[Music] [Music] good afternoon friends and colleagues and welcome to this era symposium on green nephrology this is presented on behalf of you dial or european dialysis are working one of our working groups of era there is no doubt that the health of our natural world is declining globally and at a rate that has been unprecedented in human history this decline represents a major threat to the health and well-being of human populations and environmental changes particularly climate change is having and will continue to have an impact on the incidence and distribution of many chronic diseases including kidney disease the extremes and weather conditions owing to climate change will destabilize the effects on the provision of care for patients with kidney diseases and ironically the health of the health care is part of this problem contributing substantially to depletion of resources and particularly dialysis therapy is high up on the list of treatments that need a high amount of electricity water and consumables so we need to address this issue and of course we need to provide the best care for our patients but not forgetting our environment with this in mind it is my great pleasure to put to be a moderator at the symposium on green nephrology my name is rakshana shroff i'm a doctor in pediatric nephrology at great ormond street in london today our speaker is georgina piccoli professor piccoli perhaps does not need an introduction in this symposium but she's the chief of service at the central hospital of le mans in france and also holds an honorary position in the university of torino italy georgina has many feathers in her hat but the one of the key ones is home hema dialysis establishing this network and making it possible to carry out personalized dialysis treatments for our patients of course this is important for the patient care very importantly but also very important it helps with our environmental management as well and georgina will tell us a great deal more about this also on our panel today i'd like to welcome dr vasilios lia copulos an associate professor at the aristotle university of thessaloniki in greece and also massimo torresyani who has studied and worked in pavia italy and now works with professor piccoli in le mans france all three all four of us here in fact are dialysis doctors we are passionate about the treatment we give but also we are very aware of how our treatment depletes resources so without any further ado i'm going to welcome professor picorinopicoli to give us a talk on green nephrology professor piccoli welcome and thank you for all our participants don't forget to keep adding your questions in the q a box here we will have gladly go through these in the course of the meeting so georgina over to you thank you thank you thank you very much let me try to do the most difficult thing of all the talk that is sharing you're halfway there well just yeah perfect okay perfect thank you so each time we speak about green nephrology and echo dialysis uh some friends come and say yes you're a dreamer is a very nice thing but it's just nice words and indeed in the last years we've heard a lot of nice interesting talks including the the green talk of pope francis uh speaking about how we should change our attitude towards the world the urgent challenge to protect our common home and the appreciation in particular for those who work for the poorest because pollution is not something something that might come from the reach but that affects the poor and these impacts the whole society these are problems linked to what has been called a throwaway south society a culture that reduces things to rubbish similar words have been heard from the dalai lama it's not merely a moral question is a question of our own survival and not by chance one of the recent nobel prize of the economy was about a wider project on climate challenge but that is also on society challenges what's called the tragedy of commons uh that means the fact that we are not able to really share what we have and uh even philosophical societies speak about the circular economy and how to to change these that all these circles that all end in the same way waste but we are doctors so why should it matter for us physicians well when we start thinking about dialysis the first thing that comes to the mind is waste management then we go to prescription to pre-dialysis care to ckd prevention and then to education interaction with the environment everything is linked clinics to technology we all have seen this circle reduce reuse recycle and i will try to discuss what we can practically do starting from reduce that is something that we can do from a clinical point of view choosing when and how to start renal replacement therapy using wisely nutritional management physical activity and perhaps also e-medicine the challenge of reduced needs without reducing results is old but this fantastic trial the ideal trial first made us change the way we were seeing things showing that it was not the healthy dialysis stat did not work as well as we we wished and leading several societies first of all the canadian one to change completely we approach to dialysis with an intent to defer strategy where patients should be seen by the physicians and dialysis should not be start by numbers but by saying seeing the patients professor van older who is the author of a beautiful review paper that is going to to come out in the next few days on nephrology dialysis and transplantation spoke about the cost of renal replacement replacement therapy a few years ago and underline how postponing start of dialysis was a wise way but strangely or not strangely enough five years ago seven years ago underline how green dialysis and dialysis based on clinical necessity were linked together dialysis is not a washing machine the best program may not be the same for all and some individuals may be better without dialysis or with a lower dose and it's not by chance that the the blog the australian blog on incremental dialysis is run by john agar who has been the inventor of the concept of green dialysis echo dialysis incremental dialysis is just one step further if we have to start late why not also start gradually and in this that is now the only systematic review available indeed what we see that this is less expensive helps preserving residual kidney function and it's for sure not deleterious