Extracorporeal Organ Support Sustainability: Greener as a Clinical Outcome
Main Article Content
Abstract
In the last 150 years, healthcare has become a large scale multidisciplinary human activity that involves the interaction of social, technological, legal, political, and economical issues. To be highlighted, healthcare may represent 4.6% to 8.5% of worldwide greenhouse gas emissions.
Extracorporeal organ support, one of the most life-saving interventions in emergency and critical care medicine, represents a sustainability challenge because of the amount of resources needed for every single patient and the increasing number of expected cases in the years to come.
Given that the conservation of essential resources for human life relies on the sustainability of each and all of the human activities, the development of greener healthcare policies regarding extracorporeal life support has been recognized to be of utmost importance.
Systematic, organized research should be implemented in order to establish evidence based standardized, large scale guidelines and procedures aimed not only improve survival of patients, but to ensure sustainability. Of note, the place and window of opportunity that extracorporeal organ support represent towards a greener global healthcare remains to be fully described.
Most probably, within the following years, extracorporeal organ support will represent an inflexion point into diminishing the use of further healthcare resources (i.e. early home-based ultrafiltration may preventing recurrent hospital admissions because of decompensated hearth failure).
The present manuscript is aimed to summarize the importance, challenges and current perspectives on the way to achieve sustainability of extracorporeal organ support.
Keywords:
Extracorporeal Organ support, multiorgan failure, sustainability, public healthcare, environmental ethics
Article Details
How to Cite
MUCIÑO-BERMEJO, Maria-Jimena.
Extracorporeal Organ Support Sustainability: Greener as a Clinical Outcome.
Medical Research Archives, [S.l.], v. 13, n. 5, may 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6562>. Date accessed: 20 june 2025.
doi: https://doi.org/10.18103/mra.v13i5.6562.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Colgrove J. The McKeown thesis: a historical controversy and its enduring influence. Am J Public Health. 2002;92(5):725-729. doi:10.2105/ajph.92.5.725.
2. Szreter S. Rethinking McKeown: the relationship between public health and social change. Am J Public Health. 2002;92(5):722-725. doi:10.2105/ajph.92.5.722.
3. Crane-Kramer G, Buckberry J. Changes in health with the rise of industry. Int J Paleopathol. 2023;40:99-102. doi:10.1016/j.ijpp.2022.12.005.
4. Romanello M, McGushin A, Di Napoli C, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future [published correction appears in Lancet. 2021 Dec 11;398(10317):2148. doi: 10.1016/S0140-6736(21)02429-6.]. Lancet. 2021;398(10311):16 19-1662. doi:10.1016/S0140-6736(21)01787-6.
5. Richie C. A brief history of environmental bioethics. Virtual Mentor. 2014;16(9):749-752. Published 2014 Sep 1. doi:10.1001/virtualmentor.2014.16.09.mhst2-1409.
6. Calderon PEE, Tan MKM. Care for the Environment as a Consideration in Bioethics Discourse and Education. New Bioeth. 2023;29(4):352-362. doi:10.1080/20502877.2023.2219021
7. Richie C. Guest Editorial: Sustainability and bioethics: where we have been, where we are, where we are going. New Bioeth. 2020;26(2):82-90. doi:10.1080/20502877.2020.1767920.
8. Grinberg AR, Tripodoro VA. Futilidad médica y obstinación familiar en terapia intensiva. ¿Hasta cuándo seguir y cuándo parar? [Medical futility and family obstinacy in intensive therapy. When to stop and when to keep going?]. Medicina (B Aires). 2017;77(6):491-496.
9. Rigaud JP, Giabicani M, Beuzelin M, Marchalot A, Ecarnot F, Quenot JP. Ethical aspects of admission or non-admission to the intensive care unit. Ann Transl Med. 2017;5(Suppl 4):S38. doi:10.21037/atm.2017.06.53.
10. Takala T, Häyry M. Justainability. Camb Q Healthc Ethics. Published online June 27, 2023. doi:10.1017/S0963180123000361.
11. Thomas J, Mantri P. Design for financial sustainability. Patterns (N Y). 2022;3(9):100585. Published 2022 Sep 9. doi:10.1016/j.patter.2022.100585.
12. Shelton RC, Hailemariam M, Iwelunmor J. Making the connection between health equity and sustainability. Front Public Health. 2023;11:1226175. Published 2023 Sep 26. doi:10.3389/fpubh.2023.1226175.
13. Hailemariam M, Bustos T, Montgomery B, Barajas R, Evans LB, Drahota A. Evidence-based intervention sustainability strategies: a systematic review. Implement Sci. 2019;14(1):57. Published 2019 Jun 6. doi:10.1186/s13012-019-0910-6
14. Bodkin A, Hakimi S. Sustainable by design: a systematic review of factors for health promotion program sustainability. BMC Public Health. 2020;20(1):964. Published 2020 Jun 19. doi:10.1186/s12889-020-09091-9.
15. Gusmão Louredo FS, Raupp E, Araujo CAS. Meaning of sustainability of innovations in healthcare organizations: A systematic review. Health Serv Manage Res. 2024;37(1):16-28. doi:10.1177/09514848231154758.
16. Chalil Madathil K, Greenstein JS. Designing comprehensible healthcare public reports: An investigation of the use of narratives and tests of quality metrics to support healthcare public report sensemaking. Appl Ergon. 2021;95:103452. doi:10.1016/j.apergo.2021.103452
17. Read J, Meath C. A Conceptual Framework for Sustainable Evidence-Based Design for Aligning Therapeutic and Sustainability Outcomes in Healthcare Facilities: A Systematic Literature Review. HERD. 2025;18(1):86-107. doi:10.1177/19375867241302793.
