Kidney Transplantation in the Era of Climate Change: Environmental, Structural, and Ethical Implications for Future-Ready Practice.

BACKGROUND: Kidney transplantation and dialysis are the two main modalities of kidney replacement therapy, and both are increasingly challenged by the current climate emergency landscape. Dialysis has long been scrutinised for its high energy and water demands, but transplantation, while generally more sustainable over the long term, also warrants critical evaluation concerning environmental accountability, equity, and resilience. SUMMARY: In this review, we compare the environmental and structural dimensions of dialysis and transplantation, while examining how climate change uniquely affects transplant recipients and grafts. We highlight the vulnerabilities of immunosuppressed recipients to heat stress and infectious diseases, the risks of cold chain disruption for organ preservation and shipment, and the impact of graft failure necessitating return to dialysis. We then consider how green nephrology principles can be applied to transplantation, drawing on emerging UK data, global policy frameworks such as the European Green Deal, and lessons from low- and middle-income countries. Digital healthcare solutions such as hybrid virtual clinics are explored as tangible strategies to reduce the carbon footprint of follow-up care. Recent life-cycle analyses also provide comparative estimates of dialysis and transplantation emissions, underscoring the importance of nuanced evaluation of both modalities. KEY MESSAGES: We conclude with a forward-looking agenda for clinicians and policymakers to embed environmental and social responsibility into both dialysis and transplantation, ensuring that kidney replacement therapy as a whole is resilient and sustainable in a warming world.