on survival and maybe even the reverse but if we move to precision medicine and if we move to experience-based nuanced approaches we can also discover another term that is decremental dialysis once more to try to adapt to patients need massimo torreijani ran this study that we have done in le mans uh just very simply proposing to every patient without contraindication to start on an incremental way and while confirming that survival was at least the same morbidity was slightly slow lower we shift the attention to the pre-dialysis phase having been followed up very strictly in the pre-dialysis phase increases by 10 times the probability of being able to start dialysis in an incremental way so shifting the the attention to the pre-dialysis phase let me invite you reading this beautiful short commentary paper holy cow what's good for you is good for our planet because we know we know well that cows have a very high carbon print and just avoiding eating them may lead us not only to have a better diet a better elf a better kidney elf but to do something also for our planet reducing the carbon tree can be done in many ways rediscovering simple things like physical activity that is useful in all ways we see it also in reducing the burden of drugs that have in in turn a high carbon print it's nothing is very easy however in for example in this nice small trial we saw that about starting from 75 patients only 10 patients finished a period of a few months of physical exercise so doing natural things is not always very easy but even walking the dog as denis wrote a few years ago be sound for our patients and for the carbon print telemedicine well in the carbide period we have not seen our patients we more in dialysis but in predicaments it was sometimes difficult we did not touch them we sometimes were happy in seeing them on on a cell phone is these a good option to reduce the carbon print of healthcare probably yes but we might do we might pay a lot of attention because it's too easy to to put a label it's ecological it may also be depersonalizing and in the end not a very good deal for the patients so the clinics is important the choice of a tailor-made dialysis start nutritional therapy physical therapy a holistic and personalized approach have not only a clinical but also an ecological meaning paying attention of course to clean shape leonastic demonstration and alibis to reduce the contact with patients but green nephrology is a point of view it's just a way we can see our work in under a different corner i like this this sentence says stinger saying i did not become a vegetarian for my elf i did it for the elf of the of the chickens there are some choices that we do not do for ourselves we do them for the elf of a planet let's go to technology technology management we use recycle complete the three air and complete them by water conservation energy conservation waste management and possibly it's not enough developed industrial design let me introduce john agar the genius who had first the idea of green nephrology starting from the care of his patients on home immo dialysis and he started in australia where the weather is a bit sunny with water life starts with water and the water is the first example of what we can put in and out the vital cycle again with very simple in very simple ways with very simple tools he succeeded in recycling enormous quantity of water just little homemade solution that helped food grow kangaroos drink i love this image and indeed in this wonderful review on green nephrology that um appeared some time ago on two years ago on natural review nephrology water is in the first line without going into into details uh let me invite you reading this this wonderful paper that shows that in many things including almost housekeeping in in our dialysis centers we can make a difference much attention on osmosis um recirculation not only in this paper but also in the experience of other colleagues in particular from morocco another country where water is particular particularly important but even in places like malaysia where where water is more abundant there may be very interesting and poetic solutions like growing plants and well maybe they are they're eaten afterwards so it's not so political but aquaponics um before leaving the the freshness company charles chazzo did something wonderful for a sustainable nephrology that is he made the company changed all the reverse osmosis having the consummation of water dropped down for the same number of dialysis sessions there are many things we can do some wonder if we should lower the dialysis the dialysate flow some suggest even claudio ronco who is a passionate other intensive dialysis how we can make water sparing prescriptions on a very small scale when we reduced from eight milliliter per minute to 500 milliliters per minute uh the speed of a dialysis flow in our center well we we we could fill a few swimming pools many say that peritoneal dialysis may be a choice uh because it uses far less dialysate but it's just one small thing we do not know how much water consumes the water we have in the dialysate solution and the industry is very opaque about that and we know that plastic consumes water so if we put everything together well we may gain something but is not so clear energy sparing comes with water sparing and once again john agar is the the pioneer of solar assisted hemodialysis centers we were discussing yesterday with the italian group for green nephrology on the possibility of making a statement on the ideal dialysis center using among other things solar assistance and even john agar again tried to calculate how much with or without solar energy could be the carbon print of a diet of things that are considered it's pity that a few other studies that worked on trying to to quantify the carbon footprint used different items and indeed this is one of the limitation of the use of carbon print as a global and the environmental marker we should probably be a little bit more humble and start from smaller things and once again uh jonatha reminds us that we do not know anything about the carbon print of peritoneal dialysis water and aller energy are are much linked and the window two years ago or the affordable dialysis price indeed suggested that we can produce with solar power pure water for any source that's facilitating dialysis all over the world dialysis is an