18. Kim Y, Kim Y, Lee HJ, et al. The Primary Process and Key Concepts of Economic Evaluation in Healthcare. J Prev Med Public Health. 2022;55(5):415-423. doi:10.3961/jpmph.22.195.
19. McKinnon M. Estudios Gráfcos Europeos, SA; Spain: 2012. Climate Vulnerability Monitor: A Guide to the Cold Calculus of a Hot Planet; p. 331
20. Zhao Q, Yu P, Mahendran R, et al. Global climate change and human health: Pathways and possible solutions. Eco Environ Health. 2022;1(2):53-62. Published 2022 May 7. doi:10.1016/j.eehl.2022.04.004.
21. Semenza JC, Rocklöv J, Ebi KL. Climate Change and Cascading Risks from Infectious Disease. Infect Dis Ther. 2022;11(4):1371-1390. doi:10.1007/s40121-022-00647-3.
22. Chen J, Hoek G. Long-term exposure to PM and all-cause and cause-specific mortality: A systematic review and meta-analysis. Environ Int. 2020;143:105974. doi:10.1016/j.envint.2020.105974.
23. Cavicchioli R, Ripple WJ, Timmis KN, et al. Scientists' warning to humanity: microorganisms and climate change. Nat Rev Microbiol. 2019;17(9):569-586. doi:10.1038/s41579-019-0222-5.
24. McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020;125(5):680-692. doi:10.1016/j.bja.2020.06.055.
25. Nagai K, Suzuki H, Ueda A, Agar JWM, Itsubo N. Assessment of environmental sustainability in renal healthcare. J Rural Med. 2021;16(3):132-138. doi:10.2185/jrm.2020-049.
26. The Lancet Digital Health. Curbing the carbon footprint of health care. Lancet Digit Health. 2023;5(12):e848. doi:10.1016/S2589-7500(23)00229-7
27. Lenzen M, Malik A, Li M, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020;4(7):e271-e279. doi:10.1016/ S2542-5196(20)30121-2.
28. Monteiro S, Nuno Lopes MJ, Barata Coutinho AP. EcoHealth Center: reduce, reuse, recycle!. Rural Remote Health. 2023;23(1):8178. doi:10.22605/ RRH8178.
29. Ang TL, Choolani M, Poh KK. Healthcare and environmental sustainability. Singapore Med J. 2024;65(4):203. doi:10.4103/singaporemedj.SMJ-2024-068.
30. 0. Knagg R, Dorey J, Evans R, Hitchman J. Sustainability in healthcare: patient and public perspectives. Anaesthesia. 2024;79(3):278-283. doi:10.1111/anae.16159.
31. Huber W, Ruiz de Garibay AP. Options in extracorporeal support of multiple organ failure. Optionen der extrakorporalen Unterstützung bei Multiorganversagen. Med Klin Intensivmed Notfmed. 2020;115(Suppl 1):28-36. doi:10.1007/s00063-020-00658-3.
32. Ranieri VM, Brodie D, Vincent JL. Extracorporeal Organ Support: From Technological Tool to Clinical Strategy Supporting Severe Organ Failure. JAMA. 2017;318(12):1105-1106. doi:10.1001/jama.2017.10108.
33. Ronco C. Continuous Renal Replacement Therapy: Forty-year Anniversary. Int J Artif Organs. 2017;40(6):257-264. doi:10.5301/ijao.5000610.
34. Burchardi H. History and development of continuous renal replacement techniques. Kidney Int Suppl. 1998;66:S120-S124.
35. Ronco C, Ricci Z, Husain-Syed F. From Multiple Organ Support Therapy to Extracorporeal Organ Support in Critically Ill Patients. Blood Purif. 2019;48(2):99-105. doi:10.1159/000490694.
36. Papamichalis P, Oikonomou KG, Xanthoudaki M, et al. Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future. World J Crit Care Med. 2024;13(2):92458. Published 2024 Jun 9. doi:10.5492/wjccm.v13.i2.92458.
37. Stolldorf DP. Sustaining Health Care Interventions to Achieve Quality Care: What We Can Learn From Rapid Response Teams. J Nurs Care Qual. 2017;32(1):87-93. doi:10.1097/NCQ.0000000000000204.
38. https://www.fda.gov/media/124716/download access April 1st, 2025.
39. Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care. 2022;26(1):289. Published 2022 Sep 26. doi:10.1186/s13054-022-04163-1.
40. Montini L, Antonelli M. Multiple organ failure: incidence and outcomes over time. Minerva Anestesiol. 2021;87(2):139-141. doi:10.23736/S0375-9393.21.15446-X.
41. Jansson MM, Ohtonen PP, SyrjÄlÄ HP, Ala-Kokko TI. Changes in the incidence and outcome of multiple organ failure in emergency non-cardiac surgical admissions: a 10-year retrospective observational study. Minerva Anestesiol. 2021;87(2):174-183. doi:10.23736/S0375-9393.20.14374-8.
42. Herrera-Gutiérrez ME, Seller-Pérez G, Sánchez-Izquierdo-Riera JA, Maynar-Moliner J; COFRADE investigators group. Prevalence of acute kidney injury in intensive care units: the "COrte de prevalencia de disFunción RenAl y DEpuración en críticos" point-prevalence multicenter study. J Crit Care. 2013;28(5):687-694. doi:10.1016/j.jcrc.2013.05.019.
