Green transplant: A scoping review of sustainability challenges and opportunities in transplantation

Table 1 Summary of reported carbon footprint in transplantation

Ref.	Country	Transplantation step	Type of organ	Emissions per procedure
De Simone et al[18]	Italy	Transplantation surgery (including back-table procedure)	Liver	309.8 kg CO2e
Garcia Sanchez et al[13]	Worldwide1	Hospital stay, patient & organ transportation, transplantation surgery	Kidney (living donor)	335.6-789.9 kg CO2e
Garcia Sanchez et al[13]	Worldwide1	Hospital stay, patient & organ transportation, transplantation surgery	Kidney (dead donor)	424.2-2022.3 kg CO2e
Robinson Smith et al[21]	United Kingdom	Preoperative assessment (3-day inpatient stay)	Liver	618 kg CO2e
Wall et al[22]	United States	Organ acquisition	Liver	5000 kg CO2 (per charter jet flight)
Udayaraj et al[23]	United Kingdom	Follow-up (transportation to and from medical center)	Kidney	10.67 kg CO2 (per visit)

¹Australia, Belgium, Brazil, Germany, Italy, Japan, Netherlands, Spain, United Kingdom and United States.

CO₂e: Carbon dioxide equivalent.

Table 2 The 5R framework for sustainable organ transplantations

Transplantation step/5R’s	Reduce	Refuse	Reuse	Rethink	Recycle
Preoperative assessment	Shift from 3-day inpatient to 1-day outpatient assessments[21]; reduce patient travel through remote evaluations[30,53]; streamline lab testing to avoid duplication[31,32]	Eliminate unnecessary in-person pre-op consultations when not clinically justified[50]; avoid overordering routine or irrelevant lab tests[29]	Switch to reusable gowns/Linens[54,55]; digitize forms and records	Implement structured telemedicine pathways for transplant assessments	Add bins for clean packaging; recycle office and clinical paper; train staff on recycling workflow[56]
Donor & transplantation surgery	Optimize HVAC with occupancy sensors[25,40,53]; adopt low-flow anesthesia[40,56]; Standardize trays[26]	Eliminate desflurane and N2O1[57,58]; avoid overage/unused surgical supplies[9,37]	Use reusable surgical instruments, gowns, drapes[31,59,60,61]; Repair surgical instruments instead of disposing[56,61]; adopt hybrid laparoscopic instruments[62,63]	Adopt TIVA over inhalational agents1[37,45,51]; Establish Green Teams for OR staff coordination and behavior change[64,65]	Recycle paper and plastic waste[46,56,66]; implement OR-specific recycling bins[67]
Organ Acquisition	Use local recovery teams[22]; drive instead of flying when feasible[22,53]; optimize transport routes and logistics[53]	Avoid unnecessary charter flights[22]; refuse default use of high-carbon transport modes	Prioritize machine perfusion instead of static cold storage[68]	Use electric or eco-friendly transport means (e.g., electric cars, drones)	Explore recycling of maintenance components
Postoperative period	Streamline medication use to prevent drug waste through real-time review and titration protocols[47]; apply enhanced recovery after surgery protocols to minimize length of stay and resource use[40]; extend IV-line replacement intervals safely[69]; use oral medications when clinically appropriate instead of IV formulations[49]	Avoid routine, low-yield tests unless clinically indicated[29,70]; eliminate overuse of unnecessary monitoring in low-risk postoperative patients[71]; avoid ICU admissions and extended stays not supported by clinical criteria[40]	Promote the use of reusable equipment (e.g., bedpans, gowns) where feasible and safe[40]; support reprocessing of medical devices and instruments where permitted[70]	Implement predictive AI tools to optimize resource use, track inventory, and reduce waste from expired drugs and consumables[70]; train staff on the principles of “less is more” and sustainable ICU practices[71,72]; reward and showcase sustainability champions among staff[73]	Improve access to and visibility of recycling stations for personal protective equipment and packaging[73]; enhance separation and recycling of medical waste, including fluids and packaging[70]
Follow-up	Use video/phone consultations when feasible[23,74]; minimize transport with outreach clinics[30]; implement home kits for lab monitoring[68]	Avoid unnecessary in-person visits	Implement digital tools for follow-up testing; develop dependable telehealth platforms	Explore non-invasive diagnostics for remote follow-up[68]	Recycle waste during in-person check ups

¹Measures not pertinent to organ retrieval from deceased donors.

AI: Artificial intelligence; HVAC: Heating, ventilation and air conditioning; TIVA: Total intravenous anesthesia; OR: Operating rooms; IV: Intravenous; ICU: Intensive care unit.