enormous machine waste machine i would say and waste management is very important in in this sense but uh it's a it's an important issue shared by virtually all aspects of medicine the amount of plastic waste that is produced per dialysis session can range from 1.5 to almost 8 kilograms depending upon the type of dialysis the type of supplies and also differentiation and emptying procedure green dialysis is not just cost but the cost of waste disposal is very high and sometimes we fight for having a reduction of one euro for the dialysis the new dialysis supplies when we may waste up to 16 just for discharging what's left what's left all these is plastic but only a very small part of this is potentially recyclable less than 30 percent but because the use of different types of plastic loose inks labels prevents being recycled but actually it is not done well this is a nice way of finding reuse once more is political but is just down use we could probably also rethink some taboos like reuse on hemodialysis hector perez grobas who is a great nephrologist from mexico city used wise recycling of filters to reusing of filters to allow his patients [Music] be treated by hemodia filtration whose material was is much more expensive in his country and even if nothing is done why not thinking again about all the solution what's management is a good starting point but last be bad is not good reuse prolongs the life of the options but does not change the cycle take make waste this book is a fantastic book even a physician like me could understand it so it's probably too simple but um it's the is the book of the so-called cradle cradle-to-cradle revolution rethinking the way we made things trying to to learn from nature plants synthetize nutrients feed cows bees become food for us we produce organic waste and so forth so why don't we try to imagine similar cycles for or what we produce instead of throwing it away putting it back into the same cycle waste equal food everything can be a nutrient for something else we should define the content we should re-study materials and we should use them again and again and again to do so there is a long list of things that we should ask ourselves and when we look at a dialysis machine but let's think about it these are done to be used sometime occasionally reused often when worn up in rich countries that have a fixed maximum time they may migrate to poor countries and then discharge so that we do not even have to care about that no part of this machine is done for being disassembled and to return it back to the vital cycle of objects and what will happen of these this is highly toxic among all and it's what is called we is like a cry from nature because these electrical and electronic waste are becoming the fastest growing waste generated and is now about 15 of our waste what if dialysis machines were done like this chair this one of the first object in the cradle to travel production easily reduced in more small parts recyclable and able to become a new object again and again a few years ago we started and then i i moved but it's one of my hopes to restart again uh disassemble project with a turin university trying to disassemble a dialysis machine to imagine a better way to rebuild it to make the story of the chair through for the dialysis this machine too it's feasible we just have to have enough links and enough wish to do it uh two years ago the italian society of nephrology did a statement on green nephrology and echo dialysis there is a list of things to do reduce the burden of dialysis limiting drugs suffering natural medicine encouraging the use of household material recycling paper and glass recycling non-contaminated plastic reducing water consumption energy consumption and so on demanding also planet friendly approaches in the building of new facilities um there is nothing to add for what is uh the air except adding repairing dialysis machine what's a little bit new in this position statement is to put the clinical teams in the core of a question so in summary in our helps in our dreams as physicians we may we should reduce and reinvest we may reduce dialysis need to reinvest for those who need it we may reduce garbage wisely managing it we may project new design that allows reducing plastic waste like cutting so much of bloodlines make kilometers of plastic less we need a different partnership with the industry if we want to change also the marketing strategy caller levels for a way approach durable is good instead of new is good friendly instead of nurse friendly plastic sparing instead of time sparing redesign simple objects like the dialysis key to the bloodlines more compact machines we may reuse supplies in special situation but we should overall remain open-minded towards new and old taboos why no research on safe and wise reuse water should always be recycled solar power always considered and potential for recycling should be considered we cannot do everything by ourselves but let's start asking the industry and putting these in in our decisions and we have to support redesign we know what we want so if we want to have a biosphere compatibility and not only biocompatibility it's our time to try to find partnership no nothing with will happen by itself and let me finish with some hope uh too much to do no be kind with a planet whenever possible it's always possible and it always seems impossible until it's done let's hope to be able to say this in a few years from now thank you for your attention thank you very much georgina that was a superb overview on green nephrology there is so much we can do and so much we all need to do really in this process that's a fantastic overview um may i now welcome all our all our participants to send us questions please insert them in the q a box and we will look forward to a discussion very soon on your questions meanwhile uh we have a little bit of time samasimo would you like to give us your presentation please um oh in the next few minutes okay so dr piccoli has already said a lot of things i would like just to add something to stimulate the discussion uh one of the as georgina said one of the points that is always raised in order to spare water in the dialysis units unit is to reduce the dialysate flow we know that the impact of raising the dialysis flow on the decoration is not that much and so now most of the of the patient dialies with a