43. Wahrhaftig Kde M, Correia LC, de Souza CA. Classificação de RIFLE: análise prospectiva da associação com mortalidade em pacientes críticos [RIFLE Classification: prospective analysis of the association with mortality in critical ill patients] [published correction appears in J Bras Nefrol. 2013 Jan-Mar;35(1):77]. J Bras Nefrol. 2012;34(4):369-377. doi:10.5935/0101-2800.20120027.
44. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24(1):37-42. doi:10.1681/ASN.2012080800.
45. Rewa OG, Ortiz-Soriano V, Lambert J, et al. Epidemiology and Outcomes of AKI Treated With Continuous Kidney Replacement Therapy: The Multicenter CRRTnet Study. Kidney Med. 2023;5(6):100641. Published 2023 Apr 15. doi:10.1016/j.xkme.2023.100641.
46. Dahlerus, C., Segal, J. H., He, K., Wu, W., Chen, S., Shearon, T. H., Sun, Y., Dahlerus C, Segal JH, He K, et al. Acute Kidney Injury Requiring Dialysis and Incident Dialysis Patient Outcomes in US Outpatient Dialysis Facilities. Clin J Am Soc Nephrol. 2021;16(6):853-861. doi:10.2215/CJN.18311120.
47. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015;385(9981):1975-1982. doi:10.1016/S0140-6736(14)61601-9.
48. https://www.aha.org/webinars/2020-03-26-ecmo-insights-strategies-and-key-considerations-developing-sustainable-program. Accesed April 1st, 2025.
49. Gaetani M, Uleryk E, Halgren C, Maratta C. The carbon footprint of critical care: a systematic review. Intensive Care Med. 2024;50(5):731-745. doi:10.1007/s00134-023-07307-1.
50. Bhopal A, Sharma S, Norheim OF. Balancing the health benefits and climate mortality costs of haemodialysis. Future Healthc J. 2023;10(3):308-312. doi:10.7861/fhj.2022-0127.
51. Gonzalez-Pizarro P, Brazzi L, Koch S, et al. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. Eur J Anaesthesiol. 2024;41(4):260-277. doi:10.1097/EJA.0000000000001942.
52. Piccoli GB, Nazha M, Ferraresi M, Vigotti FN, Pereno A, Barbero S. Eco-dialysis: the financial and ecological costs of dialysis waste products: is a 'cradle-to-cradle' model feasible for planet-friendly haemodialysis waste management. Nephrol Dial Transplant. 2015;30(6):1018-1027. doi:10.1093/ ndt/ gfv031.
53. Hunfeld N, Diehl JC, Timmermann M, et al. Circular material flow in the intensive care unit-environmental effects and identification of hotspots. Intensive Care Med. 2023;49(1):65-74. doi:10.1007/s00134-022-06940-6.
54. James R. Incineration: why this may be the most environmentally sound method of renal healthcare waste disposal. J Ren Care. 2010;36(3):161-169. doi:10.1111/j.1755-6686.2010.00178.x.
55. Tagaya M, Hara K, Takahashi S, et al. Antithrombotic properties of hemofilter coated with polymer having a hydrophilic blood-contacting layer. Int J Artif Organs. 2019;42(2):88-94. doi:10.1177/0391398818815480.
56. Gauly A, Fleck N, Kircelli F. Advanced hemodialysis equipment for more eco-friendly dialysis. Int Urol Nephrol. 2022;54(5):1059-1065. doi:10.1007/s11255-021-02981-w.
57. Wieliczko M, Zawierucha J, Covic A, Prystacki T, Marcinkowski W, Małyszko J. Eco-dialysis: fashion or necessity. Int Urol Nephrol. 2020;52(3):519-523. doi:10.1007/s11255-020-02393-2.
58. Chaudhary RG, Desimone MF. Synthesis, Characterization, and Applications of Green Synthesized Nanomaterials (Part 1). Curr Pharm Biotechnol. 2021;22(6):722-723. doi:10.2174/138920102206210521165455.
59. Gadour E, Kaballo MA, Shrwani K, et al. Safety and efficacy of Single-Pass Albumin Dialysis (SPAD), Prometheus, and Molecular Adsorbent Recycling System (MARS) liver haemodialysis vs. Standard Medical Therapy (SMT): meta-analysis and systematic review. Prz Gastroenterol. 2024;19(2):101-111. doi:10.5114/pg.2024.139297
60. Nagai K. Possible benefits for environmental sustainability of combined therapy with hemodialysis and peritoneal dialysis in Japan. Front Nephrol. 2024;4:1394200. Published 2024 Nov 14. doi:10.3389/fneph.2024.1394200.
61. De Bartolo L, Mantovani D. Bioartificial Organs: Ongoing Research and Future Trends. Cells Tissues Organs. 2022;211(4):365-367. doi:10.1159/000518251.
62. Ekins P, Zenghelis D. The costs and benefits of environmental sustainability. Sustain Sci. 2021;16(3):949-965. doi:10.1007/s11625-021-00910-5.
63. Tarrass F, Benjelloun H, Benjelloun M. Nitrogen and phosphorus recovery from hemodialysis wastewater to use as an agricultural fertilizer. Nefrologia (Engl Ed). 2023;43 Suppl 2:32-37. doi:10.1016/j.nefroe.2023.05.007.
64. Alayoud A, Benyahia M, Montassir D, et al. A model to predict optimal dialysate flow. Ther Apher Dial. 2012;16(2):152-158. doi:10.1111/j.1744-9987. 2011.01040.x.
