{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T18:02:50Z","timestamp":1785434570602,"version":"3.56.0"},"reference-count":33,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T00:00:00Z","timestamp":1785369600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Hemodialysis (HD) is a life-sustaining but resource-intensive therapy, consuming large volumes of water and electricity and generating substantial waste. This hybrid modeling study quantified the environmental footprint of in-center HD in T\u00fcrkiye using national registry data, published parameters, and measured facility-level data from two Turkish dialysis centers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A hybrid modeling approach combined published per-session resource parameters with measured facility-level data from two Turkish hemodialysis centers (4,000 sessions\/month combined). Literature-derived parameters (493 L water\/session at 42% RO recovery, 6.2\u201319.6 kWh electricity\/session, 1.5\u20138.0 kg waste\/session) were scaled nationally for 2023 (9.27 million sessions). Measured Turkish data (390 L water, 10.8 kWh electricity, 1.19 kg hazardous waste per session) provided empirical calibration. GHG emissions were calculated using T\u00fcrkiye-specific (0.494 kg CO\n                      <jats:sub>2<\/jats:sub>\n                      e\/kWh for electricity) and international conversion factors.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Using literature parameters, annual national estimates include 4.57 million m\u00b3 water, 57.5\u2013181.8 GWh electricity, and 13.9\u201374.2 kt waste, with total GHG emissions ranging from 45.3 to 171.1 kt CO\n                      <jats:sub>2<\/jats:sub>\n                      e\/year. Measured Turkish facility data yielded lower per-session water consumption (~390 L vs. 493 L, a 21% reduction) and hazardous waste generation (1.19 vs. 1.5 kg\/session under good segregation), while electricity consumption (mean 10.8 kWh\/session) aligned with the moderate literature scenario. Electricity was the dominant emission source (63\u201372%), followed by waste incineration (up to 47% with poor segregation).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In-center HD in T\u00fcrkiye imposes a substantial yet modifiable environmental burden. Measured Turkish facility data demonstrated that actual water consumption is meaningfully lower than international estimates, highlighting the importance of locally validated parameters. Waste segregation and electricity decarbonization represent the highest-impact intervention points for reducing the sector\u2019s carbon footprint.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0354903","type":"journal-article","created":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T17:27:47Z","timestamp":1785432467000},"page":"e0354903","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Environmental footprint of in-center hemodialysis in T\u00fcrkiye: A national, scenario-based analysis of water, energy, and waste"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0834-900X","authenticated-orcid":true,"given":"Berrak It\u0131r","family":"Ayl\u0131","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mehmet Emin","family":"Demir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arzu","family":"Akg\u00fcl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hatice","family":"\u015eahin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,7,30]]},"reference":[{"issue":"8","key":"pone.0354903.ref001","article-title":"Global, regional, and national prevalence of kidney failure with replacement therapy and associated aetiologies, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023","volume":"13","author":"GBD 2023 Kidney Failure with Replacement Therapy Collaborators","year":"2025","journal-title":"Lancet Glob Health"},{"key":"pone.0354903.ref002","volume-title":"Registry of the Nephrology, Dialysis and Transplantation in Turkey 2023: Ministry of Health and Turkish Society of Nephrology Joint Report","author":"K Ate\u015f","year":"2024"},{"issue":"2","key":"pone.0354903.ref003","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1002\/1744-9987.70118","article-title":"Predicting the future burden of renal replacement therapy in T\u00fcrkiye using national registry data and comparative modeling approaches","volume":"30","author":"A Akg\u00fcl","year":"2026","journal-title":"Ther Apher Dial"},{"issue":"4","key":"pone.0354903.ref004","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1111\/j.1440-1797.2009.01255.x","article-title":"Conserving water in and applying solar power to haemodialysis: \u201cgreen dialysis\u201d through wiser resource utilization","volume":"15","author":"JWM Agar","year":"2010","journal-title":"Nephrology (Carlton)"},{"issue":"5","key":"pone.0354903.ref005","doi-asserted-by":"crossref","first-page":"1521","DOI":"10.1016\/j.ekir.2024.02.010","article-title":"Updating the data: the resource consumption of modern-day hemodialysis systems","volume":"9","author":"KA Barraclough","year":"2024","journal-title":"Kidney Int Rep"},{"issue":"6","key":"pone.0354903.ref006","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1093\/ndt\/gfv031","article-title":"Eco-dialysis: the financial and ecological costs of dialysis waste products: is a \u201ccradle-to-cradle\u201d model feasible for planet-friendly haemodialysis waste management?","volume":"30","author":"GB Piccoli","year":"2015","journal-title":"Nephrol Dial Transplant"},{"issue":"2","key":"pone.0354903.ref007","doi-asserted-by":"crossref","first-page":"310","DOI":"10.2215\/CJN.09810911","article-title":"Solar-assisted hemodialysis","volume":"7","author":"JWM Agar","year":"2012","journal-title":"Clin J Am Soc Nephrol"},{"issue":"5","key":"pone.0354903.ref008","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1038\/s41581-019-0245-1","article-title":"Green nephrology","volume":"16","author":"KA Barraclough","year":"2020","journal-title":"Nat Rev Nephrol"},{"issue":"8","key":"pone.0354903.ref009","doi-asserted-by":"crossref","first-page":"2321","DOI":"10.1007\/s40620-025-02354-x","article-title":"Sustainable health care in a renal centre - carbon saving is coupled with cost-efficiency","volume":"38","author":"SMY Choo","year":"2025","journal-title":"J Nephrol"},{"issue":"7","key":"pone.0354903.ref010","doi-asserted-by":"crossref","first-page":"1801","DOI":"10.1007\/s40620-024-01989-6","article-title":"Hemodialysis water reuse within a circular economy approach. 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