dialysate flow of 500 ml per minute so the question is can we reduce the dialysate flow let's say to 400 ml per minute this would save 3744 liters per year per patient so if we imagine all the patients on the galaxies these can feel more than a few pools but what we do not know exactly is what happens to the declaration and if you take a look at the technical sheets of dialysis membranes actually all the clearances are usually expressed for different blood flows but just one dialysate flow which is 500 ml per minute so no one really knows what happens in a real life situation and another thing is that most of the times uh another possibility that is raised is that we can use medium cutoff membranes to obtain the same results than convective techniques why because in the studies that let's say approved the medium cutoff membranes for clinical use there was no difference in terms of deprivation for small medium and large molecules the problem is that most of these studies were done uh taking a look at the reduction ratios so the patient side of the problem and i think that one opportunity that we have now is that we have the means to quantify directly the mass transfer in vivo during a real life dialysis session with instruments like these samplers they take only a small percentage of all the dialysate that flows through the machine during a dialysis session and allow us to quantify the mass transfer what is lost during a dialysis session and i would like to give you just to present you some personal and published and confidential data that we produced in le mans here you can see a table showing nine consecutive dialysis sessions of a single patient always uh on the same technique in hdf post dilution with the same membrane and you can see that from one session to another even if the conditions of the dialysis and the patients did not change there is a great variability about what is lost in the dialysate so if under the optimal conditions let's say 300 ml per minute of blood flow and 500 ml per minute of dialysate flow we have such a great variability are we sure that uh reducing the dialysate flow will change a lot to the patient i'm not sure we should we should make some some studies about that but let me also remind the ecological impact of reducing the intensive farming of cattle but i think there are some ethical issues that let's say make the transition towards any dialysis hardware ethical issues for instance when we when we talk about reducing the dialysate flow but we don't really know what is the effect on the patients are we allowed to do that i think that we need to reflect on that to overcome these obstacles and i think that physicians alone can do a lot but not everything and we need the collaborators of the patients first of all because patients are interested in the in the future of the planet in reducing waste reducing the carbon footprint and the energy demands of our activities engineers of course in order to implement that cradle to cradle um cycle that was mentioned by dr victor colley in the industry also because the problem now is that there are no clear economic benefits and so industry is not listening to the really to the to the needs of our planet or the eco dialysis scientific societies too should push a little pressure on governments in order to facilitate the transition that are just a few hints for the discussion thank you thank you very much massimo um that was a very good overview as well so now let us open up our discussions for a group discussion and a roundtable discussion between us um again i'd like to welcome the audience to send through some questions and while you do that as an audience may i ask um yourselves georgina massimo and vasilios two questions one is if i am establishing a new dialysis unit in a new hospital that's being built um what suggestions would you give for me a second question is if i have an established dialysis unit where i can't change the structure of my building what would you advise for me and the third question is if you were from industry pd or hemodialysis and the advisor to industry what would you advise them to change as our demands as physicians and as people who care for the planet so three questions three of you georgie and i will give you the first pick which one would you like to answer well let me say something about the new dialysis unit uh i think that that there is a very a very simple um answer we have to to to push our direction to find an intelligent architect that has experience on um ecological uh buildings it's something that should be demanded structurally uh as well as one should demand that our hospitals give us zero kilometer food instead of uh horrible things in plastic wraps it's a part of the discussion that we should do with our directions it's very difficult to give one solution for all because of course the solutions that we can have in the more sunny italy may not be the as good as or the same that we can have in sweden for example but i think that uh what's sadly happening now the war will finally push us reconsidering how much energy we waste and often how much energy we waste in public settings so i i think it's time that we ask for being involved in the discussion and for involving experts in the discussion uh i think it's something that could be done also at the european edta level in the sense that it could be interesting in which each uh of us who has some colleagues uh some sometimes some friends working on these issues shares experiences to try to to to go more in this direction i think it's it's probably easier to push the industry because usually even when you have the new centers here the keys there is a capitulate that is previously done and it should be demanded that as much as possible the center is equipped with renewable energy solar power and so on it says nasimo says it's something where we can make culture we can make it not make it directly but uh but it has to be done and uh last thing that i i discussed i'm living in a in france they built the new center and it's one of the things that i insisted uh tell us uh tell us about the energy tell us about these talent no one ever asked that so we have to start asking and then someone will start answering not immediately they got mad at me but then and they they started answering exactly absolutely thank you very much and that is exactly the perseverance and the determination