65. Molano-Triviño A, Wancjer B, Neri MM, Karopadi AN, Rosner M, Ronco C. Blue Planet dialysis: novel water-sparing strategies for reducing dialysate flow. Int J Artif Organs. Published online November 8, 2017. doi:10.5301/ijao.5000660.
66. Zawierucha J, Marcinkowski W, Prystacki T, et al. Green Dialysis: Let Us Talk about Dialysis Fluid. Kidney Blood Press Res. 2023;48(1):385-391. doi:10.1159/000530439.
67. Čongradac V, Prebiračević B, Jorgovanović N, Stanišić D. Assessing the energy consumption for heating and cooling in hospitals. Energy and Buildings 2012;48:146-154. doi: 10.1016/j.enbuild.2012.01. 022
68. Piccoli GB, Cupisti A, Aucella F, et al. Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology. J Nephrol. 2020;33(4):681-698. doi:10.1007/s40620-020-00734-z.
69. Rathore SS, Nirja K, Choudhary S, Jeswani G. Green Dialysis From the Indian Perspective: A Systematic Review. Cureus. 2024;16(6):e62876. Published 2024 Jun 21. doi:10.7759/cureus.62876.
70. Eastwood MA. Global warming and the laws of nature. QJM. 2021;114(4):227-228. doi:10.1093/ qjmed/hcaa152.
71. https://ourworldindata.org/population-growth, accessed September 29, 2024.
72. Prescott, S.L.; Logan, A.C.; Albrecht, G.; Campbell, D.E.; Crane, J.; Cunsolo, A.; Holloway, J.W.; Kozyrskyj, A.; Lowry, C.A.; Penders, J.; et al. The Canmore Declaration: Statement of Principles for Planetary Health. Challenges 2018, 9, 31
73. The Lancet Planetary Health. Education for planetary health. Lancet Planet Health. 2023;7(1):e1. doi:10.1016/S2542-5196(22)00338-2.
74. Lenzen M, Malik A, Li M, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020;4(7):e271-e279. doi:10.1016/S2542-5196(20)30121-2.
75. De Bartolo L, Mantovani D. Bioartificial Organs: Ongoing Research and Future Trends. Cells Tissues Organs. 2022;211(4):365-367. doi:10.1159/000518251.
76. Chen M, Decary M. Artificial intelligence in healthcare: An essential guide for health leaders. Healthc Manage Forum. 2020;33(1):10-18. doi:10.1177/0840470419873123.
77. Rivara MB, Himmelfarb J. From Home to Wearable Hemodialysis: Barriers, Progress, and Opportunities. Clin J Am Soc Nephrol. 2024;19(11):1488-1495. doi:10.2215/CJN.0000000000000424.
78. Mleyhi S, Ziadi J, Ben Hmida Y, Ghédira F, Ben Mrad M, Denguir R. La télémédecine et les réseaux sociaux dans la gestion des ECMO à l’ère de COVID-19 : l’expérience Tunisienne [Telemedicine and social Media in the management of ECMOs in the era of COVID-19: The Tunisian experience]. Ann Cardiol Angeiol (Paris). 2021;70(2):125-128. doi:10.1016/j.ancard.2020.12.004.
79. Brunet J, Billaquois C, Viellard H, Courari F. Eco-friendly hospital architecture. J Visc Surg. 2024;161(2S):54-62. doi:10.1016/j.jviscsurg.2023.11.008
80. Sá AGA, Laurindo JB, Moreno YMF, Carciofi BAM. Influence of Emerging Technologies on the Utilization of Plant Proteins. Front Nutr. 2022;9:809058. Published 2022 Feb 11. doi:10.3389/fnut.2022.809058.
81. Gibas-Dorna M, Żukiewicz-Sobczak W. Sustainable Nutrition and Human Health as Part of Sustainable Development. Nutrients. 2024;16(2):225. Published 2024 Jan 10. doi:10.3390/nu16020225.
82. See KC. Improving environmental sustainability of intensive care units: A mini-review. World J Crit Care Med. 2023;12(4):217-225. Published 2023 Sep 9. doi:10.5492/wjccm.v12.i4.217.
83. Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978.
84. Barratt A, McGain F. Overdiagnosis is increasing the carbon footprint of healthcare. BMJ. 2021;375:n2407. Published 2021 Oct 4. doi:10.1136/bmj.n2407
85. McGain F, Burnham JP, Lau R, Aye L, Kollef MH, McAlister S. The carbon footprint of treating patients with septic shock in the intensive care unit. Crit Care Resusc. 2018;20(4):304-312.
86. Masud FN, Sasangohar F, Ratnani I, et al. Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience. Crit Care. 2024;28(1):154. Published 2024 May 9. doi:10.1186/s13054-024-04937-9.
87. Huffling K, Schenk E. Environmental sustainability in the intensive care unit: challenges and solutions. Crit Care Nurs Q. 2014;37(3):235-250. doi:10.1097/CNQ.0000000000000028.
88. Zimmermann GDS, Bohomol E. Lean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit. Rev Bras Enferm. 2023;76(3):e20220538. Published 2023 Jul 10. doi:10.1590/0034-7167-2022-0538
89. https://anzics.org/wp-content/uploads/2022/04/A-beginners-guide-to-Sustainability-in-the-ICU.pdf accessed April 18th, 2025.
90. Soreze Y, Piloquet JE, Amblard A, Constant I, Rambaud J, Leger PL. Sevoflurane Sedation with AnaConDa-S Device for a Child Undergoing Extracorporeal Membrane Oxygenation. Indian J Crit Care Med. 2020;24(7):596-598. doi:10.5005/jp-journals-10071-23487.
