between 2019 and 2024, Western Renal Services collected and analysed data from 365 incident peritoneal dialysis patients (187 incremental, 178 full-dose). The service selected patients based on clinical suitability and their consent to participate.
The results demonstrated significant reductions in carbon emissions, water use and waste generation with the incremental approach. The project faced delays in staff recruitment due to administrative processes, which slowed early progress. Despite this, the service completed the preliminary version of the web-based application, with optimisation and beta testing currently underway as of August 2025.
Incremental peritoneal dialysis significantly reduces carbon emissions
The following data quantifies the environmental benefits of incremental peritoneal dialysis compared to full-dose PD. It comes from a study of 365 patients over five years, between 2019 and 2024.
- Carbon emissions: Patients on incremental peritoneal dialysis produced 1,016kg of C02e emissions per year, compared to 1,360kg for full-dose peritoneal dialysis. This means 344kg less carbon emissions per patient, per year.
- Blue water use (fresh water used in treatment): Incremental peritoneal dialysis used 24,090 litres per patient annually, compared to 25,548 litres for full-dose. This saves 1,458 litres of fresh water per patient, per year.
- Grey water generation (wastewater from treatment): Incremental peritoneal dialysis generated 8,213 litres, while full-dose generated 10,549 litres. This is a reduction of 2,336 litres of wastewater per patient per year.
- Landfill waste: Incremental peritoneal dialysis produced 212kg of landfill waste per patient annually, compared to 271kg for full-dose. A saving of 59kg of landfill waste per patient per year.
- Recycling volume: Incremental peritoneal dialysis resulted in 73kg of recyclable waste, compared to 131kg for full-dose. A reduction of 58kg in recyclable materials per patient, per year.
Over 201,000kg CO2e saved during five-year study period
During the study period, Western Renal Services has:
- saved over 201,000 kg CO2e
- saved over 5 million litres of blue water and reduced the use of grey water by over 1.8 million litres
- prevented 27 tonnes in landfill waste and reduced the use of 16 tonnes of recyclables.
The service did not observe any adverse health effects. Patients experienced a reduction of approximately 45 minutes per day in dialysis time, allowing more time for work, family and social activities. While formal qualitative data is pending, patient feedback has been consistently positive. A future randomised controlled trial (STEP-PD) will further evaluate health outcomes.
In terms of financial outcomes, incremental peritoneal dialysis cost $1,241 per patient per month, compared to $1,581 for full-dose. This equates to a saving of $339 per patient per month. These savings represent significant efficiencies for the health system, especially when scaled across hundreds of patients.