we need to bring about change as you say georgina it's a change in mindset which is the first step before actions are taken maybe vasilios i can ask you if i have an established dialysis unit but i cannot change the structure of it what suggestions do you have for implementing greener solutions yes thank you uh well that that's a tough question because if you start from the beginning if you start from scratch then then you can make everything but i think that uh for example one idea would be to to change the reverse osmosis to a more efficient one more water saving or more energy saving that should be i think one of the main the main goals that a dialysis provider should have uh of course again for example if they if the dialysis unity is in a separate building then solar energy on the rooftop and everything could could be could be a solution could could be an alternative uh but there are also uh i think um ways that the healthcare staff could use for example uh to to to to differentiate from the hazardous from the non-hazardous the recyclables from the non-recyclables uh so that some kind of recycling could can be done uh and of course hazardous waste always should always be uh at the site and alone uh there's i think that this green culture should be implemented in all the dialysis stuff and the patients and the patients and for example i i i really liked the idea of exercise exercise and diet this is something that at first you cannot think that this may have a very big impact the environmental impact but it's not so so professor piccoli just showed us and persuaded us that it is a it is a very important aspect convincing our patients to exercise we don't need to have a new uh dialysis facility that's understandable or diet if they have a better diet for example with less phosphate rich then they need less medication less containers and etc and maybe if a dialysis provider could choose for example containers that are chlorine free if there are available uh this should be uh should reduce the the environmental burden you know excellent yes absolutely and chlorine have a very bad impact on the environment thank you very much and massimo uh perhaps the most difficult question uh as industry with pd and hemo and of course home hemo what would you tell and demand from industry that they help us change first of all i would try to reverse the situation and ask ourselves what can we do to push industry to do something and i think we should act on the economic leverage so if we are able as physicians to produce studies that show that these there is a convenience in changing the way of production industry will follow i think so that's what we can do i think we cannot expect an engagement by the industry if because industry are are not non-profit organizations of course so we should we should give them the the evidences that the transition is feasible and is convenient and if i may add a comment on the previous question i think that the key what we can do in an established inner in an already established dialysis facility is to think at the diaries facility as our own home in order to save what we do we all do we turn off the lights we turn off the computers when we when we finish uh using them or when we go to bed don't so the little actions that everyone can do is uh are a feasible option and as it is written in the review from joe nagar that appeared two years ago on nature reviews nephrology even charging someone on the personnel for who is interested in the green dialysis in the green nether in green nephrology would have an impact because it will share the [Music] behavior indeed thank you very much for that summary excellent we have two questions coming through on our chat um vasilios and massimo do you want to start going through these questions perhaps yes i can comment about incremental dialysis i'm a fan of incremental dialysis so i think it is a good way to postpone the start of dialysis and save resources moreover if we manage the patient with a low protein diet maybe a vegan vegetarian diet we can even add something more to the delay of dialysis in terms of ecologic impact and there is no doubt that not doing something is the best way to save resources so thank you vasilios would you like to take the next question the next question i think is about reuse of dialyzers yes well i i don't know maybe professor piccoli could correct me but i think that there is no study on environmental impact of single-use vessels reuse of dialyzers because you need disinfectants you need a lot a lot of and you produce a lot of liquid waste so i'm not sure that will be environmentally more effective and there are some issues some questions regarding safety and maybe even cost uh at least in the last years uh the cost of dialyzers reduced i i think at least in greece so i don't know this would be very cost effective and i i'm not aware of any studies regarding the environment i don't know if i can add something indeed i think it's a um i put it in a way to to open the discussion because of course everything changed but changed because of the fact that it was the choice of shifting from multiple use to single use was merely economical and reuse has still been done in some settings like mexico where manpower is much less costly so the point is that since it's something that was considered obsolete and since we are the throwaway society there was no new solution on reuse the way reuse has been done and is still done in some niche uh all over the world better reused than nothing is toxic is not safe is unsure one does not really know how is the advantage but there is no not even no study on the reuse as it was done but are we sure it's the only way reuse was was done when uh ethylene oxide was the standard for example now we have different means we have completely different membranes there is something that should be studied instead of studying a slightly different pore in which uh albumin gets trapped we might also uh try to study how we can do something more physiological there are ways we're moving in a way in medicine towards the sort of biomimetics approaches and we're using plastic for dialysis there is nothing new in the approach to use and reuse and even just changing the way the the the shells are done to make them really reusable uh would change a lot but i i mean there are many things that can be done but there is zero study and