91. Romagnoli S, Chelazzi C, Villa G, et al. The New MIRUS System for Short-Term Sedation in Postsurgical ICU Patients. Crit Care Med. 2017;45(9):e925-e931. doi:10.1097/CCM.0000000000002465.
92. McGain F et al. (2020) Environmental sustainability in anaesthesia and critical care,” British Journal of Anaesthesia.125(5):680-692.
93. Karimi K, Rahsepar M. Optimization of the Urea Removal in a Wearable Dialysis Device Using Nitrogen-Doped and Phosphorus-Doped Graphene. ACS Omega. 2022;7(5):4083-4094. Published 2022 Jan 24. doi:10.1021/acsomega.1c05495
94. Barraclough KA, Agar JWM. Green nephrology. Nat Rev Nephrol. 2020;16(5):257-268. doi:10.1038/s41581-019-0245-1
2. Szreter S. Rethinking McKeown: the relationship between public health and social change. Am J Public Health. 2002;92(5):722-725. doi:10.2105/ajph.92.5.722.
3. Crane-Kramer G, Buckberry J. Changes in health with the rise of industry. Int J Paleopathol. 2023;40:99-102. doi:10.1016/j.ijpp.2022.12.005.
4. Romanello M, McGushin A, Di Napoli C, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future [published correction appears in Lancet. 2021 Dec 11;398(10317):2148. doi: 10.1016/S0140-6736(21)02429-6.]. Lancet. 2021;398(10311):16 19-1662. doi:10.1016/S0140-6736(21)01787-6.
5. Richie C. A brief history of environmental bioethics. Virtual Mentor. 2014;16(9):749-752. Published 2014 Sep 1. doi:10.1001/virtualmentor.2014.16.09.mhst2-1409.
6. Calderon PEE, Tan MKM. Care for the Environment as a Consideration in Bioethics Discourse and Education. New Bioeth. 2023;29(4):352-362. doi:10.1080/20502877.2023.2219021
7. Richie C. Guest Editorial: Sustainability and bioethics: where we have been, where we are, where we are going. New Bioeth. 2020;26(2):82-90. doi:10.1080/20502877.2020.1767920.
8. Grinberg AR, Tripodoro VA. Futilidad médica y obstinación familiar en terapia intensiva. ¿Hasta cuándo seguir y cuándo parar? [Medical futility and family obstinacy in intensive therapy. When to stop and when to keep going?]. Medicina (B Aires). 2017;77(6):491-496.
9. Rigaud JP, Giabicani M, Beuzelin M, Marchalot A, Ecarnot F, Quenot JP. Ethical aspects of admission or non-admission to the intensive care unit. Ann Transl Med. 2017;5(Suppl 4):S38. doi:10.21037/atm.2017.06.53.
10. Takala T, Häyry M. Justainability. Camb Q Healthc Ethics. Published online June 27, 2023. doi:10.1017/S0963180123000361.
11. Thomas J, Mantri P. Design for financial sustainability. Patterns (N Y). 2022;3(9):100585. Published 2022 Sep 9. doi:10.1016/j.patter.2022.100585.
12. Shelton RC, Hailemariam M, Iwelunmor J. Making the connection between health equity and sustainability. Front Public Health. 2023;11:1226175. Published 2023 Sep 26. doi:10.3389/fpubh.2023.1226175.
13. Hailemariam M, Bustos T, Montgomery B, Barajas R, Evans LB, Drahota A. Evidence-based intervention sustainability strategies: a systematic review. Implement Sci. 2019;14(1):57. Published 2019 Jun 6. doi:10.1186/s13012-019-0910-6
14. Bodkin A, Hakimi S. Sustainable by design: a systematic review of factors for health promotion program sustainability. BMC Public Health. 2020;20(1):964. Published 2020 Jun 19. doi:10.1186/s12889-020-09091-9.
15. Gusmão Louredo FS, Raupp E, Araujo CAS. Meaning of sustainability of innovations in healthcare organizations: A systematic review. Health Serv Manage Res. 2024;37(1):16-28. doi:10.1177/09514848231154758.
16. Chalil Madathil K, Greenstein JS. Designing comprehensible healthcare public reports: An investigation of the use of narratives and tests of quality metrics to support healthcare public report sensemaking. Appl Ergon. 2021;95:103452. doi:10.1016/j.apergo.2021.103452
17. Read J, Meath C. A Conceptual Framework for Sustainable Evidence-Based Design for Aligning Therapeutic and Sustainability Outcomes in Healthcare Facilities: A Systematic Literature Review. HERD. 2025;18(1):86-107. doi:10.1177/19375867241302793.
18. Kim Y, Kim Y, Lee HJ, et al. The Primary Process and Key Concepts of Economic Evaluation in Healthcare. J Prev Med Public Health. 2022;55(5):415-423. doi:10.3961/jpmph.22.195.
19. McKinnon M. Estudios Gráfcos Europeos, SA; Spain: 2012. Climate Vulnerability Monitor: A Guide to the Cold Calculus of a Hot Planet; p. 331
20. Zhao Q, Yu P, Mahendran R, et al. Global climate change and human health: Pathways and possible solutions. Eco Environ Health. 2022;1(2):53-62. Published 2022 May 7. doi:10.1016/j.eehl.2022.04.004.
21. Semenza JC, Rocklöv J, Ebi KL. Climate Change and Cascading Risks from Infectious Disease. Infect Dis Ther. 2022;11(4):1371-1390. doi:10.1007/s40121-022-00647-3.
22. Chen J, Hoek G. Long-term exposure to PM and all-cause and cause-specific mortality: A systematic review and meta-analysis. Environ Int. 2020;143:105974. doi:10.1016/j.envint.2020.105974.
23. Cavicchioli R, Ripple WJ, Timmis KN, et al. Scientists' warning to humanity: microorganisms and climate change. Nat Rev Microbiol. 2019;17(9):569-586. doi:10.1038/s41579-019-0222-5.
24. McGain F, Muret J, Lawson C, Sherman JD. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020;125(5):680-692. doi:10.1016/j.bja.2020.06.055.
25. Nagai K, Suzuki H, Ueda A, Agar JWM, Itsubo N. Assessment of environmental sustainability in renal healthcare. J Rural Med. 2021;16(3):132-138. doi:10.2185/jrm.2020-049.
26. The Lancet Digital Health. Curbing the carbon footprint of health care. Lancet Digit Health. 2023;5(12):e848. doi:10.1016/S2589-7500(23)00229-7
27. Lenzen M, Malik A, Li M, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020;4(7):e271-e279. doi:10.1016/ S2542-5196(20)30121-2.
28. Monteiro S, Nuno Lopes MJ, Barata Coutinho AP. EcoHealth Center: reduce, reuse, recycle!. Rural Remote Health. 2023;23(1):8178. doi:10.22605/ RRH8178.
29. Ang TL, Choolani M, Poh KK. Healthcare and environmental sustainability. Singapore Med J. 2024;65(4):203. doi:10.4103/singaporemedj.SMJ-2024-068.
30. 0. Knagg R, Dorey J, Evans R, Hitchman J. Sustainability in healthcare: patient and public perspectives. Anaesthesia. 2024;79(3):278-283. doi:10.1111/anae.16159.
31. Huber W, Ruiz de Garibay AP. Options in extracorporeal support of multiple organ failure. Optionen der extrakorporalen Unterstützung bei Multiorganversagen. Med Klin Intensivmed Notfmed. 2020;115(Suppl 1):28-36. doi:10.1007/s00063-020-00658-3.
32. Ranieri VM, Brodie D, Vincent JL. Extracorporeal Organ Support: From Technological Tool to Clinical Strategy Supporting Severe Organ Failure. JAMA. 2017;318(12):1105-1106. doi:10.1001/jama.2017.10108.
33. Ronco C. Continuous Renal Replacement Therapy: Forty-year Anniversary. Int J Artif Organs. 2017;40(6):257-264. doi:10.5301/ijao.5000610.
34. Burchardi H. History and development of continuous renal replacement techniques. Kidney Int Suppl. 1998;66:S120-S124.
35. Ronco C, Ricci Z, Husain-Syed F. From Multiple Organ Support Therapy to Extracorporeal Organ Support in Critically Ill Patients. Blood Purif. 2019;48(2):99-105. doi:10.1159/000490694.
36. Papamichalis P, Oikonomou KG, Xanthoudaki M, et al. Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future. World J Crit Care Med. 2024;13(2):92458. Published 2024 Jun 9. doi:10.5492/wjccm.v13.i2.92458.
37. Stolldorf DP. Sustaining Health Care Interventions to Achieve Quality Care: What We Can Learn From Rapid Response Teams. J Nurs Care Qual. 2017;32(1):87-93. doi:10.1097/NCQ.0000000000000204.
38. https://www.fda.gov/media/124716/download access April 1st, 2025.
39. Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care. 2022;26(1):289. Published 2022 Sep 26. doi:10.1186/s13054-022-04163-1.
40. Montini L, Antonelli M. Multiple organ failure: incidence and outcomes over time. Minerva Anestesiol. 2021;87(2):139-141. doi:10.23736/S0375-9393.21.15446-X.
41. Jansson MM, Ohtonen PP, SyrjÄlÄ HP, Ala-Kokko TI. Changes in the incidence and outcome of multiple organ failure in emergency non-cardiac surgical admissions: a 10-year retrospective observational study. Minerva Anestesiol. 2021;87(2):174-183. doi:10.23736/S0375-9393.20.14374-8.
42. Herrera-Gutiérrez ME, Seller-Pérez G, Sánchez-Izquierdo-Riera JA, Maynar-Moliner J; COFRADE investigators group. Prevalence of acute kidney injury in intensive care units: the "COrte de prevalencia de disFunción RenAl y DEpuración en críticos" point-prevalence multicenter study. J Crit Care. 2013;28(5):687-694. doi:10.1016/j.jcrc.2013.05.019.
43. Wahrhaftig Kde M, Correia LC, de Souza CA. Classificação de RIFLE: análise prospectiva da associação com mortalidade em pacientes críticos [RIFLE Classification: prospective analysis of the association with mortality in critical ill patients] [published correction appears in J Bras Nefrol. 2013 Jan-Mar;35(1):77]. J Bras Nefrol. 2012;34(4):369-377. doi:10.5935/0101-2800.20120027.
44. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24(1):37-42. doi:10.1681/ASN.2012080800.
45. Rewa OG, Ortiz-Soriano V, Lambert J, et al. Epidemiology and Outcomes of AKI Treated With Continuous Kidney Replacement Therapy: The Multicenter CRRTnet Study. Kidney Med. 2023;5(6):100641. Published 2023 Apr 15. doi:10.1016/j.xkme.2023.100641.