of course when i say we should rethink use we should think reuse 2022. now in 2022 very use when i started studying medicine long time ago indeed absolutely right and uh georgina in addition to everything you've said there's a good question here about returning and reusing the dal is it canisters for refilling and increasing the concentrate reducing volume delivered etc so another very good point from one of our attendees in the meeting um that was very interesting indeed thank you can i ask um uh actually here there's a very good question that's come up now it says dialyzers are reused by us to produce portable water in africa that is an interesting point and in fact uh dr schneider schneiderlitz may i invite you to actually join us live and speak at this speak up um to give you a point of view in the meanwhile when he tries to connect can he add something on the previous question what should we ask to the industry a very simple thing to include the technical sheet or of their material the ecological impact of what they can a little step forward correct indeed and as georgina also said you know we don't know what the the the cost of pd is in terms of the cost to the environment and all these things need to be accountable and published published with the with the material we get absolutely worse than that several industrial industries refused telling these to joe nagar already refusing saying something telling something to john agar is not easy they refused answering so this is unacceptable in that georgina one quick question for you you gave us an extremely important point about water conservation and how crucial water conservation is and including the study by fresenius to to reuse water could you tell us a little bit more about it please well uh there are um you know the big point uh is that um the water we use for uh 100 milliliters per minute or 800 milliliters per minute comes from a larger amount of water that is not always quantified the old generation of biosmosis used up to three times more water for production now it's one and a half because there is a way in which a part of this waste water comes again into the circuit and is recycled again so there are several technical choices but roughly saying it as a human being because it's i'm not an engineer the point is most of the reduce the the water can be reduced and circulate more times but even the water that is discharged that is quite salty is less salty than many mineral waters we drink uh john agar made an experiment uh having people from because it's forbidden to reuse it in some places and so he invited um some politicians to drink the different waters and to say which was the good one and no one was able to to to make the difference so there is a point in which probably uh re recirculating impacts on the lifetime of the membranes that are very expensive and whose production is also as also a carbon print a cost in energy and everything but at that time uh that comes differently uh the water could be reused for gardening for sterilization for washing and for more poetical things like feeding kangaroos and aquaponics indeed thank you very much georgina daniel dr schneditz i'm sorry if i'm not saying your name correctly but welcome and thank you for joining us we look forward to hearing your point of view there are two points one point is the incremental dialysis which maybe was misunderstood to prescribe the dialysis according to the residual renal function that is the point so there is no need to have three times a week dialysis yeah all the time because the renal residual renal function sometimes picks up again and you can reduce the frequency and this is not i mean this is i know this is investigated by certain people but this is not a common or popular view at the moment because everything is done in a standard in a in the standard three treatments per weekly schedule and so on that's the one that's one point the other point is that the reuse of dialyzers when i worked in the united states when in some units dialyzers were reused for more than i don't know 60 times this saved a lot of money to the to the institutions and i know they used chemicals at that time but then they moved to less dangerous chemicals first they released efforts for cleaning of dialysis like citric acid and so on so i think this could be resolved and i wanted to mention that dr levine with whom i worked in new york he developed a program in africa reusing dialysis to to produce portable water for areas where you cannot where the water is contaminated by by organic waste and mud and some particulate matter so you cannot drink it it cannot be cleaned from chemicals so if it is if the water contains poisonous material but it can be cleaned to remove bacteria and all that stuff this can be done with with reusing dialysis so there are many ways to reuse equipment um and maybe one comment to to massimo torre journey about reducing the dialysate flow the reduction of dialysate flow will can the reduction of clearance can exactly be predicted by formulas how much this will reduce the the the removal of of of solutes and it will of course reduce some but it may not it may be worth while reducing the flow so i agree with that thank you that's my these are my points thank you very much [Music] that was very interesting thank you so much so we have just two minutes left and it is time to wrap up uh i think it was a really interesting session um so much more we all of us can do to improve the health of our planet and it's truly an existential issue so we need to move away and from our small day-to-day problems to the global problem of our world and do something more there um i'd like to thank all of our participants georgina for a fabulous talk massimo and vasilios thank you very much for very interesting discussions and the era detail team for helping us through this for all our participants you have the live participants will earn one european credit for that cme continuous medical education and this is an exclusive benefit for era members so if you're not a member please become one the next working group e-seminar is going to be on the 10th of may 2022 this is organized by the ckd mbt working group and this is an update on biomarkers for ckd mbd so with this thank you all very much indeed for speaking for participating and for your enthusiasm for this very important topic thank you thank you bye