46. Dahlerus, C., Segal, J. H., He, K., Wu, W., Chen, S., Shearon, T. H., Sun, Y., Dahlerus C, Segal JH, He K, et al. Acute Kidney Injury Requiring Dialysis and Incident Dialysis Patient Outcomes in US Outpatient Dialysis Facilities. Clin J Am Soc Nephrol. 2021;16(6):853-861. doi:10.2215/CJN.18311120.
47. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015;385(9981):1975-1982. doi:10.1016/S0140-6736(14)61601-9.
48. https://www.aha.org/webinars/2020-03-26-ecmo-insights-strategies-and-key-considerations-developing-sustainable-program. Accesed April 1st, 2025.
49. Gaetani M, Uleryk E, Halgren C, Maratta C. The carbon footprint of critical care: a systematic review. Intensive Care Med. 2024;50(5):731-745. doi:10.1007/s00134-023-07307-1.
50. Bhopal A, Sharma S, Norheim OF. Balancing the health benefits and climate mortality costs of haemodialysis. Future Healthc J. 2023;10(3):308-312. doi:10.7861/fhj.2022-0127.
51. Gonzalez-Pizarro P, Brazzi L, Koch S, et al. European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice. Eur J Anaesthesiol. 2024;41(4):260-277. doi:10.1097/EJA.0000000000001942.
52. Piccoli GB, Nazha M, Ferraresi M, Vigotti FN, Pereno A, Barbero S. Eco-dialysis: the financial and ecological costs of dialysis waste products: is a 'cradle-to-cradle' model feasible for planet-friendly haemodialysis waste management. Nephrol Dial Transplant. 2015;30(6):1018-1027. doi:10.1093/ ndt/ gfv031.
53. Hunfeld N, Diehl JC, Timmermann M, et al. Circular material flow in the intensive care unit-environmental effects and identification of hotspots. Intensive Care Med. 2023;49(1):65-74. doi:10.1007/s00134-022-06940-6.
54. James R. Incineration: why this may be the most environmentally sound method of renal healthcare waste disposal. J Ren Care. 2010;36(3):161-169. doi:10.1111/j.1755-6686.2010.00178.x.
55. Tagaya M, Hara K, Takahashi S, et al. Antithrombotic properties of hemofilter coated with polymer having a hydrophilic blood-contacting layer. Int J Artif Organs. 2019;42(2):88-94. doi:10.1177/0391398818815480.
56. Gauly A, Fleck N, Kircelli F. Advanced hemodialysis equipment for more eco-friendly dialysis. Int Urol Nephrol. 2022;54(5):1059-1065. doi:10.1007/s11255-021-02981-w.
57. Wieliczko M, Zawierucha J, Covic A, Prystacki T, Marcinkowski W, Małyszko J. Eco-dialysis: fashion or necessity. Int Urol Nephrol. 2020;52(3):519-523. doi:10.1007/s11255-020-02393-2.
58. Chaudhary RG, Desimone MF. Synthesis, Characterization, and Applications of Green Synthesized Nanomaterials (Part 1). Curr Pharm Biotechnol. 2021;22(6):722-723. doi:10.2174/138920102206210521165455.
59. Gadour E, Kaballo MA, Shrwani K, et al. Safety and efficacy of Single-Pass Albumin Dialysis (SPAD), Prometheus, and Molecular Adsorbent Recycling System (MARS) liver haemodialysis vs. Standard Medical Therapy (SMT): meta-analysis and systematic review. Prz Gastroenterol. 2024;19(2):101-111. doi:10.5114/pg.2024.139297
60. Nagai K. Possible benefits for environmental sustainability of combined therapy with hemodialysis and peritoneal dialysis in Japan. Front Nephrol. 2024;4:1394200. Published 2024 Nov 14. doi:10.3389/fneph.2024.1394200.
61. De Bartolo L, Mantovani D. Bioartificial Organs: Ongoing Research and Future Trends. Cells Tissues Organs. 2022;211(4):365-367. doi:10.1159/000518251.
62. Ekins P, Zenghelis D. The costs and benefits of environmental sustainability. Sustain Sci. 2021;16(3):949-965. doi:10.1007/s11625-021-00910-5.
63. Tarrass F, Benjelloun H, Benjelloun M. Nitrogen and phosphorus recovery from hemodialysis wastewater to use as an agricultural fertilizer. Nefrologia (Engl Ed). 2023;43 Suppl 2:32-37. doi:10.1016/j.nefroe.2023.05.007.
64. Alayoud A, Benyahia M, Montassir D, et al. A model to predict optimal dialysate flow. Ther Apher Dial. 2012;16(2):152-158. doi:10.1111/j.1744-9987. 2011.01040.x.
65. Molano-Triviño A, Wancjer B, Neri MM, Karopadi AN, Rosner M, Ronco C. Blue Planet dialysis: novel water-sparing strategies for reducing dialysate flow. Int J Artif Organs. Published online November 8, 2017. doi:10.5301/ijao.5000660.
66. Zawierucha J, Marcinkowski W, Prystacki T, et al. Green Dialysis: Let Us Talk about Dialysis Fluid. Kidney Blood Press Res. 2023;48(1):385-391. doi:10.1159/000530439.
67. Čongradac V, Prebiračević B, Jorgovanović N, Stanišić D. Assessing the energy consumption for heating and cooling in hospitals. Energy and Buildings 2012;48:146-154. doi: 10.1016/j.enbuild.2012.01. 022
68. Piccoli GB, Cupisti A, Aucella F, et al. Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology. J Nephrol. 2020;33(4):681-698. doi:10.1007/s40620-020-00734-z.
69. Rathore SS, Nirja K, Choudhary S, Jeswani G. Green Dialysis From the Indian Perspective: A Systematic Review. Cureus. 2024;16(6):e62876. Published 2024 Jun 21. doi:10.7759/cureus.62876.
70. Eastwood MA. Global warming and the laws of nature. QJM. 2021;114(4):227-228. doi:10.1093/ qjmed/hcaa152.
71. https://ourworldindata.org/population-growth, accessed September 29, 2024.
72. Prescott, S.L.; Logan, A.C.; Albrecht, G.; Campbell, D.E.; Crane, J.; Cunsolo, A.; Holloway, J.W.; Kozyrskyj, A.; Lowry, C.A.; Penders, J.; et al. The Canmore Declaration: Statement of Principles for Planetary Health. Challenges 2018, 9, 31
73. The Lancet Planetary Health. Education for planetary health. Lancet Planet Health. 2023;7(1):e1. doi:10.1016/S2542-5196(22)00338-2.
74. Lenzen M, Malik A, Li M, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020;4(7):e271-e279. doi:10.1016/S2542-5196(20)30121-2.
75. De Bartolo L, Mantovani D. Bioartificial Organs: Ongoing Research and Future Trends. Cells Tissues Organs. 2022;211(4):365-367. doi:10.1159/000518251.
76. Chen M, Decary M. Artificial intelligence in healthcare: An essential guide for health leaders. Healthc Manage Forum. 2020;33(1):10-18. doi:10.1177/0840470419873123.
77. Rivara MB, Himmelfarb J. From Home to Wearable Hemodialysis: Barriers, Progress, and Opportunities. Clin J Am Soc Nephrol. 2024;19(11):1488-1495. doi:10.2215/CJN.0000000000000424.
78. Mleyhi S, Ziadi J, Ben Hmida Y, Ghédira F, Ben Mrad M, Denguir R. La télémédecine et les réseaux sociaux dans la gestion des ECMO à l’ère de COVID-19 : l’expérience Tunisienne [Telemedicine and social Media in the management of ECMOs in the era of COVID-19: The Tunisian experience]. Ann Cardiol Angeiol (Paris). 2021;70(2):125-128. doi:10.1016/j.ancard.2020.12.004.
79. Brunet J, Billaquois C, Viellard H, Courari F. Eco-friendly hospital architecture. J Visc Surg. 2024;161(2S):54-62. doi:10.1016/j.jviscsurg.2023.11.008
80. Sá AGA, Laurindo JB, Moreno YMF, Carciofi BAM. Influence of Emerging Technologies on the Utilization of Plant Proteins. Front Nutr. 2022;9:809058. Published 2022 Feb 11. doi:10.3389/fnut.2022.809058.
81. Gibas-Dorna M, Żukiewicz-Sobczak W. Sustainable Nutrition and Human Health as Part of Sustainable Development. Nutrients. 2024;16(2):225. Published 2024 Jan 10. doi:10.3390/nu16020225.
82. See KC. Improving environmental sustainability of intensive care units: A mini-review. World J Crit Care Med. 2023;12(4):217-225. Published 2023 Sep 9. doi:10.5492/wjccm.v12.i4.217.
83. Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978.
84. Barratt A, McGain F. Overdiagnosis is increasing the carbon footprint of healthcare. BMJ. 2021;375:n2407. Published 2021 Oct 4. doi:10.1136/bmj.n2407
85. McGain F, Burnham JP, Lau R, Aye L, Kollef MH, McAlister S. The carbon footprint of treating patients with septic shock in the intensive care unit. Crit Care Resusc. 2018;20(4):304-312.
86. Masud FN, Sasangohar F, Ratnani I, et al. Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience. Crit Care. 2024;28(1):154. Published 2024 May 9. doi:10.1186/s13054-024-04937-9.
87. Huffling K, Schenk E. Environmental sustainability in the intensive care unit: challenges and solutions. Crit Care Nurs Q. 2014;37(3):235-250. doi:10.1097/CNQ.0000000000000028.
88. Zimmermann GDS, Bohomol E. Lean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit. Rev Bras Enferm. 2023;76(3):e20220538. Published 2023 Jul 10. doi:10.1590/0034-7167-2022-0538
89. https://anzics.org/wp-content/uploads/2022/04/A-beginners-guide-to-Sustainability-in-the-ICU.pdf accessed April 18th, 2025.
90. Soreze Y, Piloquet JE, Amblard A, Constant I, Rambaud J, Leger PL. Sevoflurane Sedation with AnaConDa-S Device for a Child Undergoing Extracorporeal Membrane Oxygenation. Indian J Crit Care Med. 2020;24(7):596-598. doi:10.5005/jp-journals-10071-23487.
91. Romagnoli S, Chelazzi C, Villa G, et al. The New MIRUS System for Short-Term Sedation in Postsurgical ICU Patients. Crit Care Med. 2017;45(9):e925-e931. doi:10.1097/CCM.0000000000002465.
92. McGain F et al. (2020) Environmental sustainability in anaesthesia and critical care,” British Journal of Anaesthesia.125(5):680-692.
93. Karimi K, Rahsepar M. Optimization of the Urea Removal in a Wearable Dialysis Device Using Nitrogen-Doped and Phosphorus-Doped Graphene. ACS Omega. 2022;7(5):4083-4094. Published 2022 Jan 24. doi:10.1021/acsomega.1c05495
94. Barraclough KA, Agar JWM. Green nephrology. Nat Rev Nephrol. 2020;16(5):257-268. doi:10.1038/s41581-019-0245-1